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UNIVERSITY OF BAGUIO COLLEGE OF NURSING GENERAL LUNA ROAD, BAGUIO CITY A Delivery Write Up Presented to the Faculty Of the College of Nursing In partial fulfillment Of the requirements In Nursing Care Management 104 RLE Of the Course Bachelor of Science in Nursing Submitted to: Ms. Maria Rhodessa M. Estacio, RN Submitted by: NPG – 3 Agustin, Henrizza Cumahling, Melody Daytec, Keziah Escobar, Kimverley Estacio, Jansen Lorenzana, Diane Mei Massey, Hamed Mose, Angelica Joy Osillo, Hazel

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UNIVERSITY OF BAGUIOCOLLEGE OF NURSING

GENERAL LUNA ROAD, BAGUIO CITY

A Delivery Write UpPresented to the FacultyOf the College of Nursing

In partial fulfillmentOf the requirements

In Nursing Care Management 104 RLEOf the Course Bachelor of Science in Nursing

Submitted to:Ms. Maria Rhodessa M. Estacio, RN

Submitted by:

NPG – 3

Agustin, HenrizzaCumahling, MelodyDaytec, Keziah

Escobar, KimverleyEstacio, Jansen

Lorenzana, Diane MeiMassey, Hamed

Mose, Angelica JoyOsillo, Hazel

Rosquita, GianelliSanchez, Rod AnthonyTorrado, Suzette

September 2009

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T A B L E O F C O N T E N T S

I. Patient's Profile

II. Pathophysiology

III. Preparation of the Patient Position Skin Preparation Draping Anesthesia

IV. Discussion

V. Instrumentation

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PATHOPHYSIOLOGY

Stages of labor1. Ist stage

Phase I: latent, dilation= 0-3, duration/interval=20-40 sec. /5-30 minutes, mild to moderatePhase II: active, dilation=4-7cm, duration/interval=40-60 sec. /3-5 minutes, moderate to strongPhase III: transition, dilation=8-10cm, duration=60-90 sec. /2-3 minutes, strong

2. 2nd stage

Phase I: station= 0 to + 2, contraction=2-3 minutes apartPhase II: station= + to +4, contraction= 2 to 2.5 mins. Apart with urgency to bear downPhase III: station= +4 to birth, contraction= to 2 mins. Apart; fetal head visible increased.

Mechanisms of labor/cardinal movements1. Engagement

fetal presenting part (normally the head) as its widest diameter reaches the level of the ischial spines of the pelvis

2. Descent Downward movement of the biparietal diameter of the fetal

head until it reaches the pelvic inlet Occurs bec. Of pressure on the fetus by the uterine

fundus Pressure of the fetal head on the sacral nerve produces a

pushing sensation which is experienced by the mother in labor

3. Flexion Shortest head diameter pass through the pelvis Fetal head reaches the pelvic floor; head bends forward

onto chest, presenting the smallest anteroposterior diameter

4. Internal rotation allows the longest fetal head diameters to match the

longest maternal pelvic diameter fetus enters the pelvic inlet

5. Extension Internal rotation is complete

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Fetal head passes beneath the symphysis pubis while in flexion; there is a resistance from tissues of the pelvic floor in the fetal head. Fetal neck stops and act as a pivot. This combination causes the fetal head to move anteriorly, or extend, while mother is pushing

6. External rotation Allow the shoulders to rotate internally to fit the

pelvis7. Expulsion

Expulsion occurs first as the anterior, ten posterior shoulder passes under the symphysis pubis

After the shoulder delivery, rest of the body will follow

3. 3rd stage

Placental delivery = 2 phases (placental separation and placental expulsion)

Sudden gush of blood Lengthening of the cord rising of the fundus globular uterus4. 4th stage

First four hours after delivery of the placenta.

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Stage I

Latent phase

Active phase

Transition phase

Stage II

Engagement

 Descent

Flexion

Internal rotation

Extension

External rotation

Expulsion

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  Stage III

 Signs of placental separation

Sudden gush of blood, lengthening of the cord, calkin’s sign

                                ↓

Stage IV

Expulsion of the placenta

 

 

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PREPARATION OF THE PATIENT

DRAPING THE PATIENT

a. The procedure of covering a patient and surrounding areas with

a sterile barrier to create and maintain a sterile field during a

surgical procedure is called draping. The purpose of draping is

to eliminate the passage of microorganisms between nonsterile and

sterile areas. Draping materials may be disposable or no

disposable. Disposable drapes are generally paper or plastic or a

combination and may or may not be absorbent. No disposable drapes

are usually double-thickness muslin. Drapes, of course, must be

sterile.

b. Since draping is very important in preparing a patient for

delivery, it must be done correctly. The entire team should be

familiar with the draping procedure. The scrub must know the

procedure perfectly and be ready to assist with it. During the

draping procedure, the circulator should stand by to direct the

scrub as necessary and to watch carefully for breaks in sterile

technique.

(1) The first step in draping is the placing of a drape sheet

from the foot to the knees. The scrub will select the sheet and

hand one end to the surgeon across the operating table,

supporting the folds, keeping it high, and holding it taut until

it is opened, then drop it (open fingers and release sheet). The

second drape sheet is handled in the same manner. This sheet is

placed below the site with the edge of the sheet just below the

site. This draping sheet provides extra thickness of material

under the area from the Mayo tray to the incision where

instruments and sponges are placed.

(2) When disposable drapes are used, the towels usually have a

removable strip with an adhesive on the folded edge. The third

step in draping is placing the four sterile towels around the

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line of incision. The scrub unfolds first towel, passes the towel

drape to the surgeon with the strip side facing the scrub, and

then removes the adhesive strip. The surgeon places the towel

within the scrubbed area on the near side of the line of

incision, leaving only enough exposed skin for the incision. The

second towel is placed in the same way, except the towel is

placed on the lower side (toward feet) of the line of incision.

The third towel is passed the same way, except the towel is

placed on the upper side (toward head) the line of incision. The

last towel is passed to the surgeon with the adhesive strip

facing the surgeon and is placed on the far side of the line of

site. The adhesive area holds the towel drapes in place.

(3) Finally, the scrub will select the surgical drape (lap

sheet). This lap sheet has a fenestration (opening) in the drape.

The scrub places the opening directly over the skin area outlined

by the drape towels and in the direction indicated for the foot

or head of the table. The lap sheet will have an arrow or some

other indication to identify the head or foot portion of the

drape. Drop the folds over the sides of the table, and then open

it downward over the patient's feet and upward over the

anesthetist screen.

Draping procedure:

1. The sterile drape is placed on the instrument table.

2. The drape, without the pouch, is handed to the circulating

nurse, who places the drape on the operating room table and

secures it in place by removing the adhesive backing.

3. The clear envelope containing the sterile blue accordion drape

must be at the end of the table, or the brake in the table, when

fixing the remainder of the drape towards the head of the

patient.

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4. The patient is placed on the drape with the buttocks on the

clear portion of the closed envelope.

5. The patient is placed in stirrups and prepped, following which

the protective clear envelope is opened by removing the

perforated strip located on the patient's right.

6 .This will expose the sterile blue accordion poly, which is

pulled to its full extent by pulling the center tab.

7. Leggings are applied to the lower extremities.

8. The self adhesive catch pouch is applied by the scrub nurse

or surgeon at a convenient location.

9. At the termination of the procedure, the dirty blue poly drape

is removed along its perforation, before the table is raised back

into position to place the legs on the table.

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DISCUSSION

NORMAL SPONTANEOUS DELIVERY

Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, support person, and neonate remain in the same room throughout their stay. Some units use a traditional labor room and separate delivery suite, to which the woman is transferred when delivery is imminent. The father or other support person should be offered the opportunity to accompany her. In the delivery room, the perineum is washed and draped, and the neonate is delivered. After delivery, the woman may remain there or be transferred to a postpartum unit. Management of complications during delivery requires additional measures

Anesthesia

Options include regional, local, and general anesthesia. Local anesthetics and opioids are commonly used. These drugs pass through the placenta; thus, during the hour before delivery, such drugs should be given in small doses to avoid toxicity (eg, CNS depression, bradycardia) in the neonate. Opioids used alone do not provide adequate analgesia and so are most often used with anesthetics.

Regional anesthesia: Several methods are available.

Lumbar epidural injection of a local anesthetic is the most commonly used method. Epidural injection is being increasingly used for delivery, including cesarean section, and has essentially replaced pudendal and paracervical blocks. The local anesthetics often used for epidural injection (eg, bupivacaine Some Trade Names MARCAINE, SENSORCAINE) have a longer duration of action and slower onset than those used for pudendal block (eg, lidocaine Some Trade Names XYLOCAINE).

Other methods include caudal injection (into the sacral canal), which is rarely used, and spinal injection (into the paraspinal subarachnoid space). Spinal injection may be used for cesarean section, but it is used less often for vaginal deliveries because it is short-lasting (preventing its use during labor) and has a small risk of spinal headache afterward. When spinal injection is used, patients must be constantly attended, and vital signs must be checked every 5 min to detect and treat possible hypotension.

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Local anesthesia: Methods include pudendal block, perineal infiltration, and paracervical block.

Pudendal block, rarely used because epidural injections are used instead, involves injecting a local anesthetic through the vaginal wall so that the anesthetic bathes the pudendal nerve as it crosses the ischial spine. This block anesthetizes the lower vagina, perineum, and posterior vulva; the anterior vulva, innervated by lumbar dermatomes, is not anesthetized. Pudendal block is a safe, simple method for uncomplicated spontaneous vaginal deliveries if women wish to bear down and push or if labor is advanced and there is no time for epidural injection.

Infiltration of the perineum with an anesthetic is commonly used, although this method is not as effective as a well-administered pudendal block.

Paracervical block is rarely appropriate for delivery because incidence of fetal bradycardia is > 15%. It is used mainly for 1st- or early 2nd-trimester abortion. The technique involves injecting 5 to 10 mL of 1% lidocaine Some Trade Names XYLOCAINE at the 3 and 9 o'clock positions; the analgesic response is short-lasting.

General anesthesia: Because potent and volatile inhalation drugs (eg, isoflurane) can cause marked depression in mother and fetus, general anesthesia is not recommended for routine delivery. Rarely, nitrous oxide 40% with O2 may be used for analgesia during vaginal delivery as long as verbal contact with the woman is maintained. Thiopental Some Trade Names PENTOTHAL, a hypnotic, is commonly given IV with other drugs (eg, succinylcholine Some Trade Names ANECTINE, QUELICIN, nitrous oxide plus O2) for induction of general anesthesia during cesarean delivery; used alone, thiopental Some Trade Names PENTOTHAL provides inadequate analgesia. With thiopental Some Trade Names PENTOTHAL , induction is rapid and recovery is prompt. It becomes concentrated in the fetal liver, preventing levels from becoming high in the CNS; high levels in the CNS may cause neonatal depression. Increased interest in preparation for childbirth has reduced the need for general anesthesia except for cesarean section.

Delivery Procedures

A vaginal examination is done to determine position and station of the fetal head; the head is usually the presenting part (see Fig. 2: Normal Pregnancy, Labor, and Delivery: Sequence of events

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in delivery for vertex presentations. ). When effacement is complete and the cervix is fully dilated, the woman is told to bear down and strain with each contraction to move the head through the pelvis and progressively dilate the vaginal introitus so that more and more of the head appears. When about 3 or 4 cm of the head is visible during a contraction in nulliparas (somewhat less in multiparas), the following maneuvers can facilitate delivery and reduce risk of perineal laceration.

The clinician, if right-handed, places the left palm over the infant's head during a contraction to control and, if necessary, slightly slow progress.

Simultaneously, the clinician places the curved fingers of the right hand against the dilating perineum, through which the infant's brow or chin is felt.

To advance the head, the clinician can wrap a hand in a towel and, with curved fingers, apply pressure against the underside of the brow or chin (modified Ritgen maneuver).

Thus, the clinician controls the progress of the head to effect a slow, safe delivery.

Forceps or a vacuum extractor is often used for vaginal delivery when the 2nd stage of labor is likely to be prolonged (eg, because the mother is too exhausted to bear down adequately or because regional epidural anesthesia precludes vigorous bearing down). If anesthesia is local (pudendal block or infiltration of the perineum), forceps or a vacuum extractor is usually not needed unless complications develop; local anesthesia may not interfere with bearing down. Indications for forceps and vacuum extractor are essentially the same.

An episiotomy is not routine and is done only if the perineum does not stretch adequately and is obstructing delivery, usually only for first deliveries at term. A local anesthetic can be infiltrated if epidural analgesia is inadequate. Episiotomy prevents excessive stretching and possible tearing of the perineal tissues, including anterior tears. The incision is easier to repair than a tear. The most common type is a midline incision made from the midpoint of the fourchette directly back toward the rectum. Extension into the rectal sphincter or rectum is a risk, but if recognized promptly, the extension can be repaired successfully and heals well. Tears or extensions into the rectum can usually be prevented by keeping the infant's head well flexed until the occipital prominence passes under the symphysis pubis. Another type of episiotomy is a mediolateral incision made from the midpoint of the fourchette at a 45° angle

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laterally on either side. This type usually does not extend into the sphincter or rectum, but it causes greater postoperative pain and takes longer to heal than midline episiotomy. Thus, for episiotomy, a midline cut is preferred. However, use of episiotomy is decreasing because extension or tearing into the sphincter or rectum is a concern. Episioproctotomy (intentionally cutting into the rectum) is not recommended because rectovaginal fistula is a risk.

When the head is delivered, the clinician determines whether the umbilical cord is wrapped around the neck. If it is, the clinician should try to unwrap the cord; if the cord cannot be rapidly removed this way, the cord may be clamped and cut. After delivery of the head, the infant's body rotates so that the shoulders are in an anteroposterior position; gentle downward pressure on the head delivers the anterior shoulder under the symphysis. The head is gently lifted, the posterior shoulder slides over the perineum, and the rest of the body follows without difficulty. The nose, mouth, and pharynx are aspirated with a bulb syringe to remove mucus and fluids and help start respirations. The cord should be double-clamped and cut between the clamps, and a plastic cord clip should be applied about 2 to 3 cm distal from the cord insertion on the infant. If fetal or neonatal compromise is suspected, a segment of umbilical cord is doubly clamped so that arterial blood gas analysis can be done. An arterial pH > 7.l5 to 7.20 is considered normal. The infant is thoroughly dried, then placed on the mother's abdomen or, if resuscitation is needed, in a warmed resuscitation bassinet.

After delivery of the infant, the clinician places a hand gently on the abdomen over the uterine fundus to detect contractions; placental separation usually occurs during the 1st or 2nd contraction, often with a gush of blood from behind the separating placenta. The mother can usually help deliver the placenta by bearing down. If she cannot and if substantial bleeding occurs, the placenta can usually be evacuated (expressed) by placing a hand on the abdomen and exerting firm downward (caudal) pressure on the uterus; this procedure is done only if the uterus feels firm because pressure on a flaccid uterus can cause it to invert. If this procedure is not effective, the umbilical cord is held taut while a hand placed on the abdomen pushes upward (cephalad) on the firm uterus, away from the placenta; traction on the umbilical cord is avoided because it may invert the uterus. If the placenta has not been delivered within 45 to 60 min of delivery, manual removal may be necessary; the clinician inserts an entire hand into the uterine cavity, separating the placenta from its attachment, then

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extracts the placenta. In such cases, an abnormally adherent placenta should be suspected.

The placenta should be examined for completeness because fragments left in the uterus can cause hemorrhage or infection later. If the placenta is incomplete, the uterine cavity should be explored manually. Some obstetricians routinely explore the uterus after each delivery. However, exploration is uncomfortable and is not routinely recommended. Immediately after delivery of the placenta, an oxytocic drug ( oxytocin Some Trade Names PITOCIN, SYNTOCINON 10 units IM or as an infusion of 20 units/1000 mL saline at 125 mL/h) is given to help the uterus contract firmly. Oxytocin Some Trade Names PITOCIN, SYNTOCINONshould not be given as an IV bolus because cardiac arrhythmia may occur.

The cervix and vagina are inspected for lacerations, which, if present, are repaired, as is episiotomy if done. Then if the mother and infant are recovering normally, they can begin bonding. Many mothers wish to begin breastfeeding soon after delivery, and this activity should be encouraged. Mother, infant, and father should remain together in a warm, private area for an hour or more to enhance parent-infant bonding. Then, the infant may be taken to the nursery or left with the mother depending on her wishes. For the first hour after delivery, the mother should be observed closely to make sure the uterus is contracting (detected by palpation during abdominal examination) and to check for bleeding, BP abnormalities, and general well-being. The time from delivery of the placenta to 4 h postpartum has been called the 4th stage of labor; most complications, especially hemorrhage occur at this time, and frequent observation is mandatory.

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