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Labor & delivery

Mrs. Deethardt lecture

The false pelvis is the wide are between iliac crest; supports weight of enlarged pregnant uterus & what else? Guides fetus into the true pelvis
What pelivs is the lower part of the pelvis at the level of the linea terminalis & consist of three parts? True pelvis
The three parts of the true pelvis? Inlet-Upper border allows fetal Head 2 easily navigate through it. WIDEST DIAMETER: TRANSVERSE & NARROWEST DIAMETER:A-P. Midpelvis-Narrowest part which fetus must pass during birth. Outlet-Lower border, WIDEST DIAMETER; A&P & NARROWEST DIAMETER:TRANSVERSE
** What is the android pelvis? Typical male pelvis with narrow dimensions. Heart shaped & not favorable for vaginal birth. Found in 20% of women.
** What is the Anthropoid pelvis? Narrowed from side to side & widened from front to back. Adequate for L&D & found in 25% of women
** What is the gynecoid pelvis? Typical female pelvis; adequate for vaginal delivery. Found in 50% of women.
What is the platypelloid Pelvis? Flattened(narrowed) from front to back & widened from side to side. Not favorable for vaginal birth & found in 5% of women
What is molding? Sutures & fontanelles allow the bones to move slightly; changing the shape of the fetal head so that it can adapt to the size and shape of the pelvis.
What are the landmarks that the fetal head is divided into? Mentum-chin; Glabella-bridge of the nose; Sinciput-brow; Bregma-anterior fontanelle; Vertex-top of head between the anterior & posterior fontanelles; Occiput-back of the head over the occipital bone.
**What is the fetal lie? Relationship of the long axis(spine) of the fetus to the long axis of the mother.
If the fetal lie is "Longitudinal" to mother; how is the fetus positioned? LOng axis of the fetus to the mother is parallel; vertex or breech presentation.
If the fetal lie is "trasverse" to mother; how is the fetus positioned? Long axis of fetus to the mother is perpendicular; shoulder presentation
What is the fetal attitude? relationship of the fetal body parts (chest, chin, arms) to each other.
With fetal attitude; its said the fetus is in flexion; what does that mean? Complete state of flexion; smallest diameter of fetal head to go through maternal pelvis.
With fetal attitude; its said the fetus is in Extension; what does that mean? Complete state of Extension; largest diameter of fetal head to go through maternal pelvis; LESS LIKELY TO BE DELIVERED BY VAGINAL DELIVERY.
What is fetal presentation? (or presenting part): Part of fetus that enters the pelvic inlet first and leads through the birth canal during labor.
Fetal presentation is in three categories; what are they? Vertex-Top of head, head completely flexed onto chest, OCCIPUT is presenting part; Millitary-Head nor flexed or extension, eyes straight ahead, top of head presenting; Brow-slight extension, SINCIPUT presenting; Face-Head is hyperextended,face presenting
What is considered breech? The buttocks/feet present first
What is considered "Frank" breech? Legs are flexed at the hips, knees & legs are extended against the abdomen & chest busttocks is presenting parts
What is considered "Complete or Full" Breech? Legs are flexed up on the fetal abdomen & knees are flexed, buttocks and feet are the presenting part.
What is considered "Single or Double Footling"? One or two legs are extended down; feet are the presenting first
What is the same as Shoulder presentation? Transverese lie; Can NEVER be a vaginal delivery
**What is the "Station"? Measures degree of DESCENT of the presenting part of the fetus through the birth canal.
How are the stations expressed? In terms of centimeters of the ischial spines of the maternal pelvis.
What is the measurement if the baby is high in the pelvis? -5 to 0
The level 0 is at the level of what? Ischial spines
At what level is +1, +2, +3, +4? at the pelvic outlet, +5 fetal presenting below ischial spines
At what level is -5, -4, -3, -2, -1? Fetal presenting part above the ischial spines; -5 at the pelvic outlet
During labor, the presenting part should move progressively from the _______stations to the midpelvis at zero station & into the ______ stations. From negative to the positive stations
What is meant by "Floating or Ballottable"? Presenting part is freely movable above inlet, in false pelvis. "Like a balloon if you tap the bottom of it; it will float up"
What is Engagement? The largest diameter of the presenting part reaches or passes through the pelvic inlet.
Fetus is said to be engaged when the biparietal diameter of the fetal head reaches what? The level of the ischial spines.
Engagement happens in a primigravida when? Often occurs approx. 2wks before labor begins
Engagement happens in a multigravida when? May not occur until labor begins.
With fetal positioning; what does ROA mean? Right occiput Anterior; So the occiput of babies head is against mom's right side of pelvis & babies spine in relation to mom's spine is Anterior.
What does LOA mean? Left occiput Anterior; So the occiput of babies head is against mom's left side of pelvis & babies spine in relation to mom's spine is posterior.
what does RMA mean? Right mentum Anterior; So the babies chin is against mom's right side of pelvis & chin facing anterior.
What does LMP mean? Left mentum posterior; So the babies chin is against mom's left side of pelvis & chin facing posterior.(Chin facing mom's spine)
What does RSA mean? Its in a breech position against mom's right side of pelvis & buttocks is facing anteriorly. (face of baby towards mom's spine)
What does LSP mean? Its in a breech position against mom's left side of pelvis & buttocks is facing posteriorly. (spine of baby is towards mom's spine)
What presentation is it if it's Occiput(O), Mentum(M), Sacrum(S), & Accordion(A)? O-Vertex, M-Face, S-Breech, A-Shoulder presentation
Locations of the fetal heart tones; best heard where? Through the fetal back or chest.
What are contractions? Involuntary, rhythmic,& intermittent tightening of the uterine muscles during labor.(Primary Force)
What is the purpose of contractions? Accomplishes effacement & dilation of the cervix & facilitates fetal descent through the pelvis.
What are the three phases of contractions? Increment-Period during which the intensity of ctx increases; Acme-Peak:during which ctx is most intense; Decrement-Decrease in intensity as uterus relaxes
** Between contractions, uterin muscles need to rest to restore UTEROPLACENTAL CIRCULATION for fetal oxygenation & adequate circulation in the uterine blood vessles. How long should it be between ctx? Need to have at LEAST 60 second resting interval between ctx; resting period becomes shorter as labor progresses
What is resting tone? The tension in the uterine muscle during the interval between ctx
What is frequency? Time between the beginning of one ctx to the beginning of the next ctx(expressed in minutes)
What is duration? Time betwen the beginning to the end of the ctx(expressed in seconds)"How long the ctx last"
What is intensity? Strength of ctx. (Mild, moderate, strong)
What is the secondary Force? Urge to Push; when the presenting part reaches the pelvic floor---woman experiences an involuntary urge to push.
The secondary force aids in expulsion of the fetus. The woman contracts? Her diaphragm & abdominal muscles & pushes the baby out.
What is Myometrial Activity? Development of the upper & lower uterine segments.
Upper segment of the uterus does what and helps with what? Becomes active & thicker as labor progresses--exert strength to expel fetus downward.
Lower segment of the uterus does what & helps with what? Becomes thin-walled & passive--fetus can be pushed out of uterus easily.
What is effacement? Softening, thinning & shortening of the cervical canal until it is completely assimilated in the lower uterine segment.
During effacement the cervix changes from____,_____ structure to one that is ____-____. Long, thick to paper-thin
How is the progress of effacement expressed? In terms of percentages (0-100%).
What is dilation? Widening of cervical opening and cervical canal from <1cm to 10cm.
When does E&D take place concurrently? For a multigravida patient.
What happens for a primigravida in relation to E&D? E-50% befor labor starts; D-take longer b/c cervical tissues have not been streched before
The example: 5/90/+1; what does that mean? Dilated-5cm, Effacement-90%, & +1 station(its below the ischial spines.
When does the first stage of labor begin? Begins with the onset of true labor & ends with complete dilation of cervix
There are three phases of labor; first phase is the latent phase; describe? begins with the initiation of regular ctx & is completed when the cervix is dilated 3 cm.
What is the dilation range in the latent phase? 0-3cm
How long does it take a nullipara to get to the latent & how long for a multipara? Nullipara- 8.6 hours; Multipara- 5.3 hours
What is the frequency, duration, & intensity of ctx in the latent phase? F- q10-30 mins & progresses to 5-7mins; D- approx. 30-40 secs; I- mild to moderate.
What is the woman's behavior like in the Latent phase? Usually happy, talkative, eager to be in labor, independence by taking care of own bodily needs & seeks info
What are some nursing care during latent phase? when mom & partner gets there greet them, orient them to environment; reinforce breathing & coping skills; If NO contraindications: encourage walking
What is the active phase? Begins @ 4cm dilation & ends at 7cm.
How long does it take a nullipara & multipara to reach the active phase? N- 4.6hrs; M- 2.4 hrs
What is the frequency, duration, & intensity of ctx in the active phase? F- q2-3 mins; D- approx. 40-60 secs; I- moderate-strong.
** In the active phase what is the cervical dilation like? Nullipara-1.2cm/hr; Multipara- 1.5cm/hr
What is the woman's behavior like in the active phase? May feel helpless, increase fatigue, restless, more dependent, very tired & anxious
What are some nursing care for a woman in active phase? Provide general care-linen or underpad changes, cool washcloths, back rubs, ice chips; Encourage freq position changes(left side best)q30mins;observe bladder-void q2hrs, encourage & reassure mom, Support
When putting mom on side what does that help with? Increase placental perfussion & helps with fetal descent.
The third phase is transitional; what does the cervix look like in this phase? Cervix is dilated 8-10cm
How long does it take a nullipara & multipara to get to the transitional phase? N- 3.6hrs; M- minutes to hours.
What is the frequency, duration, & intensity of ctx in the transitional phase? F- q1.5-2 mins; D- approx. 60-90 secs; I- strong.
** What is the fetal descent in the transition phase? Nullipara- 1cm/hr; Multipara- 2cm/hr
How is the woman's behavior in the transitional phase? Very tired & irritable, may feel she can't keep up with labor & is out of control, fear of being left alone, may fear tearing open or splitting apart with ctx, N&V r/t ^inner abdomnial pressure
What are some nursing care for women in the transitional phase? Provide general comfort needs, breathing techniques, observe for signs of 2nd stage of labor: grunting, bearing down, stating "baby is coming" or need to push
Maternal-fetal assessment during 1st stage of labor? V/S-B/P MUST be taken between ctx, Temp is an indicator of hydration & infection-q4hrs until bag broken then q2 after; Pulse ^ is normal but >100 may indicate stess, RR may increase or decrease due to type of breating; EFM-assess duration, intensity, freq
What happens with GI in the 1st stage of labor? Gas motility & absorption of solid food decreases; gastric emptying time is prolonged
** How can newborn GBS infection be prevented? All pregnant women should be screened for GBS at 35-37wks of pregnancy.
** What does SROM mean? Spontaneous Rupture Of Membranes; could be a gush or trickle
** what does AROM mean? Artificial Rupture Of Memabranes; could be a gush or trickle
** Once Membranes are ruptured; what is the priority assessment? Check fetal heart tones!! Because the umbilical cord could come out & get compressed
What other important assessment to do after the rupture of membranes? Observe color of fluid- should be clear! Thick-green-yellowish soup looking could mean meconium is in fluid.
Why is meconium in a breech baby common? When fetus is stressed- r/t relaxed anal spincter.
Progress of labor: as the ctx becomre more frequent and intense, vaginal exams assess what? Dilation, effacement, station & position
What is the Leopold's Maneuvers? A systematic method of observation & abdominal palpation to determine fetal presentation & position.
What does the first maneuver help with? Helps determine fetal presentation. If palpate hard-head; soft & irregular-butt
What does the second maneuver help with? Helps determine fetal position. Smooth, rounded-the back.
What does the third maneuver help with? Helps validate the presenting part.
What does the fourth maneuver help with? Helps determine fetal attitude.
What does the second stage of labor begin with? Begins with complete dilation of the cervix & ends with birth of the baby.
What is the freq, duration, & Intensity of ctx during the second stage of labor? F-q1.5-2hrs; D-60-90secs; I-Strong & board like
What is the time frame before giving birth for the second stage of labor for a nullipara & multipara? N- up to 3hours; M-<1hr. Avg 15 minutes
What is cardinal movements of labor? For the fetus to pass through birth canal, the fetal head & body must adjust to the passage by certain positional changes.
What is Descent? Continues downward movement of the fetus that is brought about by pressure of ctx. The head enters the inlet in occiput transverse or oblique position bc the pelvic inlet is widest from side to side
Waht is flexion? Pressure from the pelvic floor causes fetal head to bend forward onto chest. Important bc it causes smalles diameter of fetal head to present to maternial pelvic.
What is internal rotation? A 45-90degree rotation of the fetal head from OT-OA or OP position. Must occur for the fetal head to pass through the narrowest transverse (biparietal) diameter of pelvis, & bring back of the neck under symphysis pubis
What is extension? As the occiput passes under the symphsis pubis. it causes the head to exten and foremost parts of head are born.
What is restitution? Head is born in OA position & shoulders are transverse, with infants neck slightly twisted--neck turns & realigns itself with its shoulders and spine
What is external rotation? Fetal body rotates so that the shoulders are in A-P diameter of the maternal pelvis, which is the largest diameter of the outlet.Anterior shoulder is born under the symphsis pubis & posterior shoulder slides over the perineum.
What is expulsion? The rest of the body is delivered.
What does the third stage of labor begin with? Begins with the birth of the infant & ends with delivery of the placenta.
** Nursing care during third stage of labor? ** Have pitocin prepared & administer AFTER the placenta is delivered; observe for maternal blood loss & note firm uterine contractions
What is considered the the fourth stage of labor? 1-4 hours after the birth which the physiologic readjustment of the mother's body begins.
**What is nursing care during the fourth stage? Focuses on observing for hemorrhage & relieving discomfort. Important to assess V/S, fundus, bladder, lochia.
During the 4th stage: Rising maternal pulse 7/or falling B/P; often accompanied by low or no urine output could mean what? An early sign of hypovolemia caused by excessive blood loss(visible or concealed).
A soft boggy uterus could mean what? A poorly contracted uterus does not adquate compress large open vessels at the placental site, resulting in hemorrhage.
High uterine fundus, often displaced to one side Suggest a full bladder, which can interfere with uterine contraction & result in hemorrhage.
Lochia exceeding one saturated perineal pad per hour during 4th stage. Suggests hemorrhage; however, perineal pads vary in their absorbency, and this must be considered.
Intense perineal or vaginal pain, poorly relieved with analgesics Hematoma,usually of vaginal wall or perinum; signs of hypovolemia may occur with substantial blood loss into tissues.
Created by: wendi76