Family Nursing OB Exam 2 Blueprint Answers PDF

# Family Nursing OB Exam 2 Blueprint Answers ## Family Nursing (Herzing University) ### Braxton Hicks contractions, True versus False labor NSG222.03.01.01 - Braxton Hicks Contractions - which the woman may have been experiencing throughout the pregnancy, may become stronger and more frequen...

# Family Nursing OB Exam 2 Blueprint Answers ## Family Nursing (Herzing University) ### Braxton Hicks contractions, True versus False labor NSG222.03.01.01 - Braxton Hicks Contractions - which the woman may have been experiencing throughout the pregnancy, may become stronger and more frequent - typically felt as a tightening or pulling sensation of the top of the uterus - occur primarily in the abdomen and groin and gradually spread downward before relaxing - true labor contractions are more commonly felt in the lower back - aid in moving the cervix from a posterior position to an anterior position - help in ripening and softening the cervix - irregular and can be decreased by walking, voiding, eating, increasing fluid intake, or changing position. - usually last about 30 seconds but can persist for as long as 2 minutes - As birth draws near and the uterus becomes more sensitive to oxytocin, the frequency and intensity increase - if the contractions last longer than 30 seconds and occur more often than 4-6x an hour, advise the woman to contact her health care provider so she can be evaluated for possible preterm labor, especially if she is less than 38 weeks pregnant ### True Versus False Labor - Not all contractions indicate labor - False labor is a condition occurring during the latter weeks of some pregnancies when irregular uterine contractions are felt, but the cervix is not affected - true labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity - contractions bring about progressive cervical dilation and effacement - False labor, prodromal labor, and Braxton Hicks contractions are all names for contractions that do not contribute in a measurable way toward the goal of birth - Distinguishing between true and false labor is an essential nursing assessment skill and one that develops with experience | Parameters | True Labor | False Labor | |:---|:---|:---| | Contraction timing | Regular, becoming closer together, usually 4-6 minutes apart | Irregular, not occurring closer together | | Contraction strength | Starts in the back and radiates toward the front; usually moderate to strong, increasingly strong and difficult to talk through | Usually weak, felt in the front of the abdomen with or alternating in a location; often not getting stronger with time | | Contraction discomfort | Become stronger with vaginal pressure around the bony pelvis | Usually weak, not strong | | Any change in activity | Contractions continue no matter what positional change is made, may even increase with ambulation. | Contractions usually slow down or stop with any change in the woman’s activity | | Stay home? | Stay home until contractions are 4 minutes apart and 40-60 seconds in duration. | Crave walking and push around a lot if there is walking or making changes and they feel strong, go to hospital, as contractions will intensify and get greater. (Stay home and rest) | *Reference:* Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., ... & Greene, M. F. (2019). Williams obstetrics (25th ed.). New York: McGraw-Hill Education; Jeffcoat, J. K., & Jensen, J. T. (2019). The Hospital & birth center: Prenatal and maternal care, labor & delivery and postpartum care (3rd ed.). Sudbury, MA: Jones & Bartlett Learning, and Jordan, J. C., & Fenly, K. R. (2019). Prenatal and postnatal care: A textbook for midwives and other primary caregivers. New York; London: Routledge. ### Passenger NSG222.03.01.02 - fetus (with placenta) is the passenger - fetal head (size and presence of molding), fetal attitude (degree of body flexion), fetal lie (relationship of body parts), fetal presentation (first body part), fetal position (relationship to maternal pelvis), fetal station, and fetal engagement are all important factors that have an impact on the ultimate outcome in the birthing process - Fetal Head - largest fetal structure, making it an important factor in labor and birth - There is considerable variation in the size and diameter of the fetal skull - large in proportion to the rest of the body, usually about 1/3 of the body length - bones that make up the face and cranial base are fused and essentially fixed - 5 bones that make up the rest of the cranium (2 frontal bones, 2 parietal bones, and the occipital bone - are soft and pliable, with gaps between the plates of bone - The gaps, membranous spaces between cranial bones, are called sutures, and the intersections of these sutures are called fontanelles - Sutures are important as they allow cranial bones to overlap in order for the head to adjust in shape (elongate) when pressure is exerted on it by uterine contractions or the maternal bony pelvis - Some diameters shorten, while others lengthen as the head is molded during the labor and birthing process - malleability of the fetal skull may decrease fetal skull dimensions by 0.5 to 1 cm - After birth, the sutures close as the bones grow and the brain reaches its full growth - newborn may occasionally endure minor physical injury during the childbirth process involving structural or tissue impairment: - Most are temporary and self-limiting with full recovery - changed (elongated) shape of the fetal skull at birth as a result of overlapping of the cranial bones is known as molding: - Along with molding, fluid can collect in the scalp (caput succedaneum) or blood can collect beneath the scalp (cephalohematoma), further distorting the shape and appearance of the fetal head - Caput succedaneum can be described as edema of the scalp at the presenting part - swelling crosses suture lines and disappears within 3-4 days - Cephalohematoma is a collection of blood between the periosteum and the bone that occurs 7 hours after birth - does not cross suture lines - generally reabsorbed over the next 6-8 weeks - Parents may become concerned about the distortion of their newborn's head - reassurance that the oblong shape is only temporary is usually all that is needed to reduce their anxiety - Sutures also play a role in helping to identify the position of the fetal head during a vaginal examination: - Duringexamination, palpation of these sutures by the examiner reveals the position of the fetal head and the degree of rotation that has occurred - anterior and posterior fontanelles are also useful in helping to identify the position of the fetal head - allow for molding, and are important when evaluating the newborn - anterior fontanelle is the famous “soft spot” of the newborn’s head: - is a diamond-shaped space that measures from 1-4 cm - remains open for 12-18 months after birth to allow for growth of the brain - posterior fontanelle corresponds to the anterior one but is located at the back of the fetal head: - is triangular - closes within 8-12 weeks after birth and on average - measures 1-2 cm at its widest diameter - Fetal Attitude - refers to the posturing (flexion or extension) of the joints and the relationship of fetal parts to one another - most common fetal attitude when labor begins is with all joints flexed— fetal back is rounded, the chin is on the chest, the thighs are flexed on the abdomen, and the legs are flexed at the knees - most favorable for vaginal birth, presenting the smallest fetal skull diameters to the pelvis - When the fetus presents to the pelvis with abnormal attitudes (no flexion or extension), their non-flexed position can increase the diameter of the presenting part as it passes through the pelvis, increasing the difficulty of birth - attitude of extension tends to present larger fetal skull diameters, which may make birth difficult - Fetal Lie - refers to the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother - 3 possible lies: - longitudinal (most common): - occurs when the long axis of the fetus is parallel to that of the mother (fetal spine to maternal spine side-by-side) - Transverse: - occurs when the long axis of the fetus is perpendicular to the long axis of the mother (fetal spine lies across the maternal abdomen and crosses her spine) - Oblique: - fetal long axis is at an angle to the bony inlet, and no palpable fetal part is presenting - usually transitory and occurs during fetal conversion between other lies - A fetus in a transverse or oblique lie position cannot be delivered vaginally - Fetal Presentation - refers to the body part of the fetus that enters the pelvic inlet first (“presenting part”) - is the fetal part that lies over the inlet of the pelvis or the cervical os - Knowing which fetal part is coming first at birth is critical for planning and initiating appropriate interventions - determined by abdominal palpation - 3 main presentations: - cephalic (head first): - majority of term newborns (95%) enter this world in this presentation - presenting part is usually the occipital portion of the fetal head - also referred to as a vertex (A) presentation - Variations in a vertex presentation include the military (B), brow (C), and facial (D) presentations - breech (pelvis first): - occurs when the fetal buttocks or feet enter the maternal pelvis first and the fetal skull enters last - abnormal presentation poses 7 challenges at birth - largest part of the fetus (skull) is born last and may become “hung up” or stuck in the pelvis - umbilical cord can become compressed between the fetal skull and the maternal pelvis after the fetal chest is born because the head is the last to exit - buttocks are soft and are not as effective as a cervical dilator during labor compared with a cephalic presentation - possibility of trauma to the head as a result of the lack of opportunity for molding. - types of breech presentations are determined by the positioning of the fetal legs - frank breech (50-70%), the buttocks present first with both legs extended up toward the face - can result in a vaginal birth - Image A - full or complete breech (5- 10%), the fetus sits crossed-legged above the cervix - generally necessitate a cesarean birth - Image B - footling or incomplete breech (10-30%), one or both legs are presenting - generally necessitate a cesarean birth - Image C and D - associated with prematurity, placenta previa, multiparity, uterine abnormalities (fibroids), and some congenital anomalies such as hydrocephaly - shoulder (scapula first): - approximately 2% - shoulder presentation or shoulder dystocia occurs when the fetal shoulders present first with the head tucked inside - signs of shoulder dystocia appear while the woman is pushing as the neonate’s head slowly extends and emerges over the perineum but then retracts back into the vagina, commonly referred to as the “turtle sign.” - Odds of a shoulder presentation are 1 in 300 births - fetus is in a transverse lie with the shoulder as the presenting part - Conditions associated include placenta previa, prematurity, high parity, premature rupture of membranes, multiple gestation, or fetal anomalies - cesarean birth is usually necessary if identified before labor begins but will be evaluated based on the length of gestation, size of the fetus, position of the placenta, and whether the membranes have ruptured - Fetal Position - describes the relationship of a given point on the presenting part of the fetus to a designated point of the maternal pelvis - landmark fetal presenting parts include: - occipital bone (O), which designates a vertex presentation - chin (mentum [M]), which designates a face presentation - buttocks (sacrum [S]), which designate a breech presentation - scapula (acromion process [A]), which designates a shoulder presentation - maternal pelvis is divided into 4 quadrants: - right anterior - left anterior - right posterior - left posterior - quadrants designate whether the presenting pa - determined by identifying first the presenting part and then the maternal quadrant the presenting part is facing - Position is indicated by a 3-letter abbreviation as follows: - first letter defines whether the presenting part is tilted toward the left (L) or the right (R) side of the maternal pelvis. - second letter represents the particular presenting part of the fetus: - O for occiput - S for sacrum (buttocks) - M for mentum (chin) - A for acromion process - D for dorsal (refers to the fetal back) when denoting the fetal position in shoulder presentations - third letter defines the location of the presenting part in relation to the anterior (A) portion of the maternal pelvis or the posterior (P) portion of the maternal pelvis - If the presenting part is directed to the side of the maternal pelvis, the fetal presentation is designated as transverse (T) - LOA is currently the most common (and most favorable) fetal position for birthing today, followed by right occiput anterior (ROA) - positioning of the fetus allows the fetal head to contour to the diameters of the maternal pelvis. - LOA and ROA are optimal positions for a vaginal birth - An occiput posterior position may lead to a long and difficult birth, and other positions may or may not be compatible with vaginal birth - refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines - measured in centimeters and is referred to as a minus or plus, depending on its location above or below the ischial spines - Typically, ischial spines are the narrowest part of the pelvis and are the natural measuring point for the birth progress - Zero (0) station is designated when the presenting part is at the level of the maternal ischial spines - When the presenting part is above the ischial spines, the distance is recorded as minus stations - presenting part is above the ischial spines by 1 cm, it is documented as being a −1 - When the presenting part is below the ischial spines, the distance is recorded as plus stations - presenting part is below the ischial spines by 1 cm, it is documented as being a +1 station. - easy way to understand this concept is to think in terms of meeting the goal, which is birth - If the fetus is descending downward (past the ischial spines) and moving toward meeting the goal of birth, then the station is positive and the centimeter numbers grow bigger from +1 to +4 - The closer the presenting part of the fetus is to the outside, the larger the positive number (+4 cm) - If the fetus is not descending past the ischial spines, the station is negative and the centimeter numbers grow from −1 to −4 - The farther away the presenting part from the outside, the larger the negative number (−4 cm) - Fetal Engagement - signifies the entrance of the largest diameter of the fetal presenting part (usually the fetal head) into the smallest diameter of the maternal pelvis - fetus is said to be engaged in the pelvis when the presenting part reaches 0 station - determined by pelvic examination. - largest diameter of the fetal head is the biparietal diameter - extends from one parietal prominence to the other - is an important factor in the navigation through the maternal pelvis - typically occurs in primigravidas 2 weeks before term - multiparas may experience engagement 7 weeks before the onset of labor or not until labor begins ### Position (Maternal) NSG222.03.01.03 - Positioning for normal labor and birth has evolved - sitting upright with flexed hips, squatting, or less commonly standing or kneeling during the childbirth - maintain flexion at the hip joint and somewhat straighten the pelvis - Childbirth medicalization has reduced laboring women’s opportunity in a spontaneous position of choice to a recumbent one - Scientific evidence has shown that nonmoving, back-lying positions during labor are not healthy - With an upright position, gravity can help in bringing the fetus down, and there is less risk of compressing the maternal aorta which supplies oxygen to the fetus - many women continue to lie flat on their backs during labor - Some of the reasons why this continues include the beliefs that: - laboring women need to conserve their energy and not tire themselves. - nurses cannot keep track of the whereabouts of ambulating women. - it is the preference of the health care provider. - the fetus can be monitored better in this position. - the supine position facilitates vaginal examinations and external belt adjustment. - a bed is “where one is supposed to be” in a hospital setting. - the position is more convenient for the delivering health care provider. - laboring women are connected to medical equipment that impedes movement - Women should be encouraged to assume any position of comfort for them - recent randomized controlled study, the use of a peanut-shaped ball that is placed between the woman’s legs during labor decreased the length of labor and increased the rate of vaginal births - associated with a significantly lower incidence of cesarean births - can be a potentially successful nursing intervention to help progress labor and support vaginal birth, along with position changes, for women laboring under epidural analgesia - If the only furniture provided is a bed, this is what the woman will use - Furnishing rooms with comfortable chairs, beanbags, and other birth props allows a woman to choose from a variety of positions and to be free to move around during labor - Changing positions and moving around during labor and birth offer 7 benefits - Maternal position can influence pelvic size and contours - Changing position and walking affect the pelvis joints, which may facilitate fetal descent and rotation - Squatting enlarges the pelvic inlet and outlet diameters - kneeling position removes pressure on the maternal vena cava and helps rotate the fetus from a posterior position to an anterior one to facilitate birth - use of any upright or lateral position compared to supine or lithotomy positions may: - reduce the length of the first stage of labor. - reduce the duration of the second stage of labor. - reduce the number of assisted deliveries (vacuum and forceps). - reduce episiotomies and perineal tears. - contribute to fewer abnormal fetal heart rate patterns. - increase comfort and reduce requests for pain medication. - enhance a sense of control by the mother. - alter the shape and size of the pelvis, which assists in descent. - assist gravity to move the fetus downward - National Institute for Health and Care Excellence (NICE) guidelines recommend discouraging women from lying supine or semi-supine during labor and encourage them to adapt to any other position that they find comfortable since lying on the back is associated with longer labor, increase in surgical births, increased pain, and a higher incidence of fetal heart rate abnormalities ### Partners NSG222.03.01.04 - Women desire support and attentive care during labor and birth - Caregivers can convey emotional support by offering their continued presence and words of encouragement - emotional, physical, and/or spiritual support during labor is the norm for most cultures - A caring partner can use massage, light touch, acupressure, hand-holding, stroking, and relaxation - can help the woman communicate her wishes to the staff; and can provide a continuous, reassuring presence, all of which bring some degree of comfort - presence of the mother’s significant other at the birth provides special emotional support, a partner can be anyone who is present to support the woman throughout the experience - many women, the essential ingredients for a safe and satisfying birth include a sense of empowerment and success in coping with or transcending the experience in addition to having solid, positive encouragement from a support companion - Worldwide, women usually support other women in childbirth - Doula is a Greek word meaning woman servant or caregiver - now commonly refers to a woman who offers emotional and practical support to a mother or couple before, during, and after childbirth - believes in “mothering the mother,” and clinical support remains the job of the midwife or medical staff - The continuous presence of a trained female support person reduces the need for medication for pain relief, use of vacuum or forceps delivery, and need for cesarean births - been associated with a slight reduction in the length of labor - is an experienced labor companion, provides the woman and her partner with emotional and physical support and information throughout the entire labor and birth experience - Continuous support by nurses includes reassurance, encouragement, praise, and explanation - Nursing care of women during labor should incorporate finding a way to connect with her and to understand what she is experiencing (knowing); spending time with her (presence); protecting her and preserving her dignity (doing for); providing information and explanations in a clear methodical manner (enabling); and ensuring a safe childbirth experience - laboring women should always have the option to receive partner support, whether from nurses, doulas, significant others, or family - the support partner should provide the mother with continuous presence and hands-on comfort and encouragement - overall objective of providing support for women during childbirth is to create a positive experience for her while preserving her physical and psychological health ### Basic client preparation NSG222.03.01.05 - Basic prenatal education can help women manage the labor process and feel in control of the birthing experience: - literature indicates that if a woman is prepared before the labor and birth experience, labor is more likely to remain natural without the need for medical intervention - evidence indicates that well-prepared women with good labor support is less likely to need analgesia or anesthesia and is less likely to require cesarean birth - Prenatal education teaches the woman about the childbirth experience and increases her sense of control - Is able to work as an active participant during the labor and birth experience - research suggests that prenatal preparation may affect intra- and postpartum psychosocial outcomes: - Ex. prenatal education covering parenting communication classes had a significant effect on postpartum anxiety and postpartum adjustment - Special consideration of each woman’s culture, age, cognitive skills, access to health information, and health literacy all impact her understanding of the content presented - Nurses play an essential role in providing evidence-based education throughout the prenatal period - Learning about labor and birth allows women and couples to express their needs and preferences ahead of time, enhance their confidence, and improve communication between themselves and staff - Pain Management - perception of pain can be influenced by a number of factors - past experiences of pain - culture and beliefs - Stoicism - anxiety and depression - To manage a client’s plan, nurses need to understand what it is and provide support to the laboring client to enable her to deal with the pain and challenges of labor - Labor and birth, though a normal physiologic process, can produce significant pain - Pain during labor is a nearly universal experience - Controlling the uterine discomfort without harm to the fetus or labor process is the major focus of pain management during childbirth - Pain is a subjective experience involving a complex interaction of physiologic, spiritual, psychosocial, cultural, and environmental influences - Cultural values and learned behaviors influence perception and response to pain, as do anxiety and fear, both of which tend to heighten the sense of pain - challenge for care providers is to find the right combination of pain management methods to keep the discomfort manageable while minimizing the negative effect on the fetus, the normal physiology of labor, maternal–infant bonding, breastfeeding, and a woman’s perception of the labor itself ### Table 13.2 Stages and phases of labor NSG222.03.01.06 Stages of Labor - Labor is typically divided into 4 stages: - Dilation: - first stage is the longest - begins with the first true contraction and ends with full dilation (opening) of the cervix. - divided into 2 phases, latent and active, each corresponding to the progressive dilation of the cervix - Expulsive: - second stage - begins when the cervix is completely dilated and ends with the birth of the newborn - can last from minutes to hours - contractions typically occur every 2-3 minutes, lasting 60-90 seconds and are strong by palpation - women are usually intent on the work of pushing - Placental: - third stage - starts after the newborn is born and ends with the separation and birth of the placenta - Continued uterine contractions typically cause the placenta to be expelled within 5-30 minutes - If the newborn is stable, bonding of infant and mother takes place through touching, holding, and skin-to-skin contact - Restorative: - fourth stage - Also called immediate postpartum period - lasts from 1-4 hours after birth - mother’s body begins to stabilize after the hard work of labor and the loss of the products of conception - often not recognized as a true stage of labor, but it is a critical period for maternal physiologic transition as well as new family attachment - Close monitoring of mother and her newborn are done ### First Stage - fundamental change underlying the process is progressive dilation of the cervix - Cervical dilation is gauged subjectively by vaginal examination and is expressed in centimeters - ends when the cervix is dilated to 10 cm in diameter and is large enough to permit the passage of a fetal head of average size - fetal membranes usually rupture during this stage, but they may have burst earlier or may even remain intact until birth - primigravida, this stage of labor can last up to 20 hours without being considered prolonged - time can vary widely - multiparous woman, it can last up to 14 hours - women usually perceive the visceral pain of diffuse abdominal cramping and uterine contractions - Pain is primarily a result of the dilation of the cervix and lower uterine segment, and the distention (stretching) of these structures during contractions - divided into 2 phases: - Latent/Early (0-6cm) - gives rise to the familiar signs and symptoms of labor - begins with the start of regular contractions and ends when rapid cervical dilation begins - cervix dilates slowly to approximately 6 cm - Sedation can increase the duration of this phase. - Contractions usually occur every 5-10 minutes, last 30-45 seconds, and are described as mild by palpation by the nurse - Active (6-10cm) - cervix dilates up to 6 cm. - contractions last from 40 to 60 seconds and are described as moderate by palpation - contraction duration moderately increases - contraction intensity moderate to strong by palpation ### Second Stage - begins with complete cervical dilation (10 cm) and effacement and ends with the birth of the newborn - previous stage of labor primarily involved the thinning and opening of the cervix, this stage involves moving the fetus through the birth canal and out of the body - cardinal movements of labor occur during the early phase of passive descent - Contractions occur every 2-3 minutes, last 60-90 seconds, and are described as strong by palpation - Parity, delayed pushing, use of epidural analgesia, maternal body mass index, birth weight, pelvis shape, occiput posterior position, and fetal station at complete dilation all have been shown to affect the length of the second stage of labor. - A longer duration is associated with adverse maternal outcomes ex. higher rates of puerperal infection, third- and fourth-degree perineal lacerations, and postpartum hemorrhage - mother usually feels more in control and less irritable and agitated - focused on the work of pushing: - maternal urge to push is generally felt when there is direct contact of the fetus to the pelvic floor - Stretch receptors in the wall of the vagina, rectum, and perineum communicate the pressure of the fetus descending in the birth canal that, along with increased abdominal pressure, causes the overwhelming urge to push described by laboring women - Pushing - active pushing is the time in which the laboring mother is feeling rectal pressure by the fetal presenting part and physiologically feels the urge to push - If the mother has an epidural in place, this sensation to push is dulled - perineum bulges, and there is an increase in bloody show - fetal head becomes apparent at the vaginal opening but disappears between contractions - When the top of the head no longer regresses between contractions, it is said to have crowned - fetus rotates as it maneuvers out - may last up to 3 hours in a first labor and up to 2 hours in subsequent ones - Spontaneous VS Directed Pushing - 2 ways of conducting the second stage of labor: - spontaneous pushing (following the mother’s spontaneous urge) - represents a natural way of managing the second stage of labor - directed pushing (pushing directed by the caregiver) - as a result of epidural analgesia, health care providers frequently resort to directed pushing without taking into account the negative repercussions it has on the woman and her fetus - physiologic approach focuses on spontaneous pushing as the mother feels the need rather than when she is directed, which can reduce fetal oxygenation - Evidence is mounting that the management of the second stage, particularly pushing, is a modifiable risk factor in long-term perinatal outcomes: - Traditionally, women have been taught to hold their breath to the count of 10, inhale again, push again, and repeat the process 7 times during a contraction - linked to hemodynamic changes in the mother and interferes with oxygen exchange between the mother and the fetus - associated with pelvic floor damage - longer the push, the more damage to the pelvic floor - health care providers sometimes resist delaying the onset of pushing after the second stage of labor has begun because of a belief that it will increase labor time - Delaying maternal bearing-down efforts during the second stage until the woman feels the urge to push (laboring down) allows for optimal use of maternal energy, has no detrimental maternal effects, and results in improved fetal oxygenation - delaying pushing for up to 90 minutes after complete cervical dilation resulted in a significant decrease in the time mothers spend pushing without a significant increase in total time in second stage of labor - World Health Organization (WHO) has recommended that during the second stage of labor, nurses should encourage and support women to follow their own urge to push and not direct it - Using an open-glottis method (involuntary pushing with expiratory grunting and vocalization) to push supports the mother’s involuntary bearing-down efforts - Behaviors demonstrated by laboring women during this time include: - pushing at the onset of the urge to bear down - using their own patterns and techniques of bearing down in response to sensations they experience - using open-glottis bearing down with contractions - pushing with variations in strength and duration - pushing down with progressive intensity - using multiple positions to increase progress and comfort - Labor nurses need to develop an evidence-based approach that acknowledges and reinforces women’s innate ability to give birth and refrain from trying to direct women’s pushing behaviors - Laboring down (promotion of passive descent) is an alternative strategy for second-stage management in women with epidurals - fetus descends and is born without coached maternal pushing ### Third Stage - begins with the birth of the newborn and ends with the separation and birth of the placenta - ideal placement for the newborn immediately following the birth is on the mother’s abdomen, in skin-to-skin contact which promotes a positive transition from intrauterine to extrauterine life - consists of 2 phases: - placental separation - After the infant is born, the uterus continues to contract strongly and can now retract, decreasing markedly in size - contractions cause the placenta to pull away from the uterine wall - The following signs of separation indicate that the placenta is ready to deliver - The uterus rises upward. - The umbilical cord lengthens. - A sudden trickle of blood is released from the vaginal opening. - The uterus changes its shape to globular - Spontaneous birth of the placenta occurs in 1 of 2 ways: - the fetal side (shiny gray side) presenting first (called Schultz's mechanism or more commonly called “shiny Schultz”) - maternal side (red raw side) presenting first (termed Duncan mechanism or “dirty Duncan”). - placental expulsion - After separation of the placenta from the uterine wall, continued uterine contractions cause the placenta to be expelled within 2-30 minutes unless there is gentle external traction to assist - After the placenta is expelled, the uterus is massaged briefly by the attending physician or midwife until it is firm so that uterine blood vessels constrict, minimizing the possibility of hemorrhage - Normal blood loss is approximately 500 mL for a vaginal birth and up to 1,000 mL for a cesarean birth - loss of over 1,000 mL is considered severe - If the placenta does not spontaneously deliver, the health care provider assists with its removal by manual extraction - On expulsion, the placenta is inspected for its intactness by the health care provider and the nurse to make sure all sections are present - If any piece is still attached to the uterine wall, it places the woman at risk for postpartum hemorrhage because it becomes a space-occupying object that interferes with the ability of the uterus to contract fully and effectively - Worldwide, approximately 800 women die each day from preventable causes related to childbirth - single most common cause is severe bleeding, which can kill a woman within hours if care is delayed - Postpartum hemorrhage occurs mostly during the third stage of labor, and active management of it can prevent its occurrence - Active management includes: - administration of a uterotonic agent after the birth - expulsion of the placenta with controlled traction of the cord - uterine fundal message after placental expulsion - Prompt and effective management is paramount to saving the lives of these women, and prevention measures can be initiated in the third stage of labor ### Fourth Stage - begins with completion of the expulsion of the placenta and membranes and ends with the initial physiologic adjustment and stabilization of the mother (1-4 hours after birth) - initiates the postpartum period - mother usually feels a sense of peace and excitement, is wide awake, and is initially talkative - attachment process begins with her inspecting her newborn and desiring to cuddle and breastfeed them - mother’s fundus should be firm and well contracted - Typically it is located at the midline between the umbilicus and the symphysis, but it then slowly rises to the level of the umbilicus during the first hour after birth - If the uterus becomes boggy, it is massaged to keep it firm - lochia (vaginal discharge) is red, mixed with small clots, and of moderate flow - If the woman has had an episiotomy during the second stage of labor, it should be intact with the edges approximated and clean and no redness or edema present. - focus during this stage is to monitor the mother closely to prevent hemorrhage, bladder distention, and venous thrombosis - Usually the mother is thirsty and hungry during this time and may request food and drink - Her bladder is hypotonic, and she has limited sensation to acknowledge a full bladder or to void - Vital signs, the amount and consistency of the lochia, and the uterine fundus are usually monitored every 15 minutes for at least 1 hour - women will be feeling cramp-like discomfort during this time due to the contracting uterus ### TABLE 13.1 Stages and Phases of Labor | Description | First Stage | Second Stage | Third Stage | Fourth Stage | |:---|:---|:---|:---|:---| | | From 0-10 cm dilation; consists of 2 phases: latent and active | From complete dilation of the cervix to birth of the newborn; may last up to 2 hours | Separation and delivery of the placenta; takes 5-30 minutes | 1-4 hours after delivery; time of maternal physiologic adjustment | | Phases | **Latent phase** (0-6 cm dilation): *Cervical effacement from 0%-40%* *Contraction frequency: every 5-10 minutes* *Contraction intensity: mild to moderate* *Contraction duration: 30-45 seconds* *May experience mild discomfort* *Contractions last 15-30 seconds* *Active phase* (6-10 cm dilation): *Cervical effacement from 40% to 100%* *Contraction frequency: every 2-5 minutes* *Contraction intensity: moderate to strong* *Contraction duration: 45-60 seconds* *Nulliparas, last up to 6 hours, multiparas, last up to 3 hours* | **Pelvic phase** (period of fetal descent) (*Period of maximal fetal descent*) *Contraction frequency: every 2-3 minutes* *Contraction intensity: moderate to strong* *Contraction duration: up to 60-90 seconds* **Perineal phase** (period of pushing) *Contraction frequency: every 1-2 minutes* *Contraction intensity: very strong*