NURS 1400 Unit 2

Theories for the Onset of Labor Maternal factors Estrogen and progesterone Prostaglandins Oxytocin Fetal factors Fetal adrenocorticotropic hormone Estrogen & Progesterone: It is believed that progesterone causes relaxation of the myometrium, whereas estrogen stimulates myometrial contraction. Changes in these levels cause increased # of myometrial gap junctions. Gap junctions are proteins that connect cell membranes facilitating coordingated uterine contractions and myometrial stretching. Estrogen also stimulates the production of prostaglandin in the decidua and fetal membranes which increases stimulation of smooth muscle contraction of the uterus. Prostaglandins: allows the cervix to soften, efface and dilate during labor. Oxytocin: Uterus becomes more sensitivity to oxytocin. Fetal adrenocorticotropic hormone: Thought t have an effect on uterine sensitivity to oxytocin and prostaglandins thus stimulating the onset of labor.

Fetal Factors Affecting the Process of Labor Head size Molding Presentation Cephalic, breech, shoulder Lie Longitudinal, oblique, transverse Attitude Flexion Position Fetal attitude flexion, fetal lie longitudinal Fetal attitude flexion, fetal lie transverse

Factors Affecting Labor Progress The birth passageway (birth canal) The passenger (fetus) The physiologic forces of labor The position of the mother The woman’s psychosocial considerations

Passenger Fetal head Fetal attitude Fetal lie Fetal presentation Fetal position

Fetal Attitude The relation of the fetal body parts to one another (Figure 22-4) Normal attitude is flexion

Figure 22–4 Fetal attitude Figure 22–4 Fetal attitude. A, The attitude (or relationship of body parts) of this fetus is normal. The head is flexed forward with the chin almost resting on the chest. The arms and legs are flexed. B, In this view, the head is tilted to the right. Although the arms are flexed, the legs are extended.

Figure 22–4 (continued) Fetal attitude Figure 22–4 (continued) Fetal attitude. A, The attitude (or relationship of body parts) of this fetus is normal. The head is flexed forward with the chin almost resting on the chest. The arms and legs are flexed. B, In this view, the head is tilted to the right. Although the arms are flexed, the legs are extended.

Fetal Lie The relationship spinal column of the fetus that of the mother Longitudinal or transverse

Fetal Presentation Engagement Station (Figure 22-7) Ischial spines are zero station Presenting part moves from – to +

Figure 22–7 Measuring the station of the fetal head while it is descending. In this view the station is 22/23.

Fetal Position Right (R) or left (L) side of the maternal pelvis Landmark: occiput (O), mentum (M), sacrum (S), or acromion (scapula[Sc]) process (A) Anterior (A), posterior (P), or transverse (T)

Physiology of Labor Primary force is uterine muscular contractions Secondary force is pushing during the second stage of labor

Uterine Contractions Frequency Duration Intensity

Figure 22–9 Characteristics of uterine contractions.

Causes of Cervical Effacement Estrogen - Stimulates uterine muscle contractions Collagen fibers in the cervix are broken down Increase in the water content of the cervix

Cervical Effacement Physiologic retraction ring Upper uterine segment thickens and pulls up Lower segment expands and thins out Effacement

Figure 22–10 Effacement of the cervix in the primigravida Figure 22–10 Effacement of the cervix in the primigravida. A, At the beginning of labor, there is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head. C, Cervix is about one-half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the fetal head exerts hydrostatic pressure on the cervix. D, Complete effacement and dilatation.

Figure 22–10 (continued) Effacement of the cervix in the primigravida Figure 22–10 (continued) Effacement of the cervix in the primigravida. A, At the beginning of labor, there is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head. C, Cervix is about one-half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the fetal head exerts hydrostatic pressure on the cervix. D, Complete effacement and dilatation.

Figure 22–10 (continued) Effacement of the cervix in the primigravida Figure 22–10 (continued) Effacement of the cervix in the primigravida. A, At the beginning of labor, there is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head. C, Cervix is about one-half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the fetal head exerts hydrostatic pressure on the cervix. D, Complete effacement and dilatation.

Figure 22–10 (continued) Effacement of the cervix in the primigravida Figure 22–10 (continued) Effacement of the cervix in the primigravida. A, At the beginning of labor, there is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head. C, Cervix is about one-half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the fetal head exerts hydrostatic pressure on the cervix. D, Complete effacement and dilatation.

The Five Ps of Labor Passageway Passenger Powers Position Psychological response Passageway: birth canal Passenger: the fetus & placenta Powers: uterine contractions Position: of the mother Psychological response of the mother Station or relationship of the fetal presenting part to the ischial spines.

Positions of a Vertex Presentation

Leopold’s Maneuvers Is the fetal lie longitudinal or transverse? What is in the fundus? Am I feeling buttocks or head? Where is the fetal back? Where are the small parts or extremities? What is in the inlet? Does it confirm what I found in the fundus? Is the presenting part engaged, floating, or dipping into the inlet?

Figure 23–7 Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth maneuver first to identify the part of the fetus in the pelvic inlet.

Figure 23–7 (continued) Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth maneuver first to identify the part of the fetus in the pelvic inlet.

Figure 23–7 (continued) Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth maneuver first to identify the part of the fetus in the pelvic inlet.

Figure 23–7 (continued) Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth maneuver first to identify the part of the fetus in the pelvic inlet.

Powers of Labor Primary powers Secondary powers Involuntary uterine contractions Effacement Dilation Secondary powers Voluntary pushing in second stage

Maternal Position Ambulation Lateral recumbent in bed Fowler’s position in bed or chair Birthing ball Avoid supine position

Psychological Response of the Mother Culture Expectations and goals for the labor process Feedback from people participating in the birth process

Signs and Symptoms of Impending Labor Lightening Cervical change Braxton Hicks contractions Bloody show Energy spurt Gastrointestinal disturbances

Stages of Labor First stage–onset of labor to complete dilation of the cervix Latent phase (ends with cervix 3–4 cm dilated) Active phase (3–4 cm to 8 cm dilated) Transition (8–10 cm dilated) Second stage–complete dilation to birth Third stage–birth to placental expulsion Fourth stage–four hours following delivery of the placenta

True Labor Progressive dilatation and effacement Regular contractions increasing in frequency, duration, and intensity Pain usually starts in the back and radiates to the abdomen Pain is not relieved by ambulation or by resting

True Labor Table 22–1 Critical factors in labor.

True Labor Table 22–2 Implications of pelvic type for labor and birth.

True Labor Table 22–3 Characteristics associated with longitudinal versus transverse fetal lie.

True Labor Table 22–4 Factors associated with a positive birth experience.

True Labor Table 22–5 Comparison of true labor and false labor.

True Labor Table 22–6 Characteristics of labor.

False Labor Lack of cervical effacement and dilatation Irregular contractions do not increase in frequency, duration, and intensity Contractions occur mainly in the lower abdomen and groin Pain may be relieved by ambulation, changes of position, resting, or a hot bath or shower

First Stage of Labor: Latent Phase Beginning cervical dilatation and effacement No evident fetal descent Uterine contractions increase in frequency, duration, and intensity Contractions are usually mild

First Stage of Labor: Active Phase Cervical dilatation from 4 to 7 cm Progressive fetal descent Contractions more frequent and intense

First Stage of Labor: Transition Cervical dilatation from 7 to 10 cm Progressive fetal descent Contractions more frequent and intense

Second Stage of Labor Begins with complete dilatation (10 cm) Ends with birth of the baby

Figure 22–12 Mechanisms of labor. A, B, Descent. C, Internal rotation Figure 22–12 Mechanisms of labor. A, B, Descent. C, Internal rotation. D, Extension. E, External rotation.

Third Stage of Labor From birth of infant to delivery of placenta

Fourth Stage of Labor 4 hours after birth Physiologic readjustment Thirsty and hungry Shaking Bladder is often hypotonic Uterus remains contracted

Cardinal Movements of Labor

Palpation: Advantages Noninvasive Readily accessible, requiring no equipment Increases the “hands on” care of the patient Allows the mother freedom

Palpation: Disadvantages Does not provide actual quantitative measure of uterine pressure No permanent record Maternal size and positioning may prevent direct palpation

External Electronic Uterine Monitoring: Advantages Noninvasive Easy to place May be used before and following rupture of membranes Can be used intermittently Provides a permanent, continuous recording

External Electronic Uterine Monitoring: Disadvantages The nurse must compare subjective findings with monitor The belt may become uncomfortable The belt may require frequent readjustment The mother may feel inhibited to move

Internal Electronic Uterine Monitoring: Advantages Provides pressure measurements for contraction intensity and uterine resting tone Allows for very accurate timing of UCs Provides a permanent record of the uterine activity

Internal Electronic Uterine Monitoring: Disadvantages Membranes must be ruptured and adequate cervical dilation must be achieved Invasive Increases the risk of uterine infection or perforation Contraindicated in cases with active infections Use with a low-lying placenta can result in placenta puncture

Figure 23–3 INTRAN Plus intrauterine pressure catheter Figure 23–3 INTRAN Plus intrauterine pressure catheter. There is a micropressure transducer (electronic sensor) located at the tip of the catheter and a port for amnioinfusion at the distal end of the catheter. SOURCE: Photographer: Elena Dorfman.

Auscultation: Advantages Uses minimum instrumentation Is portable Allows for maximum maternal movement Convenient and economical

Auscultation: Disadvantages Can only provide the baseline fetal heart rate, rhythms, and obvious increases and decreases Does not provide a permanent record

External Electronic Fetal Heart Monitoring: Advantages Produces a continuous graphic recording Can show the baseline, baseline variability, and changes in the FHR Noninvasive Does not require rupture of membranes

External Electronic Fetal Heart Monitoring: Disadvantages Is susceptible to interference from maternal and fetal movement May produce a weak signal Tracing may become sketchy and difficult to interpret

Internal Electronic Fetal Heart Monitoring: Advantages Clearer tracings Provides information about short term variability

Internal Electronic Fetal Heart Monitoring: Disadvantages Infection Injury Requires ruptured membranes and sufficient cervical dilatation

Labor Induction and Augmentation Bishop score used to evaluate for induction Cervical ripening methods Dinoprostone (Prepidil, Cervidil), misoprostel (Cytotec) Oxytocin (pitocin) for induction/augmentation Bishop score: cervical dilation (closed 0, 1-2cm 1, 3-4cm 2, 5-6cm 3); cervical effacement 1-30% 0, 40-50% 1, 60-70% 2, 80+% 3); fetal station -3 = 0 , -2 = 1, -1 = 2, +1 +2 = 3); cervical consistency (firm 0, Med 1, Soft 2, + 3); and cervical position (posterior 0, mid 1, anterior 2, + 3) each item scored 0-3. Predictive value: score 0-4 = 45-50% induction failure rate 5-9 10% induction failure rate 10-13 0% failure rate

Labor Induction and Augmentation (continued) Nursing considerations Monitor vital signs, I&O Monitor for hyperstimulation Monitor FHR for decelerations

Forceps-Assisted Birth

Vacuum-Assisted Birth

Systemic Responses to Labor Changes in cardiac output Diaphoresis Hyperventilation Changes in ABG levels Polyuria Slight proteinuria

Systemic Responses to Labor (continued) Reduced gastric motility Increased WBCs Decreased maternal blood glucose Pain

Fetal Adaptations Fetal heart rate decelerations due to intracranial pressure Quiet and awake state Aware of pressure sensations

Nursing Management of Fetal Intolerance of Labor Normal FHR 110–160 bpm Interventions for abnormal FHR patterns Reposition the client Turn off oxytocin if infusing Increase mainline IV rate O2 at 8–10 L/minute Vaginal exam to rule out cord prolapse Notify health care provider Prepare to administer terbutaline

Analgesia in Labor Medications Fentanyl (Sublimaze) Butorphanol (Stadol) Nursing implications Given too early may slow labor Will decrease variability of the FHR Given too late may cause respiratory depression in the newborn

Nurse’s Role in Pain Relief Support decision for pharmaceutical pain relief Offer alternative therapies if pharmaceuticals not desired Support changes in decision Educate about options Reassure that accepting medication for pain is not failure

Systemic Analgesia Table 25–1 What women need to know about pain relief medications.

Common indications for medications Table 25–2 Common indications for medications in labor.

Systemic Analgesia Goal is to provide maximum pain relief with minimal risk Alteration in maternal state affects fetus

Administration of Systemic Analgesia When woman is uncomfortable Well-established labor pattern Contractions occurring regularly Significant duration of contractions Moderate to strong intensity

Maternal Assessments The woman is willing to receive medication Vital signs are stable Contraindications are not present Knowledge of other medications being administered

Fetal Assessments Fetal heart rate between 110 and 160 bpm Reactive nonstress test Short-term variability is present Long-term variability is average

Assessment of Labor Progress Contraction pattern Cervical dilatation Fetal presenting part Station of the fetal presenting part

Nursing Considerations Record the drug name, dose, route, site on EFM strip and chart Record the woman’s blood pressure and pulse (before and after) on the EFM strip and chart Safety precautions Raising the side rails Assessment of the FHR

Sedatives Use: early latent phase Purpose: relaxation and sleep Common medications - Seconal and Ambien

H1-receptor antagonists Use - Early latent phase Purpose - Sedative, antiemetic Common medications - Phenergan, Vistaril, Bendadryl

Narcotics Use: active phase Purpose - pain management Common medications - Stadol, Nubain, Demerol Narcotic antagonist - Narcan

Regional Anesthesia Temporary and reversible loss of sensation Prevents initiation and transmission of nerve impulses Types Epidural Spinal Combined epidural-spinal

Position for Epidural Block

Epidural: Advantages Produces good analgesia Woman is fully awake during labor and birth Continuous technique allows different blocking for each stage of labor Dose of anesthetic agent can be adjusted

Epidural: Disadvantages Maternal hypotension Postdural puncture seizures Meningitis Cardiorespiratory arrest Vertigo Onset of analgesia may not occur for up to 30 minutes

Spinal Block: Advantages Immediate onset of anesthesia Relative ease of administration Smaller drug volume Maternal compartmentalization of the drug

Spinal Block: Disadvantages High incidence of hypotension Greater potential for fetal hypoxia Uterine tone is maintained, making intrauterine manipulation difficult Short acting

Combined Spinal-Epidural: Advantages Spinal agent has a faster onset Medication can be added to increase the effectiveness Preserves motor functioning Most drugs are used in low dose

Combined Spinal-Epidural: Disadvantages Higher incidence of nausea and pruritus

Pudendal Perineal anesthesia for the second stage of labor, birth, and episiotomy repair Advantages are ease of administration and absence of maternal hypotension Urge to bear down may be decreased

Figure 25–7 A, Pudendal block by the transvaginal approach Figure 25–7 A, Pudendal block by the transvaginal approach. B, Area of perineum affected by pudendal block.

Figure 25–7 (continued) A, Pudendal block by the transvaginal approach Figure 25–7 (continued) A, Pudendal block by the transvaginal approach. B, Area of perineum affected by pudendal block.

Local Used for episiotomy repair Advantage is that it involves the least amount of anesthetic agent The major disadvantage is that large amounts of solution must be used

Nursing Management: Prior to Administration Assess maternal and fetal status Assess labor progress Start an IV and administer preload Help woman into position

Nursing Management: After Administration Monitor maternal and fetal vital signs Assess for hypotension Tale corrective measures for hypotension Administer antiemetics as needed Monitor respiratory rate Assess bladder and catheterize if unable to void

Complications of Epidural Anesthesia Toxic reactions Unintentional placement of the drug Excessive amount of the drug Accidental intravascular injection Spinal headaches

Complications of Spinal Anesthesia Hypotension Drug reaction Total spinal neurologic sequelae Spinal headache Nausea, shivering, and urinary retention Ineffective anesthesia

Complications of Pudendal Anesthesia Systemic toxic reaction Broad ligament hematoma Perforation of the rectum Trauma to the sciatic nerve

Methods of General Anesthesia Intravenous injection Sodium thiopental (Pentothal) Ketamine Inhalation of anesthetic agents Nitrous Oxide Low-dose halogenated agents

Complications of General Anesthesia Fetal depression Depth and duration Uterine relaxation Potential for chemical pneumonitis Decrease in gastrointestinal motility Acidic gastric secretions

Contraindications Preterm infant Preeclampsia Avoid analgesia during labor Preeclampsia Regional anesthesia is preferred General anesthesia may aggravate hypertension

Contraindications (continued) Diabetes Potential for decreased uteroplacental flow due to hypotension Increased risk of cardiovascular depression with regional Cardiac Continuous epidural avoids cardiovascular changes with bearing down

Contraindications (continued) Bleeding Regional blocks are contraindication due to reduction in volume

Regional Analgesia and Anesthesia: Epidural Disadvantages Client is confined to bed May interfere with pushing efforts May cause hypotension May not be aware of the need to void

Regional Analgesia and Anesthesia: Epidural (continued) Nursing implications IV bolus prior to procedure Monitor VS, especially BP and FHR Client must remain in bed Assess bladder filling

Maternal Status Assessment Presenting complaint EDC Parity Contraction pattern Status of the membranes, fluid color Allergies Bloody show Complications during pregnancy

Risk Factor Assessment Preexisting medical diseases Diabetes, hypertension, heart disease, infections, renal disease, anemia Previous poor pregnancy outcome Perinatal mortality, preterm delivery, IUGR, malformations, hemorrhage

Risk Factor Assessment (continued) Risk factors developing during the pregnancy PIH, GDM, multiple gestation, placenta previa, abnormal presentation, IUGR, drug exposure, smoking, alcohol use Inadequate maternal weight gain

Fetal Status Methods for monitoring Fetal heart rate and pattern External ultrasound transducer Fetal scalp electrode Fetal heart rate and pattern Fetal heart rate response to contractions Presentation Lie Engagement (station)

Labor Status Methods for monitoring Uterine activity External tocotransducer Intrauterine pressure catheter (IUPC) Uterine activity When contractions began Frequency Duration Strength Resting tone

Fetal Membrane Status Normal fluid is colorless and clear Tests to assess rupture of the membranes Nitrazine test, Fern test Risk factors Polyhydramnios Oligohydramnios Meconium PROM, PPROM Foul-smelling fluid (chorioamnionitis) Polyhydramnios: more than 1500-2000ml of amniotic fluid has accumulated (800ml average amount) Oligohydramnios: amniotic fluid volume decreased to 500ml. Meconium: Fetus has been stressed and expelled meconium into amniotic fluid. PROM: Spontaneous rupture of anmniotic membranes before onset of labor. PPROM: Spontaneous rupture of membranes before the onset of labor (PROM), which occurs before 37 completed weeks of gestation. Chorioamnionitis: Infection of amniotic fluid that can be transferred to the infant before delivery.

Cervical Status and Fetal Descent Effacement Thinning of the cervical canal Expressed in % Dilation Opening of the cervix Closed to 10 cm (complete) Presenting part Vertex most common Station Expressed in cm above or below the ischial spines

General Systems Assessment Vital signs BP, P, R, T Abdomen Rash, lesion, scars, Leopold’s maneuvers Bladder Lower extremities Edema DTR Clonus

Evaluation of Laboratory Tests Urine specimen analysis Protein, glucose, ketones, infection Blood tests Rh factor, antibodies, rubella, syphilis, hepatitis B, HIV, glucose levels, hemoglobin Cultures GBS, gonorrhea, chlamydia, herpes

Nursing Responsibilities During Labor Maternal assessment Vital signs Hydration and nutrition Elimination

Nursing Responsibilities During Labor (continued) Fetal assessment Baseline FHR Variability Accelerations Periodic changes (decelerations) Early (head compression) Late (placental insufficiency) Variable (cord compression)

Interventions for Nonreassuring Fetal Heart Rate Pattern Change maternal position Oxygen Increase IV fluids Stop pitocin Vaginal examination to rule out cord prolapse Notify the primary care provider Anticipate administration of terbutaline Anticipate starting an amnioinfusion Document all information

Stages and Phases of Labor First stage (0–10 cm dilated) Latent phase (0–3 cm) Active phase (4–7 cm) Transition phase (8–10 cm) Second stage (10 cm to birth) Third stage (birth to delivery of the placenta) Fourth stage (recovery)

Labor Progress: First Stage Uterine assessment Montevideo units Rupture of fetal membranes Spontaneous (SROM) or artificial (AROM) Assess FHR, color, odor, amount Documentation and communication Activity Montevideo units: numerical method of calculating adequacy of contraction strength.

Labor Progress: First Stage (continued) Comfort measures Pain management Psychologic considerations Friedman labor curve Role of the support person Friedman labor curve: Friedman curve, the gold standard for rates of cervical dilation and fetal descent during active labor, was developed almost 50 years ago. Not used much today.

Labor Progress: Second Stage Continued assessment of contractions and fetal status Fetal descent assessment Psychological considerations Maternal positioning Coaching maternal breathing and pushing efforts

Preparation for Delivery Prepare instrument table Adequate lighting Oxygen and suction equipment Radiant warmer, blankets, identification for newborn Pitocin available for administration after delivery

Preparation for Delivery (continued) Positioning of mother for birth Gown, gloves, and protective equipment for personnel Cleansing of the perineum

The Process of Birth Delivery of the head Crowning Delivery of the body

Third Stage Newborn care Delivery of the placenta Time of birth noted Drying, stimulation, suctioning of the newborn Respiratory effort, heart rate, color, tone noted One- and five-minute Apgar scores assigned Cord blood obtained Identification Delivery of the placenta Oxytocin administered to control bleeding Repair of episiotomy/tears

Immediately after birth Delivery of the placenta Applying the cord clamp Controlling maternal bleeding

Fourth Stage Newborn-family attachment Maternal status Family together if infant stable Breastfeeding initiated Maternal status Uterus Lochia Perineum Bladder Vital signs Pain Psychosocial status

Nursing Interventions: Latent Phase Anticipatory guidance Encourage ambulation Offer fluids

Nursing Interventions: Active Phase Palpate contractions every 15-30 minutes Vaginal exams to assess cervical dilatation, effacement, and fetal station and position Encourage client to void Assess vital signs every hour

Nursing Interventions: Active Phase (continued) Auscultate fetal heart rate every 30 minutes Start IV fluid infusion if unable to tolerate fluids Assess color and odor of amniotic fluid and fetal heart rate when ruptured

Nursing Interventions: Transition Phase Palpate contractions every 15 minutes Sterile vaginal exams to assess labor progress Assess maternal vital signs every 30 minutes Assess fetal heart rate every 30 minutes Assist with breathing Keep woman from pushing until fully dilated

Nursing Interventions: Second Stage Sterile vaginal exams to assess fetal descent Assess maternal vital signs every 5 minutes Provide support and information about labor progress Assist with pushing Assist the physician or CNM with the birth

Nursing Interventions: Third Stage Provide newborn care Assist with delivery of placenta

Nursing Interventions: Fourth Stage Palpate fundus every 15 minutes for one hour Assess vaginal bleeding Encourage bonding and breastfeeding Assess perineum Perineal care

Figure 24–12 Suggested method of palpating the fundus of the uterus during the fourth stage. 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.

Comfort Measures: First Stage Frequent position changes Hydrotherapy Perineal care Clear fluids and ice chips Birthing balls Provide information and support

Comfort Measures: First Stage (continued) Relaxation between contractions Distraction Effleurage Firm pressure on back or sacrum Visualization Controlled breathing

Comfort Measures: Second Stage Same as first stage Cool cloths Encourage rest between contractions Assist into pushing position Sips of fluids or ice chips Reassurance

Figure 24–4 A birthing ball is used to promote maternal comfort during labor. The birthing ball facilitates fetal descent and fetal rotation and helps increase the diameter of the pelvis.

Comfort Measures: Fourth Stage Heated blanket Provide food Encourage rest

Care of the Newborn Maintain respirations Provide and maintain warmth Apgar score Physical assessment Newborn identification Facilitate attachment

Figure 24–11 A newborn infant being suctioned with a DeLee mucus trap to remove excess secretions from the mouth and nares. SOURCE: Photographer, Elena Dorfman.

Third Stage of Labor Watch for signs of placental separation Palpate fundus Encourage breathing and abdominal relaxation during delivery of placenta Possible administration of Pitocin

Facilitating Attachment Minimize newborn interventions Provide privacy Keep lights low Facilitate parental wishes

APGAR System Table 24–11 The apgar scoring system.

Initial newborn evaluation Table 24–12 Initial newborn evaluation.

Forceps-Assisted Birth: Maternal Indications Heart disease Acute pulmonary edema or pulmonary compromise Certain neurological conditions Intrapartal infection Prolonged second stage Exhaustion

Figure 27–5 Application of forceps in occiput-anterior (OA) position Figure 27–5 Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the pelvis over the parietal bone. B, The right blade is inserted along the right side wall of the pelvis over the parietal bone. C, 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.

Figure 27–5 (continued) Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the pelvis over the parietal bone. B, The right blade is inserted along the right side wall of the pelvis over the parietal bone. C, 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.

Figure 27–5 (continued) Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the pelvis over the parietal bone. B, The right blade is inserted along the right side wall of the pelvis over the parietal bone. C, 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.

Forceps-Assisted Birth: Fetal Indications Premature placental separation Prolapsed umbilical cord Nonreassuring fetal status

Types of Forceps Outlet forceps Midforceps Breech forceps

Figure 27–4 Forceps are composed of a blade, shank, and handle and may have a cephalic and pelvic curve. (Note labels on Piper and Tucker-McLean forceps.) The blades may be fenestrated (open) or solid. The front and lateral views of these forceps illustrate differences in blades, open and closed shanks, and cephalic and pelvic curves. Elliot, Simpson, and Tucker-McLean forceps are used as outlet forceps. Kielland and Barton forceps are used for midforceps rotations. Piper forceps are used to provide traction and flexion of the aftercoming head (the head comes after the body) of a fetus in breech presentation.

Fetal Risks Ecchymosis, edema, or both along the sides of the face Caput succedaneum or cephalhematoma Transient facial paralysis Low Apgar scores Retinal hemorrhage Corneal abrasions

Fetal Risks (continued) Ocular trauma Other trauma (Erb’s palsy, fractured clavicle) Elevated neonatal bilirubin levels Prolonged infant hospital stay

Maternal Risks Lacerations of the birth canal Periurethral lacerations Extension of a median episiotomy into the anus More likely to have a third- or fourth-degree laceration Report more perineal pain and sexual problems in the postpartum period Postpartum infections

Maternal Risks (continued) Cervical lacerations Prolonged hospital stay Urinary and rectal incontinence Anal sphincter injury Postpartum metritis

Nursing Management Explains procedure to woman Monitors contractions Informs physician/CNM of contraction Encourages woman to avoid pushing during contraction Assessment of mother and her newborn Reassurance

Indications for Vacuum Extraction Prolonged second stage of labor Nonreassuring heart rate pattern Used to relieve the woman of pushing effort When analgesia or fatigue interfere with ability to push effectively Borderline CPD

Vacuum Extraction Procedure Suction cup placed on fetal occiput Pump is used to create suction Traction is applied Fetal head should descend with each contraction

Figure 27–6 Vacuum extractor traction Figure 27–6 Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, Traction is maintained to lift the fetal head out of the vagina.

Figure 27–6 (continued) Vacuum extractor traction Figure 27–6 (continued) Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, Traction is maintained to lift the fetal head out of the vagina.

Figure 27–6 (continued) Vacuum extractor traction Figure 27–6 (continued) Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, Traction is maintained to lift the fetal head out of the vagina.

Nursing Management Inform woman about procedure Pumps the vacuum Supports the woman Assesses the mother and neonate for complications

Neonatal Risks with Vacuum Extraction Scalp lacerations and bruising Shoulder dystocia Subgaleal hematomas Cephalhematomas Intracranial hemorrhages Subconjunctival hemorrhages

Neonatal Risks with Vacuum Extraction (continued) Neonatal jaundice Fractured clavicle Erb’s palsy Damage to the sixth and seventh cranial nerves Retinal hemorrhage Fetal death

Maternal Risks with Vacuum Extraction Perineal trauma Edema Third- and fourth-degree lacerations Postpartum pain Infection More sexual difficulties in the postpartum period

Indications for Cesarean Birth Complete placenta previa CPD Placental abruption Active genital herpes Umbilical cord prolapse Failure to progress in labor

Indications for Cesarean Birth (continued) Proven nonreassuring fetal status Benign and malignant tumors that obstruct the birth canal Breech presentation Previous cesarean birth Major congenital anomalies Cervical cerclage

Indications for Cesarean Birth (continued) Severe Rh isoimmunization Maternal preference for cesarean birth