Fast Track into OB

Labor and Delivery

Lightening

Five Ps of Labor

Passage

Passenger

Psyche

Powers

Pain

Passage: the bony pelvis and soft tissue

False pelvis (upper flaring part)True pelvis (lower part)

InletMiddleOutletShaped like a wide curved funnel

Soft TissueImpacted by previous birthsImpacted by scaring

More on the true and false pelvis

See text page 25Divided by false line: linea terminalis

Extends from sacroiliac joint to anterior iliopubic prominence

The upper false pelvis support the enlarging uterus and guides fetus into true pelvisThe TRUE pelvis however dictated the bony limits of the birth canal

Anatomical picture of pelvic inlet

Passage dimensions

Anatomical features of the pelvic outlet Page 25-26

Transverse diameter between the inner surfaces of the ischial tuberosities (spines) (bi ischial diameter)

Anterior posterior measurement of outlet is between lower border of symphysis pubis and tip of sacrum.

Passenger Page 122

Fetal skull page 123

Lie: orientation to Mom’s spine

Attitude: normally flexed

Presentation: part entering pelvis

Position: how a reference point on the fetal presenting part oriented within the mother’s pelvis

The Passenger

Passenger

Molding

Transverse Lie

Fetal Lie

Fetal Lie LongitudinalFetal Presentation: Vertex

Attitude: Flexion/Extension

Fetal Attitude: a well flexed head

Attitude; Brow

Presentation: Breech

Presentation

Fetal Positions

Position: Posterior

Fetal Positions

Using Fetal Heart Tones to Determine Position

Psyche

Woman’s mental state

Emotional; not described as surgical procedure

Mental State greatly impacts mothers ability to cope and tolerate discomfort

Perception of pain

Anxiety

Powers of Labor

Involuntary forces of labor

Contractions

Voluntary forces of labor

Mother’s pushing efforts

Contraction Cycle

Effects of contractions on the cervix

EffacementThins the cervix

Before labor approximately 2 cm long

Thinning of cervix is expressed in %

100% thin slick membrane at edge of fetal head

DilationOpening of the cervix

Described in cm of opening

Full dilation at 10 cms

Effacement and Dilation

Effects of Contractions on Cervix

Effacement

Dilation

Mechanisms of Labor

Descent

Flexion

Rotation

Extension

Restitution

External Rotation

Engagement: Stations

Mechanisms of labor with effacement and dilation

Read to learn activity

Signs of impending labor (page 131)

Signs of True Labor (136)

Signs of False Labor (135-136)

Read those sections and then we will do a quiz together. RELAX!

Contractions; Page 120-21

Frequency

Duration

Interval

Increment/Peak/decrement

Intensity: Mild, moderate, strong

Contraction MonitoringThe basics

FrequencyFrom the beginning of one contraction to the beginning of the next contraction

Duration From the beginning of one contraction to the end of that contraction

IntervalThe space between two contractions; from the end of one contraction to the beginning of the next one

Rule of contractions

Based on infant getting adequate oxygenation

The frequency must not be less than two minutes

The duration must not be more than 90 seconds

The interval must not be less than 60 seconds

Fetal Heart monitoring

IntermittentAllows freedom of movement

Does not offer a continuous record

Obtain a baseline rate

Rule: any FHR outside the normal limits or slowing that persists after the contraction ends is promptly reported to the health care provider

See box 6-2 page 133

Continuous Fetal Heart Monitoring

Offers a written record

Allows collection of more data

May however run a strip on admission and then re run a strip at regular intervals during the labor

Referred to in terms of reassuring and non reassuring patterns.

Box 6-3 page 135

Fetal and Contraction MonitoringThe Basics

Top of strip is the fetal heart monitoring

Bottom of strip is the contraction pattern

Each small square is 10 seconds

Between each bold line is 60 seconds

Reassuring fetal heart/contraction pattern

110-160 bpm

Variability

Accelerations

Early decelerations

Contraction frequency greater than every 2 minutes, duration less than 90 seconds; relaxation interval of at least 60 seconds.

Non reassuring patterns

Fetal tachycardia

Fetal bradycardia

Variable decelerations

Late decelerations

Absences or decreased variability

Decelerations

Early Due to fetal head compression during contractions and are expected

LateDue to utero-placental insufficiency and are non reassuring

VariableDue to cord compression and are non reassuring.

Early decelerations

Reassuring pattern of deceleration during the early contraction due to fetal head compression

Always return to baseline before the end of the contraction

They often mirror a contraction

Picture of an early deceleration

Late deceleration

NON reassuring

Due to lack of oxygen to the baby

Uteroplacental insufficiency

Do NOT return to baseline FHR after the contraction ends

Picture of late deceleration

Variable Deceleration

Due to cord compression

V, W, or U shaped

Do not exhibit a consistent pattern in relation to the contractions

Picture of variable deceleration

Nursing responses to non reassuring patterns

Reposition mom, especially helpful in the variable decelerations

Oxygen 100% per tight face mask

IV fluids to expand blood volume and to dilute Pitocin (if given)

Stopping Pitocin

Giving tocolytic drugs to decrease uterine contractions

More FH patterns to look at

Stages of Labor

FirstOnset of labor until cervical effacement and dilation is complete (10 cm)

SecondFrom the completion of effacement and dilation until the baby is born

Third Expulsion of placenta

FourthRecovery phase

First stage divisions

Latent4-6 hours1-4 cmMild to moderate intensity

Active 2-6 hours4-7 cmModerate to firm intensity

Transition.5-2 hours7-10 cmFirm intensity

Descent

Mechanism of Labor, Continued

Mechanism of labor; continued

Delivery of shoulders

Second Stage

Second stage is also divided into three stages in other texts

Uncontrollable urge to push if no epidural

Exhaustion after each contraction

Unable to follow directions

“BABY IS COMING!!!”

Baby is HERE!

Third stage

Expulsion of placenta

Elation and relief

Shivers and tremors

Signs of placental seperationLengthening of cord

Uterus rises and becomes firm

Fresh blood expelled from vagina

Recovery Period

Number one priority for the mother’s care is prevention of hemorrhageInfant care focuses on

airway, breathing and circulation maintaining body temperature maintaining blood glucose

Critical period of bonding and breast feeding.

Immediate care of Mother

Assessment and care bullets; Page 148

Observing for hemorrhage

Maintaining a firm fundus

Preventing bladder distention

Promoting comfortIce pack

Warm blanket

Assisting with breast feeding

Assessment of lower extremities

Immediate Care of the Infant

First hour infant is in “quiet alert” phase and this is critical time form bonding and breast feeding.

Unless the infant is in a medical emergency most of care can be done right at mother’s breast

Now let’s see what will happen when you observe a birth!!!!

Immediate Care of Infant

APGAR scoreKeep warm: dry and place on mothers chest: skin to skin with blanket over and cap onAssure that the nose is clean, bulb suction nose as well as mouth. Usually done at perineumClamp the cord.Vigilant observation of infants cardiorespiratory status

Later Needs of the Infant

Detailed examination

Bath

Erythromycin eye ointment

Aquamephyton (vitamin K injection)]

Hepatitis B vaccination

APGAR Score; Page 143

APGAR Score

Let’s take some time to score to do the critical thinking exercise on APGAR scoring found in your workbook

NCLEX Prep question

A client at 38 weeks gestation tells the nurse that it feels like her baby is sitting on her bladder causing her to urinate more frequently. However, the client states it has made it easier for her to breathe. The nurse recognizes that this is a sign of:

LighteningQuickeningContractionsFlexion

NCLEX Prep QuestionA client reports that her contractions started about 2 hr ago, did not go away when she had two glass of water and rested, and became stronger since she started walking. She thinks the contractions occur every 10 minutes and last about half a minute. She hasn’t had any fluid leak from her vagina, however, she did think she saw some blood when she wiped after voiding. The nurse should recognize that the client is experiencing:

Braxton Hick contractions

Rupture of membranes

Fetal descent

True Contractions

NCLEX Prep QuestionA nurse is monitoring the FHR and contractions of a client in labor. The FHR is in the 140s. Contractions are every 5 min and 45-50 sec in duration. The nurse performs a vaginal exam and finds the cervix is 2 cm dilated, 50% effaced and the fetus is at the -2 station. One hour later the dilation is still 2 cm, but now the effacement is 80% Which of the following stages and phases of labor is this client experiencing?

The first stage, latent phaseThe first stage, active phaseThe first stage, transition phaseThe second stage of labor

NCLEX Prep QuestionA nurse is admitting a client to the birthing unit. The client suddenly states, A”I think I urinated on myself. It’s all wet down there, I’m so embarrassed.” Which of the following actions should the nurse take at this time?

Test the fluid with Nitrazine paper, it will confirm urine by turning blueTest the fluid with Nitrazine paper, which will confirm urine by turning pink. Test the fluid with Nitrazine paper, which will confirm amniotic fluid by turning it blueTest the fluid with Nitrazine paper, which will confirm amniotic fluid by turning it yellow.

NCLEX Prep Question

A client experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. The nurse’s first action should be to:

Test to see if the fluid is amnionic fluidMonitor fetal heart rate for distressDry the client and make her comfortableMonitor the client’s maternal contractions

NCLEX prep question

While conducting an admission history for a client at 39 weeks gestation, the client tells the nurse that she has been leaking water from her vagina for 2 days. The nurse knows that this client is at risk for:

Cord prolapse

Infection

Malpresentation.

hydramnios

NCLEX Prep Question

A client in active labor becomes nauseous with emesis, is very irritable, and feels she needs to have a bowel movement. She states, “I’ve had enough. I can’t do this anymore. I want to go home right now.” The nurse knows that these signs indicate the client is in the:

Second stage of laborFourth stage of laborTransition phase of labor.Active phase of labor