Chapter 21: Assessment of

Fetal Wellbeing
Ultrasound
Most commonly used diagnostic and
screening tool
Uses a transducer
Transabdominal vs transvaginal
Uses high-freq soundwaves which produce
image based on density of object
Bone = white
Soft tissue = grey
Fluid = black
Methods
?full bladder
Abdominal
Vaginal
Ultrasound
Limited U/S
Fetal presentation
Placental location
Confirmation of viability
Determine amniotic fluid volume
Diagnose multiple gestations
Guide amniocentesis
Comprehensive U/S
Above + looks at individual structures
Ultrasound

Gestational Age
Crown-Rump (CR) length at 6-10 wks
most accurate
Later in pregnancy
Measurement of BPD, head circumference,
abd circumference, femur length

As pregnancy progresses, accuracy

becomes less
Ultrasound

Pregnancy Wellness
Growth comparisons
Amniotic fluid volume index (AFI)
Measurement of deepest pocket of fluid in
each quadrant, added together
Placental location and status
Doppler flow studies
Estimation of fetal wt
Ultrasound
Pregnancy Wellness
Biophysical Profile
Fetal “breathing”
Fetal movement
Fetal tone
AFI
FHR acceleration (measured with NST)
Scored as 0 or 2
Highest score is 10 (with NST)
Most significant is NST and AFI
Other tests
hCG: Qualitative or Quantitative
Charts to compare values
Peaks at about 60-90 days
CVS
Small sample of chorionic villi from edge
of developing placenta
Done ~ 10-12 weeks
 risk of fetal complications if done
earlier
Other tests
MSAFP
Fetal protein produced by yolk sac then
fetal liver
If NTD,  AFP levels
Most accurate during 15 – 16th week
Values based on wks gestation
Detects 85% of NTDs, false + 3-4% (?)
Low levels can indicate down syndrome
or “dying” fetus
Other tests

Amniocentesis
Procedure on pg 548
Can ID genetic disorders, chromosome
disorders
Best done about 15-20 wks
Also done toward end of pregnancy for
lung maturity
Lecithin and sphingomyelin (L/S ratio) 2:1
Phosphatidylglycerol (PG) present
Other tests

Fetal movement assessment

+ fetal movement  intact CNS
Mom counts fetal kicks or movement in
hour
Careprovider assigns # kicks/hr that is
OK
Other tests
Non-stress Test (NST)
Uses external fetal monitor
Looks at response of fetal heart to movement (“No
stress” of contractions)
FHR accels w/ movement indicated intact NS
SNS matures first, then PNS
Interpretation
Reactive: (2) 15 x 15 accels in 20 mins (10 x 10 if < 32 wks
gest)
Non-reactive: one or no accels
May use acoustical stimulator to “awaken” baby
Other tests
Contraction Stress Test (CST)
Evaluates response of fetus to
“stress” of contractions (oxygenation)
Identifies problems with respiratory function
of the placenta
How can fetus tolerate  O2? How well does
placental reserve work?
Contractions are stimulated (spontaneous, Pitocin,
breast stimulation)
Must establish 3 U/Cs of at least 40 sec. in 10 min.
Interpretation
Negative: no late or significant variable decelerations
Positive: late decelerations in 50% or more of
contractions
Chapter 22: Processes and
Stages of Labor and Birth
Critical Factors in Labor

5 critical factors
Birth passage
Fetus
Relationship of Maternal Pelvis and
Presenting Part
Physiologic forces of labor
Psychosocial considerations
Birth Passage

Size of pelvis
Type of pelvis
Gynecoid
Android
Arthropoid
Platypelloid
Combination
Fetus
Fetal head
Largest and least flexible
Bones of the base of the cranium are
fixed; vault (frontal, parietal, occipital)
are not
Molding
Fetus
Sutures: Lambdoidal
suture
Frontal
Sagittal
Sagittal
Coronal suture
Lambdoidal
Coronal
suture
Frontal suture

Note: sutures are actually membranous spaces that meet at fontanels

Fetus
☺Fontanelles: intersection of sutures,
allows for molding, helps identify position
of head
Anterior (bregma)
Diamond shaped
Approx 2-3 cm
Ossifies in ~12-18 months
Posterior
Triangle shaped
Smaller
Closes in 8-12 weeks
Fetus

Other landmarks on the fetal head

Mentum
Sinciput
Vertex
occiput
Fetus

Fetal attitude
Relation of fetal parts to one another
Normal: mod flexion of head, flexion of
arms onto chest, flexion of legs onto abd

Changes in attitude can contribute to

longer, more difficult labor or C/S
Fetus

Fetal lie
Relationship of the spine (cephalocaudal
axis) of the fetus to the spine of the mom

Longitudinal: parallel
Transverse: right angle
Fetus

Fetal presentation
Body part entering the pelvis (presenting
part)
Cephalic
Breech
Shoulder
Fetus
Fetal presentation: Cephalic
☺Vertex presentation
Most common
Head completely flexed on chest
Suboccipitobregmatic (Smallest diameter)
Occiput in presenting part
Military presentation
Fetal head neither flexed nor extended
Occipitofrontal diameter presents
Top of the head is presenting part
Fetus

Fetal presentation: Cephalic

Brow presentation
Fetal head partially extended
Occipitomental diameter presents
Sinciput is presenting part
Face presentation
Head hyperextended
Submentobregmatic diameter presents
Face is presenting part
Fetus
Fetal presentation: Breech
Sacrum is the landmark
Complete breech
Knees and hips are flexed, thighs on abd (“fetal
position”)
Buttocks and feet are presenting parts
Frank breech
Hips flexed, knees extended
Buttocks is presenting part
Footling breech
Hips and legs extended
Feet are presenting parts (single vs double)
Fetal presentation: Shoulder
Acromion process of shoulder is presenting part
Relationship of maternal pelvis and
presenting part
Engagement
Largest diameter of presenting part
reaches or passes thru the pelvic inlet
Happens about 2 weeks before labor in
primigravida; anytime for multigravida
When vertex presentation, BPD is
largest dimension to pass thru inlet
Floating or ballotable
Relationship of maternal pelvis and
presenting part
Station
Relationship of presenting part to
imaginary line drawn between ischial
spines of pelvis (0 station)
Measured cm above (+) or below ischial
spines (-)
Some use +3 to -3; some use +5 to -5
In normal pelvis, narrowest diameter thru
which fetus passes
Failure to descend, CPD
Relationship of maternal pelvis and
presenting part
Fetal position
Relationship of the landmark on the
presenting part to the anterior (A),
posterior (P) or transverse (T) side of the
maternal pelvis
3 notations
R or L
Landmark: O, M, S, A
Where landmark: A, P, T
Relationship of maternal pelvis and
presenting part
Relationship of maternal pelvis and
presenting part
OA most common, easiest to deliver
Other positions are considered
malpositions
Position influences labor and birth
Largest diameter in posterior position:
back pain, longer 2nd stage
Can tell position by palpation of abd
and VE
Physiologic forces of labor

Primary: uterine muscles (causes

dilation and effacement)
Secondary: abdominal muscles (for
2nd stage)
Physiologic forces of labor

Phases of contractions
Increment
Acme
Decrement
Relaxation
Uterine muscle rest
Rest for mom
Restores oxygenation to baby
Physiologic forces of labor

Frequency
Duration
Intensity
Physiologic forces of labor

Intensity:
indirect: palpation: mild, mod,
strong, subjective
direct: mmHg pressure with IUPC
objective
Physiologic forces of labor

Early labor: mild, short duration,

irregular
As labor progresses: stronger, longer,
more regular, closer together
Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)
involuntary and voluntary muscles
Psychosocial Considerations

Fears
Anxiety
Social support
Past experience
Knowledge
Physiology of Labor

What causes labor? Unknown, but

hypotheses
Progesterone withdrawal
End of pregnancy there is a decrease in
availability of progesterone to myometrial
cells
Prostaglandins
Initiation of labor can be demonstrated with
prostaglandins and PTL can be stopped with
antiprostaglandins
Physiology of Labor
What causes labor? Unknown, but
hypotheses
Corticotropin-releasing hormone
CRH increases during pregnancy with sharp increase
at term
CRH is increased in PTL
CRH is increased in mult gestations
CRH is known to stimulate synthesis of prostaglandin
F to E
Fetal
Secretes fetal fibronectin
Other stimuli
Stretching of myometrial cells
Physiology of Labor
Myometrial activity
Divides into 2 portions: physiologic retraction
ring
Upper becomes thicker (contractile part); lower
become thinner (passive part)
With each contraction, muscles of upper uterine
segment shorter and exert longitudinal traction
of the cervix  effacement
☺Effacement recorded as %
Primips usually precedes dilation; multips
usually after dilation
Physiology of Labor
Myometrial activity
With each contraction, uterus elongates
decreasing horizontal diameter
Causes a straightening of the fetal body,
pushing the presenting part toward the
lower uterine segment and the cervix
As uterus elongates, long muscle fibers
are pulled over presenting part 
dilatation
Recorded in cm (closed, fingertip, to 10)
Physiology of Labor
Muscular change in the pelvic floor
Levator ani muscle and fascia of the
pelvis draw rectum and vagina upward
As presenting part descends, causes
perineum to thin out (5cm  paper thin)
Leads to physiologic anesthesia
Premonitory signs of Labor

Lightening
Braxton-Hicks contractions
Cervical changes (ripening)
Loss of mucous plug/Bloody show
ROM
Sudden burst of energy
diarrhea
Premonitory signs of Labor
Note on ROM
If ROM at home, told to come in
In term preg, ~80% will go into
spontaneous labor w/i 24 hrs; if no labor
w/i 12? Hrs, will induce
SROM vs AROM
☺Problem if ROM before engagement
Prolapsed cord
Problem if ROM before labor
infection
True vs False Labor☺
True False
Conts Reg, ↑freq, dur, Irreg, short
intensity duration, mild
Pain Starts in back, Begins in abd
radiates to front
Cx Dilation/efface No change
change
Cont Does not decrease Decreases
change with rest or warm with rest,
bath; walking warm bath;
makes stronger walking slows
Stages of Labor ☺
Stage 1
Onset of regular contractions to
complete dilatation
Stage 2
Complete dilatation to birth
Stage 3
Birth of infant to birth of placenta
Stage 4
Birth of placenta to 1-4 hrs recovery
Stages of Labor ☺
Stage 1 divided into 3 phases
Latent phase: 0-3 cm
Primip 8.6 hrs
Multip 5.3 hrs
May have irreg contractions, short, mild –
mod
Excited, talkative, smiling
Active phase: 4-7 cm
Primip 4.6 hrs; dilation at least 1.2 cm/hr
Multip 2.4 ; dilation at least 1.5 cm/hr
u/c q 2-5 min, 40-60 sec, mod – strong
↑ anxiety, sense of hopelessness, fear of
loss of control
Stages of Labor ☺
Transition phase: 8-10 cm
Primip 3.6 hrs
Multip variable
u/c q 1 ½ - 2 min; 60-90 sec, mod – strong
Acutely aware of intensity of u/c, significant
anxiety, restless, can’t get comfortable, fears
being alone, yet may not want anyone to
touch her, hot-cold, apprehensive

As dilation progresses, ↑ bloody show,

ROM. As gets to closer to complete, ↑ rectal
pressure, splitting feeling, urge to push
Stages of Labor ☺
2nd stage
Usually <2 hrs (less in multips)
Affected by epidural, maternal pushing,
position of presenting part, size of pelvis
As head approaches perineum, labia
separate, may see presenting part with
pushing, then recede. Rectum bulges
and flattens
Crowning
Stages of Labor ☺
Positional changes of the fetus
Descent- enters OP or oblique
Flexion- resistance
Internal rotation- to fit narrowest diameter
Extension- extends as it comes under
symphysis
Restitution- shoulders still oblique  neck
twisted. Once head is free, turns to one side
and aligns with shoulders
External rotation- as shoulders rotate, head is
turned farther to one side
Expulsion- shoulders slip under symphysis,
then body
Stages of Labor ☺
3rd stage
Usually w/i 5 mins. May be up to 30
mins. Retained after 30 mins.
Signs of separation
Globular shaped uterus
Rise in fundus
Sudden gush or heavy trickle of blood
Lengthening of cord from vagina

Shiny schultze
Dirty duncan
Stages of Labor ☺
4th stage
Blood loss normal up to 500mL (vag del)
Hemodynamic changes  ↓ BP, ↑ pulse
pressure, tachycardia
Uterus contracted and midline ~1/2 way
between symphysis and umbilicus.
Within 1st hour about level with umbilicus
Shaking, hunger, thirst
Bladder is hypotonic
Maternal Systemic Response to
Labor
Cardiovascular System
With strong u/c, stops or severely impedes
blood flow to uterus  redistribution of 300-500
mL of blood to peripheral circ and ↑ in
peripheral resistance  ↑ BP, ↓ pulse, ↑ CO by
~ 30%
When lying supine, CO, SV, BP and pulse ↑.
(Pushing also)
Immediately after birth, CO peaks at 80% ↑
over pre-labor then ↓s over 1st hour. Still has
elevation for ~ 24 hrs.
Maternal Systemic Response to
Labor
BP
Rises during 1st and 2nd stage
Fluid and electrolyte balance
Insensible water loss from sweating,
hyperventilation
Resp system
↑ O2 demand and consumption
Hyperventilation  ↓PaCO2 and resp alkalosis
Acid base balance levels return to preg levels
by ~24 hrs; to norm w/i few weeks
Maternal Systemic Response to
Labor
Renal
↑ maternal renin, renin activity and
angiotensinogen
Polyuria is common
May have some hematuria
GI
Gastric emptying time prolonged
At risk if surgery needed
Fluids generally OK
Blood values
WBCs increased to 25-30,000
↓ glucose
Fetal Response to Labor
FHR changes: can cause
decelerations
Acid-Base: ↓ pH, ↑ PaCO2, ↓ PO2, ↑
base deficit
Hemodynamic: fetal and placental
reserves carry fetus thru anoxic
periods
Behavioral states: sleep/awake states
Fetal sensation: sensitive to light,
sound, touch
Chapter 23: Intrapartal
Nursing Assessment
Maternal Assessment

History
Obtained from mom and record
Include culture, educational needs, support
Intrapartal High Risk Screening
Excessive wt gain mult gestation
Abnormal presentation meconium fluid
Bleeding post dates
pre existing med cond drug use
Maternal Assessment

Intrapartal physical and psychosocial

assessment
Physical done on admission and ongoing
Factors assessed depends on risk factors,
hosp policy
Always vital signs, labor status, fetal status
Maternal Assessment
Physical
VS: BP ≤ 140/90, pulse 60-90;
resp 14-22; pulse ox > 95%
Wt: 25-35 # normal, slightly more for underweight;
15-25# overweight
Lungs: clear, norm breath sounds
Fundus: just below xiphoid process
Edema: slight
Skin and mucous membranes: norm turgor, smooth,
pink, moist
Perineum: tissues smooth, pink; may have mucoid
d/c, may be blood tinged
Maternal Assessment
Labor status
Regular contractions
Membranes ?ROM, color, odor
Cervix: progressive dilation/effacement, fetal
descent
Fetal status
FHR 110-160
Presentation
Position
Activity
Methods of Evaluating Labor Progress

Contractions
Palpation: fundus, mild, mod, strong
Electronic: external
Uses tocodynamometer (no gel)
Placed on fundus
Measures freq and duration only
Methods of Evaluating Labor Progress

Contractions
Electronic: external
Advantages:
– Used on anyone
– Non-invasive
– Can be used intermittently
Disadvantages
– No intensity measurement
– Dependent upon women to remain fairly still
– Belt uncomfortable
– Maternal body size may make it diff to measure
contractions
Methods of Evaluating Labor Progress

Contractions
Electronic: internal
Uses IUPC
Advantages
– Accurately measures freq, duration, intensity, resting
tone
– Can use for amnioinfusion
Disadvantage
– ROM must have occurred
Methods of Evaluating Labor Progress

Cervical Assessment
VE: dilation, effacement, station,
presentation, position,
membrane status
Methods of Evaluating Fetal Status

Determination of Position and

Presentation
Inspection of abd
Palpation of abd
VE
U/S
Methods of Evaluating Fetal Status

Inspection of abd
Is the uterus longitudinal or transverse?
VE
U/S
Methods of Evaluating Fetal Status

Palpation of abd
Leopold’s maneuver
1st maneuver
– What is in fundus?
– Head is firm, round, moves independently of trunk;
buttocks is softer, symmetric, moves with trunk
2nd maneuver
– Where is the fetal back located?
– Back is firm smooth, hands and feet are irregular
3rd maneuver
– What is above the inlet (what presentation)?
4th maneuver
– Where is the brow and back of head (what position?)
Methods of Evaluating Fetal Status

Auscultation of FHR
Fetoscope, doppler, EFM
Heart tones heard best thru fetal back:
OA in lower quad
Breech above umb
Found lower and more midline as fetus descends
Listen before, during and after contraction
Intermittent monitoring has been found to be
just as effective as continuous for low risk.
Hosp policy determines who, when, how often
Methods of Evaluating Fetal Status

Electronic Fetal Monitoring: External

U/S transducer (sound waves)
Uses gel
Advantage:
Continuous observation of FHTs
Disadvantage:
May be difficult to trace if baby active, mom
moving, obese/hydramnios/mult gest
Methods of Evaluating Fetal Status

Electronic Fetal Monitoring: Internal

Use of spiral electrode attached
to fetal head or buttocks
Not applied to face, sutures, fontanels,
perineum, cervix
Advantage:
Accurate heart rate tracing
Disadvantage:
Must have ROM
Very slight risk of infection
Telemetry
Fetal Heart Rate Pattern
Interpretation

MUST LOOK AT WHOLE PICTURE

MUST LOOK AT WHOLE PICTURE
MUST LOOK AT WHOLE PICTURE

Significance of fetal monitor strip

Fetal Heart Rate Pattern
Definitions
Baseline: FHR between U/C for 10 mins
(doesn’t include rate during contraction)
Normal term: 110-160
Tachycardia: >160 for >10 min
Bradycardia: <110 for >10 min
Acceleration: transient increases in FHR above
baseline for < 10 min
Deceleration: transient decrease in FHR from
baseline for < 2 min
Prolonged deceleration: decrease in FHR from
baseline for 2-10 min
Fetal Heart Rate Pattern
Baseline
Tachycardia: >160 for >10 min
Causes:
– early fetal hypoxia
– Maternal fever
– Betasympathomimetic drugs
– Dehydration
Non-reassuring if associated with other signs or if
pathologic
Fetal Heart Rate Pattern
Baseline
Bradycardia: <110 for >10 min
Causes:
– Maternal hypotension
– Prolonged umbilical cord compression
– Fetal asphyxia – profound
– Fetal heart block
Non-reassuring sign
Tx: correct cause
– Position change
– ↑ fluid
– O2
– d/c pitocin
– Delivery (?)
Fetal Heart Rate Pattern

Variability:
Interplay between sympathetic and
parasympathetic nervous system
MOST important parameter of fetal well-being
May be decreased with fetal sleep (short-
term)
Fetal Heart Rate Pattern
Variability:
Long term variability
Rhythmic fluctuations of FHR
difference between lowest and highest FHR
Decreased: <6 BPM
Mod/avg: 6-25 BPM
Marked (saltatory): >25 BPM
Short-term variability
Difference between successive heartbeats as measured by
R-R waves.
Present or absent
Only measured with internal electrode
Indicator of fetal oxygen reserve
Fetal Heart Rate Pattern

Variability:
Sinusoidal
Indulating pattern with no short-term variability or
accels
Ominous sign
Psuedosinusoidal
Associated with med use
Fetal Heart Rate Pattern
Accelerations
15 x 15 or 10 x 10
Reassuring sign
Fetal Heart Rate Pattern
Early Decelerations
Associated with head compression
Waveform consistently uniform
Mirrors contractions
Onset is just before or early in contraction
Lowest level consistently at or before midpoint of
contraction
Range usually within 110-160
Can be single or repetitive
Benign or reassuring
Most often seen in 2nd or 3rd phase
Treatment:
NONE
Fetal Heart Rate Pattern
Late Decelerations
Associated with uteroplacental insufficiency
resulting in hypoxemia
Waveforms uniform, shape reflects
contractions
Onset is late in contraction and lowest level
consistently
after midpoint of cont (Depth not indicative of
threat)
Range usually within 110-160
Fetal Heart Rate Pattern
Late Decelerations (continued)
Can occur occasional, consistent,
gradually increasing, repetitive
May be caused by pathologic (myocardial
depression, calcified placenta, abruption) or
physiologic (supine, hypotension, tetanic
contractions)
Non-reassuring
Tx: correct cause
Position change O2
↑ fluid d/c pitocin
Fetal Heart Rate Pattern
Variable Decelerations
Associated with cord compression
Varies in onset, duration, intensity
and waveform
Generally drops and returns; abrupt with fetal insult
Onset not related to cont
May be single or repetitive
Usually benign
Tx: correct cause
VE to r/o prolapsed cord O2
Position change d/c pitocin
↑ fluid
Fetal Heart Rate Pattern
Prolonged Decelerations
Can be non-reassuring or benign
depending upon variability and
if returns to baseline
Tx: correct cause
Position change
↑ fluid
O2
d/c pitocin
Evaluation of FHR tracings

Resting tone
u/c: freq, duration, intensity
Baseline FHR: normal?
Variability: STV and LTV
Changes from baseline: accels,
decels
Reassuring or non-reassuring
Evaluation of FHR tracings

Reassuring
Within normal range
STV present
LTV average or better
Accels
Evaluation of FHR tracings

Non-Reassuring
Not within normal range
STV absent
LTV minimal or absent
Absence of accels
Prolonged decelerations
Severe bradycardia
Other methods of fetal assessment

Scalp stimulation
Acoustic stimulation
Stimulation of abdomen
Fetal scalp blood sampling (pH)
Fetal oximetry
Cord blood analysis
Chapter 24: The Family in
Childbirth: Needs and Care
When do I go to the hospital?

ROM
Regular, frequent contractions
(primip q 5min for 1 hr; miltip q 6-8
min for 1 hr) VERY GENERAL
Vaginal bleeding
Decreased (absent) fetal movement
What is going to happen to me
when I arrive?
History
Physical
Assessment during 1st Stage
NOTE: general standards; individualized for
patient status and hospital policy

Latent:
VS q 1 hr; temp q 4 hrs unless ROM,
then q 1-2 hrs
U/C status q 1 hr
Fetal heart rate status q 30 min – 1 hr
Assessment during 1st Stage
NOTE: general standards; individualized
for patient status and hospital policy

Active:
VS q 1 hr, temp q 4 hrs unless ROM,
then q 1-2 hrs
U/C status q 1 hr
Fetal heart rate status q 15 -30 min
Assessment during 1st Stage
NOTE: general standards; individualized for
patient status and hospital policy

Transition:
VS q 1 hr; temp q 4 hrs unless ROM,
then q 1-2 hrs
U/C status q 1 hr
Fetal heart rate status q 15 min
Comfort during 1st stage

Ambulation, Rocking Chair

Position changes: knee chest, sitting,
side-lying, birthing ball, birthing bar
Personal Care
Bath, shower
Empty bladder
Po fluids, vaseline to lips
Perineal care
Comfort during 1st stage

Anxiety
Keep informed
Establish rapport
Express confidence
Provide support
Comfort during 1st stage

Supportive Relaxation Techniques

Distraction
Touch
Efflurage
Massage
Warm compresses
Visualization Techniques
Comfort during 1st stage
Breathing Techniques
Pattern-paced breathing
Cleansing breath
Slow
Moderate
Pattern

Hyperventilation: tingling, numbness in nose,

mouth, lips, fingers, toes, spots before eyes
Tx: encourage to slow down breathing; paper
bag
Care during 2nd stage
VS q 15 – 30 min
U/C status q 15 – 30 min
Fetal heart rate status
(low risk) q 15 min
(high risk) q 5 min
Comfort
Cool cloths
Fanning
Fluids
Support
Care during 2nd stage
Pushing positions
Side
Squatting
Sitting
Knee-chest
Towel pull
Bed bars
Perineal Assistance
Warm compresses
Perineal massage
rest
Care during 2nd stage
Preparing for Delivery
Perineal prep
Betadine, Hibiclens, soap and water
Procedure
Stirrups
Padded
Adjusted (no pressure on back of calves or knees)
Legs in and out together☺
HOB elevated
Care during 2nd stage
Positions for delivery
Litotomy
Advantages:
– assessment of FHTs
– Performance and repair of episiotomy
Disadvantages:
– Many
Lateral
Advantages:
– More comfortable
– No venous compromise
– Less pressure on neck
Disadvantages:
– Performance and repair of episiotomy
– Inability to use assistive devices
Care during 2nd stage
Positions for delivery
Squatting/Sitting
Advantages:
– Increases pelvic outlet
– Helps pushing efforts
– Uses gravity
Disadvantages:
– Perineum relatively inaccessible
– FHT monitoring difficult
– Performance and repair of episiotomy
– Inability to use assistive devices
Care during 2nd stage
Positions for delivery
Hands and knees
Advantages:
– Less pressure on perineum
– Increases pelvic diameter
– Increased placental flow
Disadvantages:
– Increased fatigue
– Decreased eye contact between pt and caregiver
– Inability to use assistive devices
Care during 2nd stage
Delivery of Head
Check for nuchal cord
Suction mouth and nose
Delivery of Shoulders
Release of anterior shoulder
Release of posterior shoulder
Delivery of Baby
Mouth/nose suction
Placed on mom’s abd
Cord clamped and cut
Held level with vagina to prevent loss/excess blood from/to
baby
Check for 3 vessels
Care during 3rd stage
Observe for signs of placental separation
To aid in delivery
Bear down
Gentle traction on cord
Fundal pressure
Manual removal
Inspection of placenta
Inspection of cervix/perineum
Palpation/Massage of fundus
Oxytoxics
Given IV or IM after placental delivery
Prevents uterine atony and excessive bleeding☺
Initial Newborn Care

Given to mom or radiant warmer

1st Priority=Airway☺
Placed in modified trendelenburg
Suctioned with bulb syringe/deep
suctioning
2nd priority=provide warmth☺
Kept dry (head first)
Initial Newborn Care

Apgar Score☺
Heart rate
Resp effort
Muscle tone
Reflex irritability
Color
Initial Newborn Care
Physical Assessment
Gross inspection
Vital signs
Temp: >97.6 (1st temp rectally)
Pulse: 110-160, may be irregular
Resp: 30-60, irreg, abd breathing; no retractions,
nasal flaring, grunting. Lungs may be “wet”
Gestational Age Assessment (Dubowitz)
Newborn Identification
ID bands
Footprints/ mother’s fingerprint
Initiation of attachment
Nursing Care During 4th Stage of
Labor
Vs, uterus, bleeding q 15 min x 1 hr
Uterus: @ U, firm, midline
Lochia: rubra, small-mod
Bladder: atonic, fills rapidly, can displace
uterus, usually to Right  uterine atony
Perineum: no hematoma, some swelling,
ice
Shaking, tired, hungry, thirsty
Nursing Care During Precipitous
Birth
Nurse delivery or unattended
Same care as previously mentioned
Important to remain calm, confident
Chapter 25
Pain Management During
Labor
The What, Whens and Hows of
Pain Management
Pain in 1st stage:
Dilatation of cervix
Hypoxia of myometrial cells
Stretching of lower uterine segment
Pressure on adjacent structures
Pain in 2nd stage:
Hypoxia of myometrial cells
Distention of vagina and perineum
Pressure on adjacent structures
Pain in 3rd stage:
Uterine contractions
Cervical dilatation
The What, Whens and Hows of
Pain Management
Factors affecting response to pain:
Preparation
Culture
Fatigue and sleep deprivation
Previous experiences
anxiety
The What, Whens and Hows of
Pain Management
40-45% receive epidural anesthesia
35-40% receive analgesia
Many receive combination
Systemic Analgesics
Maintaining normal vital signs and
homeostasis are important because they
affect fetal well-being
All systemic meds cross placental barrier
Fetal liver and kidneys are inadequate to
metabolize agents
Blood-brain barrier is more permeable at time of
birth
% of blood volume flowing to brain ↑s during
uterine stress so hypoxic fetus gets larger amt of
depressant drug
Systemic Analgesics
Administration is usually when labor well
established and maternal and fetal
assessment within normal parameters
Systemic Analgesics
Narcotics
Butorphanol
agonist-antagonist
Usual dose 1-2 mg
30-40x more potent than Demerol; 7x more
potent than Morphine
Reverses analgesic effects of other opiods or
narcotics and precipitates withdrawal in drug
dependent women☺
Can cause resp depression in mom and baby
Narcan is reversal agent
Systemic Analgesics

Narcotics
Nalbuphine Hydrochloride
Same effects as Stadol
Usual dose 10 mg
Meperidine
Narcotic agonist
Usual dose 25 – 100mg
n/v big problem
Resp depression in mom and baby
Systemic Analgesics

Opiate Antagonist
Naloxone
Reverses depression and sedation from small
doses of opiates
Competes for opiate receptor sites
Has little agonistic effects so is drug of choice
when depressant is unknown because it will not
cause further depression
Resp depression can recur as it wears off
Dosage is wt based; can be given to mom or
baby
Systemic Sedatives

H1 receptor antagonists
Sedatives, anti-emetics, narcotic
potentiators
Promethazine
Hydroxazine
Diphenhydramine
Regional Analgesia and Anesthesia

Regional Anesthesia
Temporary and reversible loss of
sensation produced by injecting an
anesthetic agent into an area that brings
the agent into direct contact with the
nervous system
Epidural
Spinal
Combination
Regional Analgesia and Anesthesia
Lumbar epidural block
Local anesthetic injected into epidural space
Can be intermittent or continuous
Pain sensation vs motor sensation
Usually given when labor well established
Adv:
Good analgesia
Fully awake
Positive birth exp
Mother can rest
Disadv:
Maternal hypotension
Requires skilled persons to administer and manage
May have decreased ability to push
Regional Analgesia and Anesthesia
Lumbar epidural block
IV bolus☺
Positioned
Insertion
Care after placement
Adverse effects:
Hypotension
– Uterine displacement
– IV fluids increased
– O2
– Ephedrine
Inadequate anesthesia
Pruritis
Slight temp elevation
Regional Analgesia and Anesthesia
Spinal Block
For C/S
Anesthetic agent injected into
subarachnoid space
Immediately positioned after injection
Anesthesia is almost immediate
No direct effect on fetus
Complications:
Hypotension
Drug reaction
Spinal headache (controversial) Treatment
Total spinal block
Local Anesthesia
Pudendal Block
Anesthesia into area of pudendal nerve
Perineal anesthesia
Local
Anesthetic injected into perineum
Does not absorb systemically
General Anesthesia
May be needed for emergency
Not used as often for non-emergency
surgery
Complications:
Fetal depression
Some degree of uterine relaxation
Increased risk of gastric aspiration
Failure to establish airway
Other complications associated with resp
system
Analgesic and Anesthetic
Considerations for High Risk
PTL
Fetus more susceptible
Epidural preferred
Preeclampsia
Epidural preferred if hematology studies OK
DM
Epidural Ok
Watch closely for hypotension
Cardiac
Epidural with forceps
Bleeding
?epidural
?general
Chapter 26:
Childbirth at Risk: Intrapartal
Period
Psychologic Disorders

Alterations in thinking, mood or

behavior
Keep her well oriented and promote
optimal functioning in labor. Focus on
maintaining safe environment and
ensuring fetal and maternal well-being
Dystocia r/t dysfunctional
contractions
Accounts for ~ 50% C/S for primips; <5%
C/S for multips
Hypertonic: in 1st phase- poor quality U/Cs,
become more frequent, but ineffective and
changing dilatation or effacement
prolonged latent phase
Tx: sedation, oxytocin, amniotomy
Hypotonic: irreg, low amplitude protracted
labor and arrest of dilatation
Tx: oxytocin, amniotomy
Active Management of Labor
Standardized criteria for diagnosis of labor
Standardized method of labor management
One-to-one nursing care in labor
Prenatal education to teach re: this protocol
Method:
Amniotomy right away
VE frequently
If change not as expected, oxytocin
Precipitous Labor and Birth
From beginning of regular contractions
to delivery is 3 hours or less
Risks:
Abruption
Cervical and perineal lacerations
Fetal head trauma
PPH
Women with history may be scheduled
for induction
Post-term Pregnancy
> 42 completed weeks
Cause of true post-term is unknown; often
incorrect dates
Maternal Risks:
Large baby and associations
Psychologic ills
Fetal-Neonatal Risks:
Placental changes  insufficiencies
Oligohydramnios
LGA or macrosomia birth trauma, glucose maintenance problems
Meconmium stained fluid (aspiration)
As pregnancy approached term, fetal well-being studies
done
Fetal Malposition

OP position:
Fetus must rotate 135° or occasionally
born in OP position
If born OP, increased risk of 3rd or 4th
degree laceration, broken symphysis
May use forceps or manual rotation
Positioning: knee chest, pelvic rocking
Fetal Malpresentation
Brow
Usually C/S recommended due to CPD
Perinatal morbidity and mortality:
Trauma: cerebral and neck compression; damage to
trachea and larynx
Tx: pelvimetry, oxytocin?, C/S
Face
Perinatal morbidity and mortality:
Risk of CPD and prolonged labor, fetal edema,
swelling of neck and internal structures, petechiae,
ecchymosis
Tx: C/S in no progress
Fetal Malpresentation

Breech
Most common malpresentation
Frank breech most common
Risk of cord prolapse; fetal anomolies 3x
higher
If vag del: head trauma, fetal entrapment
Tx: external version (50-60% success), if
vag del: epidural, double set-up
Fetal Malpresentation

Shoulder
Version may be attempted
C/S

Compound presentation
Macrosomia
>4500 g
Obese 3-4x more likely to have
macrosomic baby
↑risk of perineal lacerations, PPH, infection
Most significant problem is shoulder dystocia
OB emergency permanent injury of brachial plexus,
fx clavicle, asphyxia, neurologic damage
Tx:
Assessment of adequacy of pelvis
McRobert’s maneuver
Suprapubic pressure
Woods Screw maneuver
Intentional breaking of clavicle
?C/S
Multiple Gestation
Two separate ova: dizygotic
One ova: monozygotic
If division occurs
w/i 1st 72 hrs: diamnionic, dichorionic
w/i 4th-8th day: diamnionic, monochorionic
9th – 13th day: monoamnionic, monochorionic
Only 50% of pregnancies diagnosed with twins
during 1st ∆ result in birth of 2 live infants
2nd ∆ loss associated with cong anomolies,
IUGR, chromosome abnormalities, cx
incompetence, twin-twin transfusion, PTL
Multiple Gestation
Mother at risk for:
SAB
Hypertension or preeclampsia
Anemia
Hydramnios
PPROM, IUGR, incompetent cx
PPH
Malpresentation
More physical discomforts
Multiple Gestation

Tx:
U/S to diagnose amnion/chorion, follow
growth, observe for twin-twin transfusion
Frequent office visits to monitor for
problems
Likely to deliver by C/S
Abruptio Placentae
Premature separation of normally
implanted placenta from the uterine wall
Very high mortality
Cause unknown but r/t
Maternal hypertension
Maternal trauma
Cigarettes, cocaine
Short umbilical cord, high parity
More common in Caucasian and African
American than Asian or Latin American
Abruptio Placentae

Classification
O=asymptomatic, diagnosed after birth
I=mild, most common
II=mod, both mom and baby show signs
of distress
III=severe, maternal shock and fetal
death likely
Abruptio Placentae

Types
Marginal-blood passes between fetal
membranes and uterine wall and escapes
vaginally; separation at periphery of
placenta
Central-separates centrally, blood trapped
between placenta and uterine wall. No
overt bleeding
Complete-massive vaginal bleeding in
presence of almost total separation
Abruptio Placentae

Blood invades myometrial tissue 

pain and uterine irritability.
May necessitate hysterectomy after
delivery secondary to inability to
uterus to contract.
May lead to coagulation defects
Abruptio Placentae
Maternal Risks
Blood coagulation problems
Shock
Renal failure (r/t hemorrhage)
Possible hysterectomy
Fetal-Neonatal Risks
If separation ~50%  100% demise
Depending upon separation, time before
delivery, maturity of baby  neurologic
damage
Abruptio Placentae

Tx
Continuous EFM (if baby alive)
Develop plan for birth
Maintain CV status/tx hypovolemic
shock
Follow blood coag studies/have blood
factors available
Placenta Previa
Improperly implanted in lower uterine
segment
Types
Low lying: close proximity to os, but doesn’t
reach it
Marginal: edge of placenta at margin of the os
Partial: internal os is partially covered by
placenta
Total: internal os completely covered
Placenta Previa
Cause unknown, but associated with
Multiparity
Increased age
Defective development of blood vessels in
decidua
Defective implantation of the placenta
Prior C/S
Smoking
Recent SAB or induced AB
Large placenta
Placenta Previa

Tx
Continuous EFM
Differential diagnosis
☺No vag exam until previa r/o (U/S,
other assessments)
Care depends on amt bleeding,
gestational age, assessment of fetus
Other Placental Problems

Review p. 727
Note re: infarcts and calcifications
As placenta matures  calcifications
and infarcts
Calcification more often r/t age and diabetes
Infarcts more often r/t severe preeclampsia
and smoking
Prolapsed Cord

Umbilical cord precedes presenting part

May be visible or occult
More common with
Abnormal lie
Low birth weight
> previous births
Amniotomy
Long cord
Prolapsed Cord
Maternal Risk
No direct risk
Fetal-Neonatal Risk
Cord compression  ↓O2  possible death or
neurologic compromise
Tx
Prevention!
If palpated, keep pressure off cord
☺When ROM occurs, listen to FHTs for full minute;
if decel heard, do vag exam to r/o cord prolapse
Umbilical Cord Abnormalities

2 vessel cord: associated with

abnormalities, esp kidney
Check for 3 vessels at time of birth (2
arteries 1 vein)
Amniotic Fluid-Related Complications
Embolism: bolus of amniotic
fluid enters maternal circulation then
lungs.
OB emergency!
High mortality.
Amniotic Fluid-Related Complications
Hydramnios: >2000mL of fluid
Cause unknown but associated with
congenital abnormalities
(swallowing/voiding problems);
also diabetes, Rh sensitization, infections such
as CMV, Rubella, syphilis, toxoplasmosis,
herpes
If severe (>3000mL) may experience SOB,
severe edema, hypotension (from vena cava
compression) and pain
Tx
Supportive
Corrective: may do amniocentesis, Indocin (to ↓
fetal urine output)
Amniotic Fluid-Related Complications
Oligohydramnios
<500mL fluid or largest pocket of
fluid on U/S is <5cm
Associated with postmaturity, IUGR,
major renal problem in fetus (malformation,
blockage)
If occurs early in preg, may cause fetal adhesions
also fetal skin and skeletal abnormalities may occur,
pulmonary hypoplasia, cord compression
Tx:
Monitor
Amnioinfusion
Fetal surgery
Complications of 3rd and 4th stage
Retained placenta
☺Lacerations: cervical or vaginal suspected when
bright red bleeding in presence
of well contracted uterus
1st degree: fourchette, perineal skin, vag mucousa
2nd degree: perineal skin, vag mucosa, underlying
fascia, muscles of perineal body
3rd degree: extends thru perineal skin, vag mucosa and
perineal body and involves anal sphincter
4th degree: same as 3rd degree, but extends thru rectal
mucosa to the lumen of the rectum
Intrauterine Fetal Demise (IUFD)

May be found prior to coming to hosp

or at time of admission
May be unexplained or r/t materanal
disease process or fetal insult
May be induced right away or wait for
spontaneous labor. C/S not
automatically done
Pain med give freely
Intrauterine Fetal Demise (IUFD)

Provide privacy for families

Listen
Avoid inappropriate consolations
Give accurate info
Obtain mementos
Allow opportunity to see and hold
Provide information re: burial options
Provide support information
Chapter 27: Birth Related
Procedures
Procedures
Version
External
Internal
Cervical Ripening
Cervidil
Cytotec
Amnioinfusion
~250-500 mL warmed saline or LR is infused
into uterus via IUPC over 20-30 min
Used to correct variables, dilute mec stained
fluid
Labor Induction

Stimulation of U/C before spontaneous

onset of labor
Prior to starting induction
Verification of gestation age
Confirmation of fetal presentation
Assessment of risk factors
Well-being assessment of mom and baby
Cervical Assessment
Labor Induction

Cervical Assessment (Bishop’s

Score)
Know chart on pg 745
Higher the score, more successful the
induction will be
Favorable cervix is most important
criteria for successful induction
Labor Induction
Methods
Stripping membranes
Oxytocin
☺Always given via IV pump (may be given IM after
del)
Site closest to insertion
Continuous EFM
Risks
– Hyperstimulation
– Uterine rupture
– Water intoxication
– Fetal risks associated with maternal problems,
hyperbilirubinemia, trauma from rapid birth
Episiotomy

Decline over the years

May make it more likely will have
deep tears
Lacerations heal more quickly in
absence of epis
3rd or 4th degree lacerations more
likely with epis
Episiotomy
Midline
from vag orifice to fibers of rectal sphincter
Less blood loss, easier to repair, heals with less
discomfort
Mediolateral
From midline of posterier forchette to 45° angle to right
or left
Provides more room but has > blood loss, longer healing
time and more discomfort
Tx
Pain relief measures
Ice
Inspect!
Operative Assisted Deliveries
Forceps
Maternal complications
Trauma
Increased pain in pp period
Weakening of the pelvic floor
Fetal-neonatal complications
Caput
Caphalohematoma
Transient facial paralysis
trauma
Operative Assisted Deliveries
Vacuum Extractor
Longer duration of suction, more likely
scalp injury
Maternal complications
Perineal trauma
Edema
Genital tract and anal sphincter probs (< than with forceps)
Neonatal complications
Scalp lacerations
Bruising/subdural hematoma
Cephalohematoma
Jaundice
Fx clavicle
Retinal hemorrhage
death
Cesarean Birth
1970 - ~5%
1988 – 24.7%
2001 – 21%
2005 - ? But higher
Indications
CPD
Failure to progress/descend
Previa/abruption/prolapse cord
Non-reassuring fetal status
Malpresentation
Previous C/S
Maternal morbidity and mortality is > than vag
delivery
Cesarean Birth
Technique
NOTE: Skin incision NOT
indicative of uterine incision
Transverse (Pfannenstiel)-lower uterine segment
Adv: below pubic hair line, less bleeding, better
healing
Disadv: difficult to extend if needed, requires more
time, if adipose fold difficult to keep clean and dry
Vertical-between naval and symphysis
Adv: quicker, more room
Disadv: scar obvious, longer
Cesarean Birth
Technique
Uterine incision (type depends on
need for C/S)
Transverse-lower uterine segment
Adv: thinnest  less blood loss, only mod dissection
of bladder, easier to repair, site less likely to rupture
during subsequent pregnancies, less chance of
adherence of bowel or omentum to incision line
Disadv: takes longer, limited in size due to major
blood vessels, greater tendency to extend into
uterine vessels
Cesarean Birth
Technique
Lower Uterine Segment Vertical Incision
Preferred for multiple gestation,
abnormal presentation, previa,
preterm, macrosomia
Adv: more room
Disadv: may extend into cx, more extensive
dissection of the bladder is necessary, if
extends upward hemostasis and closure
more difficult, higher risk of rupture in
subsequent pregnancies
Cesarean Birth
Technique
Classic incision
Upper uterine segment
Adv: more room, quicker to do
Disadv: more blood loss, difficult to repair,
higher risk of rupture in subsequent
pregnancies
Cesarean Birth

Prep for C/S (time dependent)

Permits NPO
IV Oral/IV antacids, H2 inhibitors
Foley Teaching
Shave
Immediate PP care
Freq vs (q 5-10 min) Lungs
Check dressing I&O
Lochia and uterus Anesthetic level
VBAC

That was then, this is now

Specific criteria
Must sign consent
Contraindications
Classic incision or previous fundal uterine
surgery
Known CPD
Most common risk is hemorrhage and
uterine rupture