1. N 106 Labor and Delivery

2. Female external genitals
First we will review the anatomy.
The vulva is the area from the mons pubis to the fourchette.
The perineal area is between the fourchette and the anus
Female external genitals

3. L&D- the P’s of Labor Power uterine contractions maternal pushing
Passage bony boundaries of pelvis softening of cartilage linking pelvic bones
Passenger lie attitude presentation occiput brow, face shoulder sacrum position – LOA,ROP
Psych

4. POWER Uterine muscle layers. Muscle fiber placement.
The layers of the myometrium show the three types of smooth muscle fiber. The outer layer is longitudinal fibers – mostly found in the fundus, the middle layer has figure 8 fibers and the inner layer has circular fibers these are mostly found where the fallopian tubes enter the uterus and surround the cervical os controlling entry.
Uterine contractions and maternal pushing
Uterine muscle layers. Muscle fiber placement.

5. Pelvic types: gynecoid, android, anthropoid, platypelloid
PASSAGE
There are basically four shapes to the pelvic bone. – most women do not have a true pelvic shape but a combination of these four.
Gynecoid 50% - round cylindrical shape throughout. Good for vag birth. This pelvic shape has wide diameters and gentle curves throughout Most favorable for vaginal birth all the diameters are adequate.
Android – 30% heart or triangular-shaped inlet. Narrow diameters throughout. Narrow public arch – poor for vaginal birth.
Anthropoid 25% white and 50% non-white – The shape is long, narrow oval. Anteroposterior diameter is longer than transverse diameter. Narrow pubic arch. Favorable.
Platypelloid – 3% flattened, wide, short, oval in shape Transverse diameter wide, but anteroposterior diameter short. Wide public arch. Poor prognosis for vaginal birth.
Pelvic types: gynecoid, android, anthropoid, platypelloid

6. PASSENGER Typical anteroposterior diameters of the fetal skull.
Typical anteroposterior diameters of the fetal skull. When the vertex of the fetus presents and the fetal head is flexed with the chin on the chest, the smallest anteroposterior diameter (suboccipitobregmatic) enters the birth canal.
Typical anteroposterior diameters of the fetal skull.

7. LIE
The relationship of the long axis of the fetus to the long axis of the woman
99% the lie is longitudinal and parallel
Transverse lie – fetus is at right angle to mother
Transverse lie - uncommon

8. Fetal attitude is the relationship of fetal body parts to itself.
Flexion is normal
flexed
extension
Fetal attitude is the relationship of fetal body parts to itself.

9. PRESENTATION The fetal part that first enters the pelvis
Cephalic Vertex presentation.
p.268
Vertex – most common or occiput presentation.
Military head is in neutral position
Brow – head partly extended
Face = head is extended
Breech presentation
Breech presentation.

10. Cephalic presentations
Occiput/vertex
Brow
Face
Military

11. Breech presentations Full Breech Frank Breech Footling Breech
Complete breech in left sacral anterior (LSA) position.
Breech presentation. Frank breech.
Incomplete (footling) breech
Footling Breech

12. Position
Fetal position describes the location of a fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvis
Abbreviations of presenting part is “cuddled” between maternal pelvis
LOA, LOP, ROA, ROP, RSA, LMP
Occiput, Sacrum, Mentum (chin), Anterior, Posterior

13. Categories of presentation.

14. A B C D
Quiz

15. PSYCHE Preparation and information Anxiety and fear decrease coping
Culture affects views
Both physical and emotional experience
Do not “nurse the machines”

16. L&D nursing responsibilities
History Antepartal weight gain fetal gest & growth risk factors present status
Obstetrical
Medical surgical
interval
Assessment maternal vital signs uterine activity bladder status I&O bloody show response to labor maternal discomfort fetal heart rate Amniotic fluid

17. L&D Leopold’s maneuvers
Palpate upper abdomen
Palpate opposite side in circular motion for fetal extremities
Palpate for engagement of presenting part
Palpate to identify cephalic prominence

18. What fetal part is in fundus
Figure 16–5a Leopold’s maneuvers for determining fetal position and presentation. First maneuver: Facing the woman, palpate the upper abdomen with both hands. Note the shape, consistency, and mobility of the palpated part. The fetal head is firm and round and moves independently of the trunk. The buttock feels softer, and it moves with the trunk.
What fetal part is in fundus

19. Figure 16–5b Second maneuver: Moving the hands on the pelvis, palpate the abdomen with gentle but deep pressure. The fetal back, on one side of the abdomen, feels smooth, and the fetal extremities on the other side feel knobby.
Palpate for back

20. Palpate for engagement of presenting part
Figure 16–5c Third maneuver: Place one hand just above the symphysis. Note whether the part palpated feels like the fetal head or the breech and whether it is engaged.
Palpate for engagement of presenting part

21. Palpate position of head – determine descent & flexion
Figure 16–5d Fourth maneuver: Facing the woman’s feet, place both hands on the lower abdomen and move hands gently down the sides of the uterus toward the pubis. Note the cephalic prominence or brow.
Palpate position of head –
determine descent & flexion

22. Location of FHR in relation to the more commonly seen fetal positions.

23. Location of FHR in relation to the commonly seen fetal position

24. Electronic fetal monitoring by external technique
Electronic fetal monitoring by external technique. The tocodynamometer (“toco”) is placed over the uterine fundus. The toco provides information that can be used to monitor uterine contractions. The ultrasound device is placed over the area of the fetal back. This device transmits information about the fetal heart rate. Information from both the toco and the ultrasound device is transmitted to the electronic fetal monitor. The fetal heart rate is displayed in a digital display (as a blinking light), on the special monitor paper, and audibly (by adjusting a button on the monitor). The uterine contractions are displayed on the special monitor paper as well.
Electronic fetal monitoring by external technique. The tocodynamometer (“toco”) is placed over the uterine fundus. The ultrasound device is placed over the area of the fetal back.

25. Intrapartum Fetal Assessment
Fetal Heart Rate
Electronic Fetal Monitoring ultrasound transducer
Response to contractions tocotransducer
Internal fetal monitoring – RBOW
fetal scalp electrode intrauterine pressure catheters (IUPC)

26. Attached spiral electrode with the guide tube removed.

27. Characteristics of uterine contractions.

28. Normal fetal heart rate pattern obtained by internal monitoring.
Note normal FHR, 140 to 158 beats/min, presence of long- and short-term variability, and absence of deceleration with adequate contractions. Arrows on bottom of tracing indicate beginnings of uterine contractions.
Normal fetal heart rate pattern obtained by internal monitoring.

29. Fetal Heart Rate Patterns
Tachycardia – greater than 160 for 10 min
Bradycardia – less than 110 for 10 min
Absent or minimal beat-to-beat variability
Early decelerations – head compression
Late decelerations – uterine placenta insufficiency
Variable decelerations – cord compression

30. A B
Figure 19–1 a & b Comparison of labor patterns. A, Normal uterine contraction pattern. In this example contraction frequency is every 3 minutes; duration is 60 seconds. The baseline resting tone is below 10 mm Hg. B, Hypotonic uterine contraction pattern. In this example the contraction frequency is every 7 minutes (with some uterine activity between contractions), duration is 50 seconds, and intensity increases approximately 25 mm Hg during contractions.
Power – contraction not effective
Comparison of labor patterns. A) Normal uterine contraction pattern. B) Hypotonic uterine contraction pattern..

31. Types and characteristics of early, late, and variable decelerations.

32. Nursing Interventions for Decelerations
Early Continue to observe
Late Stop oxytocin Replace fluids Change mother’s position Check B/P and Pulse Administer oxygen Notify physician
Variable Stop oxytocin Replace IV fluids Change mothers position Check for prolapsed cord Check B/P and Pulse Administer oxygen Notify the physician Prepare to assist with fetal scalp blood sample

33. Conditions Associated with Fetal Compromise
FHR below 100 or above 160
Amniotic fluid Meconium-stained (greenish) Cloudy, yellowish, or foul-smelling
Contractions lasting longer than 90 seconds occurring less than 2 minutes apart
Maternal hypotension, hypertension, fever
FHR below 100 or above 160
Amniotic fluid Meconium-stained (greenish) - fetal distress or post mature
Cloudy, yellowish, or foul-smelling – suggests infection
Contractions lasting longer than 90 seconds - reduces placenta blood flow.
occurring less than 2 minutes apart – may not give placental blood flow time to resume during interval
Incomplete uterine relaxation and intervals shorter than 60 seconds between contractions – reduces placental blood flow.
Maternal hypotension, hypertension, fever
Hypotension – may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heat
Hypertension – may be associated with vasospasm in spiral arteries, which supply the intervillous spaces of the placenta
Fever (100.4 or higher

34. Actions to increase oxygen to fetus
If receiving Pitocin stop or slow rate
Reposition mother
Increase non-additive IV fluids
Administer 100% oxygen thru snug face mask to mother at rate of 8-10 liters/min
Keep mothers bladder empty
Change under-pads regularly
p. 353

35. L & D true vs false labor True labor contractions:
Start in back & move wavelike toward abdomen
Become more intense with walking
Result in ripening of cervix, dilation & effacement
False labor contractions: Noticed primarily in abdomen Begin & remain consistent Disappear with walking No change in cervical dilation or effacement

36. Before labor begins, the cervix is long (approximately 2
Before labor begins, the cervix is long (approximately 2.5 cm), the sides feel thick, and the cervical canal is closed, so an examining finger cannot be inserted. During labor, the cervix begins to dilate, and the size of the opening progresses from 1 cm to 10 cm in diameter.
To gauge cervical dilatation, the nurse place the index and middle fingers against the cervix and determines the size of the opening.

37. Measuring the station of the fetal head while it is descending

38. Mechanism of Labor Engagement / Decent Flexion Internal rotation
Extension
Restitution
External rotation
Expulsion

39. A, Engagement and decent B, Flexion. C, Internal rotation. D, Extension. E, External rotation.
Mechanisms of labor.

40. Stages of Labor
Stage I cervical dilation to 10 cm & effacement to 100% early/latent active transition
Stage II crowning to birth of baby
Stage III birth of baby to delivery of placenta
Stage IV 1-4 hours after delivery of placenta stabilization recovery

41. Phases of Stage I of Labor
Early/latent - dilates cm contractions q 5 min X sec
Active - dilates – cm contractions q 2-5 min X sec
Transition- dilates – 8-10 cm contractions q 2-3 min apart X sec
p. 275
Early/latent - dilates cm contractions q 5 min X 30 sec
Primip 8-9 hours Multip 5-6 hrs
Contractions mild and may start in back. Many describe as if menstrual cramps. Woman is usually social, excited and cooperative
Active - dilates – cm contractions q 2-5 min X sec
Primip 4-5 hours multip 2-3 hours
Contractions are moderate to strong in intensity
Behavior changes becomes anxious and feels helpless. Sociability is gone and replaced by serious inward focus. If will take pain medication – now is the time to do it.
Transition- dilates – 8-10 cm contractions q 2-3 min apart X sec
Primip – 3-4 hours for primip multip – times varies
Contractions are very strong. – Leg tremors, nausea, and vomiting are common.
Behavior – irritable and lose control. Partner becomes confused because actions that were helpful just a short time ago now bother her.

42. Effacement of the cervix in the primigravida. Beginning of labor
Effacement of the cervix in the primigravida. Beginning of labor. There is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid.

43. Beginning cervical effacement
Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head.

44. Cervix about one-half effaced and slightly dilated
Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic fluid exerts hydrostatic pressure.

45. Complete effacement and dilatation.
End of Stage 1

46. Friedman Curve Predicable progression of labor for
Nulliparous and Multiparous
Primip = 1 cm per hour
Multip is usually from 8-10 hours
Primip is usually from hours

47. Responsibilities during First Stage of Labor
Promote Comfort positioning, lighting temperature, cleanliness bladder, mouth care
Relieve pain breathing techniques nonpharmacologic massage, touch, pressure hydrotherapy imagery or focal point
p. 310
Promote Comfort positioning - assume any position she finds comfortable other than supine and change positions frequently
lighting - soft indirect lighting
temperature - cool, damp washcloths on woman's face and neck promote comfort
cleanliness bloody show and amniotic fluid leak and should change the sheets and gown frequently
bladder - a full bladder intensifies the discomfort and can delay fetal descent. Empty bladder at least every two hours. mouth care – ice chips, hard candy on a stick, frozen fruit bars.
Relieve pain breathing techniques – p
Nonpharmacologic
Relaxation – comfortable environment, general comfort measures, reduce anxiety, Self-massage, massage by others – body powder. Sacral pressure helps with back pain, two tennis balls in a sock. Touch, stroking, warmth to back
Hydrotherapy
Mental stimulation – imagery and focal point.

48. Stage 2 From 10cm 100% to birth of Baby
Assist mother with pushing
Preparation of sterile delivery table
Perineal cleansing
Sutures for episiotomy or laceration
Initial care and assessment of newborn
APGAR

49. Effects of labor on the fetal head. Caput succedaneum formation.
Figure 19–2a Effects of labor on the fetal head. Caput succedaneum formation. The presenting portion of the scalp area is encircled by the cervix during labor, causing swelling of the soft tissue.
Effects of labor on the fetal head. Caput succedaneum formation.

50. Care of Infant Maintaining cardiopulmonary function – APGAR
Supporting thermoregulation
Identifying infant
Examining for obvious anomalies and birth injuries
Medication administration
p. 323
Assess APGAR
Place infant on a prewarmed warmer with head turned to one side to allow drainage of secretions. Suction secretions from the infants mouth and nose with a bulb syringe as needed.
Thermoregulation = hypothermia raises the infants metabolic rate and oxygen consumption worsening any respiratory problems. Apply towels to reduce evaporative heart loss. The head should be dried well. 0 it is about ¼ of body's surface area. The stimulus of drying the skin promotes vigorous crying and lung expansion in most healthy infant. Stockinet cap reduces heat loss. Not to wear cap in warmer because it slows transfer of heat to baby.
Band with matching imprinted numbers and identifying information are the primary means to ensure the right mother goes with the right infant. Apply two bands for infant and mother and support person wears the fourth.

51. Clamp is positioned 1/2 to 1 in from the abdomen and then secured.

52. APGAR Heart rate – above 100 Respiratory Effort – spontaneous with cry
Muscle tone – flexed with movement
Reflex response – active, prompt cry
Color – pink or acrocyanosis
0-3 infant needs resuscitation
4-7 Gentle stimulation – Narcan
8-10 – no action needed
p. 324

53. Cut cord. The one vein and two arteries can be seen.

54. Placenta Separation Stage 3
Uterus changes shape
Uterus rises upward in the abdomen
Cord begins to move out of the vagina
Gush of blood noted from vagina
p. 279
Stage 111 = shortest stage lasting about 30 min with an average of 5-10 minutes.
When the infant is born, the uterine cavity becomes much smaller. The reduced size decreases the size of the placenta site, causing it to separate form the uterine wall. Fours signs suggest placenta separation.
The uterus has a spheric shape
The uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward.
The cord descends further from the vagina.
A gush of blood appears as blood trapped behind the placenta is released.

55. Stage III
Placental separation and expulsion.
Schultze mechanism.

56. Stage 4 of Labor First 1-4 hours after delivery of placenta
Palpate fundus
Assess vital signs
Assess lochia
Ice pack to perineum
Care of infant and Care of mother
Identification
Promoting bonding

57. Stage 4
Physical recovery of mother and baby lasts 1-4 hours.
Uterus at or below umbilicus
Many women complain of chills lasting about 20 min care – warm blanket, hot drink or soup may help.
Ice packs to perineum help
Ideal time for bonding because the interest of both the parents and the newborn is high. May initiate breastfeeding if no problems.
Baby is alter and seeks eye contact with the new parents..
The left hand is placed just above the symphysis pubis, and gentle downward pressure is exerted. The right hand is cupped around the uterine fundus.
Suggested method of palpating the fundus of the uterus during the fourth stage.

58. Common Intrapartum Procedures
Amniotomy
Stimulation of labor induction augmentation
Assisted delivery episiotomy forceps vacuum extractor
Cesarean delivery

59. Amniotomy Artificial rupture of fetal membranes
Advantages decrease some labor assessment of fluid for meconium permits internal monitoring
Risks cord prolapse infection
p. 396
Assess baseline FHT prior. At least min
Assess for complications
check FHT for one full minute after check for quality, color, and odor of amniotic fluid.
Vernix may mean preterm Greenish may be post term or placental insufficiency.
Hydramnios
Check woman temp q 2-4 hours report if above or FHR above 160

60. Assessment of Fluid Quality, Color, and Odor
Greenish, meconium stained
Large amount of vernix
Strong order, cloudy or yellow
Hydramnios
Oligohydramnios
Fluid should be clear often with bits of vernix and have a mild odor.
Greenish, meconium stained - post term or placental insufficiency
Large amount of vernix – suggests fetus may be preterm
Strong order, cloudy or yellow suggests chorioamnionitis
Hydramnios is associated with some fetal abnormalities
Oligohydramnios – lack may be associated with placental insufficiency or fetal urinary tract abnormalities

61. Risk during ROM
Prolapse of the umbilical cord.

62. Induction & Augmentation of Labor During Stage 1
Definitions
Criteria – Bishop’s scoring, 39 weeks gest.
Methods surgical – amniotomy drugs Oxytocin (Pitocin) – IV stimulate contractions Cervical ripening agents prostaglandin Misoprostol (Cytotec)- tab dinoprostone (Prostin E2) Cervidil/Prepidil - vaginal/cervical gel
Induction – any attempt to initiate uterine contractions before their spontaneous onset to facilitate a vaginal delivery
Not having contractions
Augmentation – any attempt to stimulate uterine contractions during the course of labor to facilitate a vaginal delivery having contractions
Bishops scoring – 13 is highest p. 399 needs be 7 or higher for primip and 5 or higher for multip Rating 0,1,2,3
5 factors –four are of cervix of mother
Dilation 0, 1-2, 3-4, 5-6, effacement 0-30%, 40-59%, 60-70%, 80% and more, cervical consistency firm, med, soft, cervical position posterior, middle, anterior
and one of fetus – station 3, 2, 1 or 0, +1 or +2

63. Episiotomy Most common operation primip – 70% multip – 30%
Types midline – most common problem with 3-4th degree laceration
mediolateral increased PP pain, more scaring
Main risk – infection
Complication of infection – prolonged dysparenia
Prevention – perineal massage & stretching beginning at 34 weeks.
Midline p. 409
Advantages
Minimal blood loss Neat healing with little scarring less postpartum pain than mediolateral
Disadvantages an added laceration may extend into the anal sphincter limited enlargement of the vaginal sphincter
Prolonged dysparenia is painful intercourse
Mediolateral
More enlargement of the vaginal opening
Little risk that the episiotomy will extend into the anus
Disadvantages
More blood loss
Increased postpartum pain
More scarring and irregularity in the healed scar
Painful intercourse

65. Lacerations
First degree - limited to fourchette, perineal skin, vaginal membrane
Second degree - underlying fascia and muscle of the perineal body
Third degree – involves the anal sphincter
Fourth degree – extends thru the rectal mucosa to lumen of rectum
Could be extension of episiotomy

66. Interventions During Stage 2
Forceps & Vacuum Extraction
Assist with decent and rotation of fetal head
Risk- trauma to maternal and fetal tissue
Criteria scalp is visible at vaginal opening normal scalp ph is above 7.25 Low forceps - station is +2 or lower Mid forceps - station 0 to +2
Normal scalp ph is above 7.25 or infant is hypoxic with acidosis and in distress if lower

67. Forceps With correct placement of the blades, the handles lock easily.
During uterine contractions traction is applied to the forceps in a downward and outward direction to follow the birth canal.
With correct placement of the blades, the handles lock easily.

68. The cup is placed on the fetal occiput and suction is created
The cup is placed on the fetal occiput and suction is created. Traction is applied in a downward and outward direction.
Vacuum extractor

69. Risks to Mother and Infant
Mother laceration hematoma of the vagina
Infant ecchymoses facial and scalp lacerations and abrasions cephalhematoma intracranial hemorrhage
Chignon –scalp edema from vacuum extractor p

70. Cesarean Birth About 22% of all births
Indications – dystocia, CPD, PIH, DM, genital herpes, prolapsed cord, fetal malpresentations, placenta previa or abruptio placentae
Maternal risk same as any abdominal OR
Infant’s greatest risk is lung immaturity
Maternal mortality is higher for C/S than for vaginal birth but is still relatively low

71. Preparation for C/S NPO, get operative permit signed Pre-op teaching
Lab work – CBC, clotting series, type and cross match one or more units
Single IV dose of antibiotics
Famotidine (Pepcid) and citrate (Bicitra)
Shave abdomen
Insert foley catheter
Perform abdominal scrub

72. Incisions for C/S
Abdominal incision vertical – umbilicus to symphysis transverse or bikini – above symphysis
Uterine incisions low transverse low vertical classic
Abdominal and uterine incisions do not always match

73. Low transverse incision
Uterine incisions for a cesarean birth. This transverse incision in the lower uterine segment is called a Kerr incision. preferred
Low transverse incision

74. classic uterine incision
Figure 20–5c This view illustrates the classic uterine incision that is done in the body (corpus) of the uterus. The classic incision was commonly used in the past but is associated with increased risk of uterine rupture in subsequent pregnancies and labor.
Used for placenta previa
classic uterine incision

75. Nursing Considerations C/S
Routine assessments q 15 min X 1 hr, q 30 min X 1 hr then hourly VS fundus for firmness, height, deviation lochia urine output abdominal dressing
Assess need for pain medication
TCDB – support incision with pillow

76. Intrauterine Infection
Signs Fetal tachycardia – FHT greater than 169 Maternal fever – greater than Foul or strong-smelling amniotic fluid Cloud or yellow appearance to amniotic fluid

77. Nursing Care for Infection
Prevention wash hands limit vaginal examinations keep under pads dry
Assess VS q 4 hours if ROM than q 2 hrs
Collect culture specimens

78. Intrapartum complications
Dystocia
CPD – cephalopelvic disproportion
Placenta previa
Abruptio placenta
Prolapsed umbilical cord
Macrosomia - Shoulder dystocia

79. Dystocia Abnormal progress of labor
Contributing factors sedation, anxiety, anesthesia, unripe cervix, supine position, cephlopelvic disproportion - CPD
Management depends on cause
Dysfunctional labor – problem with powers of labor
Hypotonic contractions or Hypertonic contractions
Ineffective maternal pushing
Cephlopelvic Disproportion Fetal head size too big for maternal pelvis

80. Complications of Pregnancy
Hemorrhage – late in pregnancy
Placenta Previa
Abruptio Placentae
p.671
After 20 weeks the major causes of hemorrhage are placenta previa and abruptio placentae

81. Placenta previa Placenta located over/near cervical opening
S&S: painless bleeding in 3rd trimester, hemorrhage, fetal distress
Risk factor: multiparity in older women
TX: Hospitalization, bedrest, ultrasound
Care: Do not perform vag exam Monitor mother and fetus Prepare for delivery / no oxytocin
The three classifications of placenta previa depend on how much of the internal cervical os is covered by the placenta. This is determined by ultrasound
Incidence 1 in 200 births higher in women with previous previa, older women, multipara, cigarette smoking
Signs and symptoms
Sudden onset of painless uterine bleeding
No manual examinations and no administration of oxytocin to prevent strong contractions that could result in sudden placental separation and rapid hemorrhage

82. Placenta previa. Low placental implantation.
Marginal (low-lying)
Placenta is implanted in lower uterus but its lower border is >3 cm from the internal cervical os
These are common in early ultrasound examinations and often appear to move upward and away form the internal cervical os as the fetus grows. Only about 10% of placenta a previa diagnosed in the second trimester will remain a previa at term
Delivery occasionally by CS
Placenta previa. Low placental implantation.

83. Total placenta previa
Total: Placenta completely covers internal cervical os
With frank bleeding delivery always by C/S

84. Abruptio Placentae Premature separation of placenta
S&S: Concealed or apparent hemorrhage in 3rd trimester, uterine tenderness, abd Pain, Board like abdomen, shock, fetal distress
Risk factors: PIH, multiparty, DM
TX: Replacement of blood loss, IV fluids, delivery
Care: Explain procedures, monitor mother and fetal condition, prepare for delivery
Also known as placenta abruption, hemorrhage many be apparent or concealed. The severity depends on how much bleeding.
Classic four symptoms are above can also have pack pain, signs of hypovolemic shock, fetal distress, or fetal death
Dangerous condition
Major danger is hemorrhage, Hypovolemic shock and clotting abnormalities

85. Marginal abruption with external hemorrhage.
Abruptio placentae.
Bleeding with abdominal pain that is constant
Marginal abruption with external hemorrhage.

86. Abruptio placentae
Complete separation with concealed bleeding.

87. Shoulder Dystocia
Risk factors diabetes; macrosomic infant obesity prolonged second stage previous shoulder dystocia
Morbidity
Management
Incidence – 1 out of ever 300 deliveries
Risk factors diabetes; macrosomic infant obesity - poor muscle control
prolonged second stage previous shoulder dystocia
Morbidity –
Fractured clavicle or humerus
Brachial plexus injury – no use of arm - $11 million settlement
Asphyxia and fetal/neonatal death
Management
Generous episiotomy
McRoberts maneuver. Hyperflex the mothers hips against her abdomen thus rotating the pelvis

88. Position for prolapse cord

89. Prolapsed Cord
Cause – increase risk - high station, AROM, poor fit, hydramnios, breech
Signs of prolapse – visible, suspect
Management – Emergency - Call Light Reduce cord compression Position hip higher than head Hold fetal part upward Give oxygen 8-10 liters/min
Prompt delivery is the priority p
Causes – when the fetal presenting part has a poor fit in the pelvis fetus at high station, very small fetus, breech presentation, Transverse lie , Hydramnios
Signs – visible cord or changes in FHT such as bradycardia or variable decelerations

90. Other Complications Precipitous delivery Retained placenta
Uterine inversion
Uterine rupture
Umbilical cord problems
Multiple births
Precipitous delivery – delivery within 1 hour after onset of labor
Retained placenta - placenta has not delivered spontaneously within 30 minutes of delivery, Management – gentle traction on cord and notify anesthesia and prepare for manual removal
Uterine inversion – ER partial or complete – attempt to replace may need anesthesia so can relax enough to replace, follow with Pitocin
Uterine rupture – May occur with scarred uterus, trauma, over use of Pitocin, over-distended uterus
Presents with fetal distress, pain, bleeding, change in uterus contour, stopping of contractions
Umbilical cord problems
1) True knots – occur in about 1% of deliveries, Caused by fetal tumbling inside uterus
Perinatal mortality 6%
2 nuchal cord longer cord ) normal about inches, Loops of cord around fetal neck
20-25% of all deliveries, Causes variable decelerations
3) Abnormal insertion sites of cord to placenta ,Battledore – insertion of margin- no clinical significance
4) single umbilical artery, 1% of all – may indicate GU abnormalities
5) Cord prolapse