Maternal Midterm Reviewer PDF

FACTORS AFFECTING LABOR & DELIVERY PROCESS: Lies at the junction of the coronal and sagittal sutures Diamond shape COMPONENTS OF LABOR...

FACTORS AFFECTING LABOR & DELIVERY PROCESS: Lies at the junction of the coronal and sagittal sutures Diamond shape COMPONENTS OF LABOR Posterior fontanelle (Lambda) A. Passage Lies at the junction of the lambdoidal and sagittal sutures Triangular shape 2 Important Pelvic Measurements 1. Diagonal Conjugate (Anterior-posterior diameter of inlet) 2. Transverse Diameter of outlet Vertex - space between two fontanelles B. Passenger Sinciput- the area over the frontal bone Structure of the Fetal Skull: Occiput - the area over the occipital bone a. Cranium - uppermost portion, comprises 8 bones 4 superior bones (frontal, 2 parietal and occipital) Other 4 bones Diameters of the Fetal Skull: (sphenoid, ethmoid, 2 temporal) b. Chin (Mandible) a. Suboccipitobregmatic Inferior aspect of the occiput to the center of the anterior fontanelle Narrowest diameter (9.5 cm) b. Occipitofrontal Bridge of the nose to the occipital prominence 12 cm c. Occipitomental From chin to posterior fontanelle Widest anteroposterior diameter 13.5 cm Molding: Change in the shape of the fetal skull; overlapping of sutures Molding can decrease biparietal diameter by -1cm Lasts for 1 -2 days 4 ways of recording molding: Suture Lines - membranous interspaces 0 - bones are separated; sutures can be felt easily a. Sagittal Suture - joins the 2 parietal bones 1(+) - sutures apposed or just touching each other b. Coronal Suture -juncture of the frontal bones and 2 parietal 2(++) - sutures overlapping but reducible bones 3(+++) - sutures severely overlapping; not reducible c. Lambdoid Suture -juncture of the occipital bone and 2 parietal bones Fetal Presentation and Position: Fontanelles - membrane covered spaces found at the junction of the main suture lines Fetal Attitude Anterior fontanelle (Bregma) Describes the degree of flexion a fetus assumes during labor or relation of the fetal parts to each other. Attitude (Flexion of Fetus): a. Full Flexion (Good or Complete) Smallest anteroposterior diameter enters the pelvis b. Moderate Flexion (Military/Alert/Sinciput) Occipitofrontal diameter enters the pelvis c. Partial Extension (Brow) Brow is presented d. Poor Flexion (Face) Occipitomental enters the pelvis Engagement Settling of the presenting part of a fetus far enough into the pelvis to be at the level of the ischial spines Fetal Lie The widest part of the fetus (biparietal diameter or intertrochanteric) has passed through the pelvis (adequate relationship between the long axis of the fetal body and the long pelvic inlet) axis of a woman’s body. Causes of Non-engagement (Primipara) Abnormal presentation or position Abnormality of the fetal head Types of Fetal Presentation: CPD Combination of fetal lie and degree of fetal flexion In multiparas, engagement may or may not be present Floating A. Cephalic Presentation not engaged presenting part Most common; 95% Fetal head presents Dipping Acutely flexed head that touches the thorax/sternum and occipital fontanel presents. has descend but not reached ischial spines Types: Station ○ Vertex Ideal presenting part; most common type Relationship of the presenting part of a fetus to the level of the Aids in cervical dilatation and prevents such ischial spines complication (prolapsed umbilical cord) Measures the degree of fetal descent Caput succedaneum 0 (engagement) Swelling of the scalp in a ○ level of the ischial spines newborn. It is most often brought Minus stations (-) on by pressure from the uterus or ○ above the ischial spines vaginal wall during a head-first Plus stations (+) (vertex) delivery. o below the ischial spines Crowning the encirclement of the widest diameter of fetal head by the vulvar ring ○ the presenting part at the perineum, can be seen if the vulva is separated. (Station+3)  ○ Brow Fetal head is midway between full flexion (vertex) and hyperextension (face) along a longitudinal axis Moderately-extended head, brow presentation ○ Face Fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying in a C. Shoulder longitudinal axis. Face nearest the birth canal The presenting part is usually shoulder (acromion process), iliac ○ Mentum/Sinciput or Military crest, hand or elbow a fetal chin (mentum) is the point Transverse lie; fewer than 1% designated for reference during a vaginal Abdomen is distorted, fuller at sides examination. Moderately flexed head with the large Etiology: diamond-shaped anterior fontanelle Maternal cause: presenting Relaxed abdominal walls (multiparity) & uterine muscles B. Breech Pelvic contraction and pelvis Fetal cause Either buttocks or feet in contact with the cervix Occur 3% of births and affected by fetal attitude Placenta previa Etiology: Prematurity Polyhydramnios Prematurity Multiple pregnancy Multiple (or multifetal) pregnancy (twins, triplets or more) Abnormal volume of amniotic fluid (poly and oligohydramnios) Delivery: CS Fetal anomalies Uterine abnormalities Complications: Prior CS Types: (Breech) Obstructed labor, may lead to rupture of uterus-and ○ Complete/Full(10%) fetal-hypoxia The baby's hips and knees are flexed so that the baby is sitting cross-legged,with feet beside the bottom. Good flexion; buttocks and small foot parts Fetal Position: are felt Position relationship of the presenting part to a specific quadrant of a woman's pelvis Indicated by an abbreviation of 3 letters ○ Middle letter - fetal landmark ○ First letter -whether pointing to mother's right or left ○ Last letter - whether pointing anteriorly (A), posteriorly (P),or transverse(t) Influence the process and efficiency of labor ○ Frank/Incomplete (65%) LOA (most common and ideal) and ROA (frequent) The baby’s bottom comes first, and his or her legs are flexed at the hip and extended Maternal Pelvis: at the knees (with feet near the ears) divided into 4 quadrants according to right and left 65-60% of the breech babies are in the 1. right anterior frank breech position. 2. left anterior 3. right posterior 4. left posterior 4 Fetal landmarks (describe relationship of presenting part to pelvis): 1. Occiput (O) – vertex presentation 2. Chin/Mentum (M) – face presentation 3. Sacrum (S) – breech presentation 4. Scapula or acromion process (A) – shoulder presentation Possible Fetal Positions: ○ Footling(25%) One or both feet come first, with the bottom a. Vertex Presentation (Occiput) at a higher position. LOA rare at term but relatively common with ○ most common; ideal position premature fetuses. ○ Head is acutely flexed; fetal occiput points left maternal abdominal wall (anterior) ○ Fetus facing towards mother's right back LOP  ○ head is acutely flexed; occiput points towards the left maternal back of sacrum (posterior) LOT or ROT ○ head is acutely flexed; occiput points to either left or right side of the mother ROA ○ head is acutely flexed; occiput points toward the right maternal abdominal wall ROP ○ head is acutely flexed; occiput is pointing toward the right maternal back/or sacrum. b. Breech Presentation (Sacrum) LSA/RSA Importance of Determining Fetal Presentation and Position: ○ fetal sacrum points towards the left or right maternal abdominal wall Determine possible risk: LSP/RSP ○ fetal sacrum points towards the left or right Narrow pelvis maternal back or sacral region Rupture membranes (infection) LST/RST Fetal anoxia and meconium staining at birth ○ fetal sacrum points towards the left or right side of the mother 4 Methods (Determine Fetal Positions): 1. Leopold’s Maneuvers 2. Vaginal Examination c. Face Presentation (Mentum) 3. Auscultation of FHT LMA, LMP, LMT, RMA, RMP, RMT 4. Sonography Causes ○ Grand multiparous patients ○ Large fetus and contracted pelvis ○ Neck swelling (e.g. Cystic Hygroma, c. Powers of Labor Thyroid Goiter) Implemented by. ○ Anencephaly Uterine contractions Abdominal muscle contraction d. Shoulder Presentation (Acromion Process) LADA/RADA Uterine Contractions: ○ acromio-dorso points towards the left/right maternal abdominal wall a. Origins LADP/RADP ○ acromio-dorso points towards the Begin at pacemaker point (myometrium near one of the right-maternal back or sacral region uterotubal junctions) Uncoordinated contractions may slow labor & can lead to: Mechanisms (Cardinal Movements) of Labor: Failure to progress Fetal distress a. Descent downward movement of the biparietal diameter of the b. Phases of Contraction: fetal head to within the pelvic inlet b. Flexion 1. Increment - intensity increases ("building up"-of contraction) head bends forward onto the chest, making the 2. Acme - contraction at its strongest smallest anteroposterior diameter the one presented 3. Decrement - intensity decreases ("letting up") to the birth canal c. Internal Rotation head flexes as it touches the pelvic floor end the occiput rotates until it is superior, or just below the symphysis pubis bringing the into the pelvic outlet d. Extension as the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. ○ The head extends, and the foremost parts of the head, the face and the chin are born e. External Rotation (Restitution) Characteristics of Uterine Contractions: head rotates back to diagonal or transverse position of the early part of labor 1. Interval or Resting Period ○ Brings the upcoming shoulders into Denotes the time from the end of one contraction to anteroposterior position (Shoulder Rotation) the start of the next contraction f. Expulsion - once shoulders are born, the rest of the baby born Expressed in minutes easily and smoothly Decreases from 10 minutes early in labor to only 2 to 3 minutes  Frequency minus duration = Interval o cervical canal ½ of its original length (now about 1 Interval is the best time to: cm) 75% 1. Auscultate FHT o cervical canal ¼ of its original length (now about ½ 2. Check maternal BP cm) 3. Deliver fetal head in extension 100% o no more canal or "paper-thin" (fully effaced cervix) 2. Duration length contractions last the time from the start of increment of one contraction to the end of decrement. expressed in seconds increasing from 20-30 seconds to a range of 60-90 seconds. 3. Frequency How often contractions are felt The time interval between the start of one contraction to the start of the next contraction Assessed by noting the number of contractions in 10 minutes b. Dilatation - enlargement or widening of the cervical canal Expressed in minutes Reasons why occur: 4. Intensity Uterine contractions gradually increase the diameter of the Strength of a contraction at acme cervical canal lumen by pulling the cervix up over the presenting Estimated by palpating the contraction part of the fetus Classification: Fluid-filled membranes press against the cervix o Mild -Uterine wall can be indented with ease Dilatations: o Moderate - Uterine wall can be indented with difficulty o Strong -Uterine wall can no longer be indented Expressed in centimeters (cm) One fingerbreadth is approximately 1.0 to 1.5 cm in width Fully dilated is approximately 10 cm c. Contour Changes Closed cervix ○ one finger cannot be accommodate through the Become elongated cervical os Open cervix 2 distinct functioning areas: ○ at least 1 finger can pass through the cervical os 1. Upper portion - thicker and active 2. Lower segment- thin-walled, supple and passive Physiologic Retraction Ring: Boundary between the two portions or areas Pathologic Retraction Ring (Bandl's Ring): Normal physiologic retraction ring is prominent and with observable abdominal indentation Signifies impending rupture of lower uterine segment d. Psyche (obstruction not relieved) Psychological state or feelings that a woman brings into labor Feeling of apprehension or fright; excitement or awe Cervical Changes: THEORIES OF LABOR ONSET: a. Effacement 1. Uterine muscle stretching – results in the release of prostaglandins shortening and thinning of the cervical canal 2. Pressure on the cervix – stimulates the release of oxytocin o Long and Thick - uneffaced from post pituitary o Short and Thin - effaced 3. Oxytocin Stimulation works together with prostaglandins to Note: initiate contractions 4. Change in ratio of estrogen to progesterone The cervix of the primigravida effaces first before it dilates In 5. Placental age multipara, effacement and dilatation generally progresses 6. Rising fetal cortisol levels, which reduce progesterone formation together. and increase prostaglandin formation 7. Fetal membrane production of prostaglandins, which stimulates contraction Estimation of the degree of thickness: Preliminary Signs: 0% 1. Lightening or descent o cervical canal uneffaced with original length of 2 cm Primiparas 25% ○ occurs approximately 10 to 14 days before o cervical canal ¾ of its original length (now about 1.5 labor begins cm) Multiparas 50%  ○ usually on the day of labor or even after labor has begun Effect: ○ Shooting leg pains ○ Increased amount of vaginal discharge ○ Urinary frequency 2. Increased in Level of Activity Related to increase in epinephrine release Prepares the woman’s body 3. Braxton Hicks Contractions Last week or days before labor begins SIGNS OF LABOR: Difference between True and False Labor Contractions: Signs of True Labor: Values/Importance of Partograph: 1. Uterine Contractions Surest sign, productive contractions Prevention of prolonged or augmented labor 2. Show Improvement in maternal outcomes Mucus plug is expelled with blood (pink tinged) Improvement in neonatal outcomes Show or bloody show 3. Rupture of Membranes Principles of Partograph use: Sudden gush or scanty, slow seeping of clear fluid from the vagina 1. The active phase of labor commence at 3cm cervical dilatation 2. The latent phase of labor should last not longer than 8 hours Partograph 3. During active labor, the rate of cervical dilatation should be not An inexpensive, effective and pragmatic tool which presents a slower than 1cm/hr graphical depiction of a labor "curve" 4. A lag of 4 hours between a slowing of labor and the need for Can be used to assess labor and its progress intervention is unlikely to compromise the fetus or the mother Evaluates progress of labor in terms of cervical dilatation in and avoids unnecessary intervention. centimeters against duration of labor in hours 5. Vaginal examination should be performed as infrequently as is Begins to use in the active phase of labor with 3cm or more compatible with safe practice. (once every 4 hrs) cervical dilatation uterine contractions of two or more in 10 mins 6. The partograph shows graphically the rate of progress of labor: each lasting 20 seconds or more. a. rate of cervical dilatation b. rate of fetal descent c. duration and frequency of uterine contractions d. monitoring vital signs 7. The partograph should be enlarged to full size before use.  May experience momentary nausea or vomiting: diaphoresis, distended neck veins Perineum bulge and tense; anus everted and stool may be expelled: crowning C. Third Stage (Placental Stage) From the birth of the infant and ends with the delivery of the placenta Uterus after birth of infant: firm, round mass inferior to the level of the umbilicus After few minutes of rest; uterus is discoid shape till placental separation (approximately 5 minutes after birth of infant) 2 Phases: STAGES OF LABOR: 1. Placental Separation Active bleeding on maternal surface of placenta A. Stage 1 begins with separation: sinking at the lower uterine 1st stage of dilatation segment of upper vagina From true labor contractions and ends with full Signs: dilatation of the cervix (10cm) ○ Lengthening of the umbilical cord (most PHASES: definitive sign) ○ Sudden gush of vaginal blood 1. Latent Phase/Preparatory Phase ○ Change in the shape of the uterus (Calkin's sign) Begins at onset of regular contractions and ends with rapid ○ Firm contraction of the uterus cervical dilatation begins ○ Appearance of placenta at the vaginal Contractions: mild, short; lasting 20 to 40 seconds opening Cervical effacement occurs Cervix dilates from 0 to 3 cm Lasts approximately 6 hrs (nullipara); 4.5 hrs (multipara) Reasons for prolonged latent phase: Analgesia CPD 2. Active Phase Cervical dilatation occurs rapidly (from 4 to 7 cm) Contractions: stronger, lasting 40 to 60 seconds: every 3 to 5 Kinds of Placental Delivery: minutes Lasts approximately 3 hrs (nullipara) 2 hrs (multipara) 1. Schultze placenta (Shiny) Show and spontaneous rupture of membranes may occur Placenta separates at the center and last on its edges Can be exciting and frightening time for mother Fetal surface evident 3 Periods: Shiny and glistening from the fetal membranes 1. Acceleration Approximately 80% 4-5 cm 2. Duncan Placenta (Dirty) 2. Maximum slope Placenta separates first at its edges 5-9 cm Maternal surface evident rapid cervical dilatation (ave. 3.5 cm/hr in Looks raw, red and irregular with ridges or cotyledons nulliparas; 5-9 cm/hr in multiparas) showing 3. Transition Phase Contractions reach its peak of intensity; every 2 to 3 minutes; lasting 60 to 9o seconds Maximum dilatation of 8 to 10 cm Spontaneous rupture of membranes and show appear Both full dilatation (10 cm) and complete cervical effacement have occurred Experience intense discomfort accompanied by nausea and vomiting; loss of control, anxiety; panic; or irritability B. Second Stage 2. Placental Expulsion From full dilatation and cervical effacement to birth of the infant Delivery of the placenta Takes about 1 hour a. Natural bearing down Contractions pattern: from crescendo-decrescendo to b. Crede's Maneuver uncontrollable urge to push or bear down gentle pressure on the contracted uterine fundus  c. Manual delivery Inspecting Placenta for Completeness and Normality: a. Assessing Placental membranes Assess amniotic membranes (chorion and amnion) Chorion - thicker membranes, nearer the maternal side and helps from the placenta; maximum amount of 1,000 mL at 36-38 weeks gestation. Amnion - thinner membrane nearer the fetal side; secretes amniotic fluid. Can be peeled from the chorion up to the cord Membranes are recorded as: Complete Half- retained Ragged membranes b. Assessing the Maternal Side 1. Remove the blood clots from the maternal side (assess amount of blood loss) 2. Determine health of maternal side Normal (dark-bluish red color and firm consistency) Determine completeness of cotyledons (about 15- 20); fits together if laid flat on a surface c. Assessing the Fetal Side 1. Check the umbilical cord for INSERTION (central attachment) Battledore placenta - marginally attached cord 2. Measure the LENGTH usually 55-60 cm (mean = 55cm) Short (less than 35-40 cm) ○ 3% ○ Uterine inversion and abruption placenta (may result) Longer (greater than 70cm) ○ 4% ○ Nuchal cord and cord prolapse (may result) 3. Check for presence of 3 blood vessels 2 arteries and 1 vein Incomplete may be associated with genitourinary problems Measuring Weight of Placenta: Ligamentum Teres - vein after cord clamping Mature placenta weights about 500 grams or ⅙ of the weight of Umbilical Ligamenta - arteries after cord clamping the baby at term. 20 cm in diameter and 1 inch in thickness. Detecting Abnormalities: 1. Soft and mushy maternal side: unhealthy placenta 2. Greenish membranes and cord: meconium - stained (meconium aspiration syndrome) 3. Placenta succenturiata: has an accessory lobe of placental tissue in the fetal sac membrane with blood vessels running to the main placenta most significant; extra lobe can be retained in utero (profuse postpartal bleeding) 4. Placenta Circumvallata: placenta has double layer of amnion and chorion which has undergone infarction. 5. Placenta bipartita: placenta has 2 complete or almost complete lobes. 6. Placenta tripartita: has 3 complete or almost complete lobes 7. Edema of the placenta: placenta is large and pale, with water oozing from it. Associating with hydrops fetalis (most serious form of hemolytic disease of the newborn) 8. Placenta Velamentosa: cord is inserted into the membranes of the fetal sac 5-10 cm from the edge of the placenta, with umbilical blood vessels running between placenta and cord. 9. Battledore placenta: cord is situated at the very edge of the placenta DANGER SIGNS OF DURING LABOR AND DELIVERY: a. Fetal Danger Signs 1. High or Low Fetal Heart Rate Fetal tachycardia (more than 160 bpm) ○ sign of possible fetal distress ○ late or variable deceleration pattern (important sign 2. Meconium Staining Green color in the amniotic fluid May indicate fetal hypoxia 3. Hyperactivity May be a sign of hypoxia 4. Fetal Acidosis Scalp capillary technique - blood analysis ○ Blood pH lower than 7.2 Compromised fetal wellbeing b. Maternal Danger Signs 1. Rising Blood Pressure (PIH) Systolic pressure - greater than 140 mmHg (increase of more than 30 mmHg) Diastolic pressure - greater than 90 mmHg (increase of more than 15 mmHg) Falling Blood Pressure ○ Associated with other signs of shock (apprehension, increased PR, and pallor ○ Indicate hemorrhage 2. Abnormal Pulse greater than 100 bpm Indication of hemorrhage 3. Inadequate Contractions (hypotonicity) Inertia - less frequent, less intense, shorter in duration Prolonged Contractions (hypertonicity) ○ Contractions lasting than 70 seconds 4. Pathologic Retraction Ring indentation across a woman’s abdomen Sign of extreme uterine stress and possible impending uterine rupture Periodic assessment of abdominal contour during labor 5. Abnormal Lower Abdominal Contour may indicate full bladder (round, bulge) May injure the bladder and may not allow fetal head to descend 6. Increasing Apprehension can be a sign of oxygen deprivation of internal hemorrhage 7. Prolapse of the cord or any of the small parts (hand or feet) 8. Difficult labor (dystocia) more than 24 hours  9. Bleeding, moderate, or profuse may be due tooo: Suck hard candy or ice chips Placenta previa Administration of IV fluids Abruptio placenta Amniotomy – artificial rupture of membranes Uterine rupture ○ Allows fetal descend and increase Uterine inversion contractions Uterine atony ○ At least 3 cm dilated Lacerated soft parts ○ Amniohook or hemostat 10. Non-palpation of the fetal head at the lower abdomen (abnormal presentation 11. Excessive bleeding after birth of the baby (postpartal hemorrhage) normal blood loss (250-300 mL) 500 mL or more (sign of postpartal hemorrhage) 12. Prolonged separation and delivery of the placenta more than 30 minutes after delivery of the baby Placenta Acreta - placenta partially grown into the myometrium Placenta Increta - placenta is totally grown into the myometrium Care of a Woman During The 2nd Stage of Labor: Support person Experienced health care provider Assessment of FHT a. Preparing the Place of Birth Labor room Delivery room Postpartum room b. Birthing Room Convert the room for the mother and newborn ○ table with equipment ○ baby island or newborn care area (radiant heat warmer, suction and resuscitation, eye prophylaxis, and identification of newborn) CARE OF CLIENTS DURING LABOR AND DELIVERY: Care of Woman During The 1st Stage of Labor: a. Powerlessness r/t duration of labor Pain relief – priority need Respect contraction time (breathing exercises) Promote change of positions c. Positioning for Birth ○ walk, sit, kneel or squat Lithotomy position ○ lie (side) ruptured membrane Alternative positions: ○ remain in bed (narcotic is given) ○ Lateral or sim’s Provide voiding and promote bladder care (q 2 to 4 ○ Dorsal recumbent hrs) ○ Semi-sitting b. Risk for ineffective breathing pattern r/t breathing exercises ○ Squatting Hyperventilation: ○ Adv. ○ Light headed Less tension on the perineum ○ Tingling or numbness (toes and fingers) Fewer perineal tears ○ May lead to coma d. Promoting Effective Second-Stage Pushing ○ Mgt: Allow to push if with urge Keep paper bag nearby Best positions: semi-Fowler’s, squatting or all fours (breathing exercises) position Cupped hands Urge to breathe out during a pushing effort to prevent c. Anxiety r/t stress of labor valsalva maneuver; diminished feto-placental Depends on person’s perception of the event, support exchange and diminished perfusion of oxygen across people and past experience the placenta Offer support (touch and contact) Multiparas – instruct to pant with contractions during Respect and promote the support person’s activities second stage Support a woman’s pain management efforts (breathing techniques; analgesia) When to Push: d. Risk for fluid volume deficit r/t prolonged lack of oral intake 1. In the second stage of labor or from the moment the cervix is and diaphoresis from the effort of labor fully dilated (10 cm open) Apply creams on lips 2. During a uterine contraction  3. Third stage of labor, the woman may be coached to push to May be done without anesthesia (natural) or pudendal deliver a fullyseparated placenta block g. Birth When not to Push: Ritgen Maneuver – sterile towel is placed over the rectum and 1. During the 1st stage of labor press forward on the fetal chin while the other hand is pressed Pushing may result to: downward on the occiput. ○ Greater maternal fatigue Helps achieve extension ○ Added fetal strain Controls the rate at which the head is born ○ Possible injury to the fetal presenting part Done if fetus is prominent (caput succedanum) ○ Cervical edema ○ Cervical bruising or trauma 2. At intervals of contraction Can result to: ○ Added maternal fatigue ○ Added fetal strain ○ Overstretching of the transverse cervical uterine ligaments, which can predispose to uterine prolapse 3. In crowning May cause perineal lacerations 4. When has a cardiac disease Suction infants mouth immediately after birth of the head (bulb syringe) e. Perineal Cleaning (Sterile prep) Pass fingers along the occiput to the newborn’s neck (nuchal Purposes: cord) 1. To prevent infection ○ loosen and draw down over the fetal head 2. Increase visibility of the area ○ clamped and cut if tightly coiled Clean with warmed antiseptic and rinse Apply gentle pressure after expulsion of head to deliver with designated solution shoulder From vagina outward Note time of birth and sex of infan Include a wide area (vulva, upper inner h. Cutting and Clamping the Cord thigh, pubis and anus) Head in slightly dependent position (allow secretions to drain) Sterile drapes are placed Place newborn over mothers abdomen f. Episiotomy – surgical incision of the perineum Clamp with 2 kelly hemostats (8 to 10 inches from infant’s Purpose: umbilicus) 1. To prevent tearing of the perineum Umbilical clamp is applied 2. To release pressure on the fetal head with birth Count number of vessels Midline episiotomy: Midline of the perineum Heals more easily, cause less blood loss, less postpartal discomfort Delay cutting of the cord (advantage): Allow as much as 100 mL of blood to pass Adequate RBC count Delay cutting of the cord (disadvantage): Over infusion with placental blood Possibility of polycythemia and hyperbilirubinemia i. Introducing the Infant Mediolateral: Wrap in sterile blanket Begun at midline but directed laterally away from the rectum Hold newborn firmly Tearing is away from the rectum (less danger of complications Lay on radian heat warmer and dry well from rectal mucosal tears) Care of a Woman During the 3rd and 4th Stage of Labor Advantages (episotomy): 1. Clean cut instead of rugged tears a. Oxytocin (Pitocin) 2. Minimize pressure on the fetal head Increase uterine contraction and minimizes bleeding 3. Shorten last portion of second stage of labor  IM or IV Free of connecting wire that could hamper Given: movements during labor ○ 20 to 40 U/L (IV) Internal pressure uterine lead is inserted and fetal ○ 10 U (IM) scalp electrode is attached Obtain BP prior to administration Radio transmitter is placed in the vagina b. Placental Delivery FETAL HEART RATES AND UTERINE CONTRACTION RECORDS Manual or spontaneous delivery Note the placenta Fetal Heart Rate Patterns: a. Baseline Fetal Heart Rate c. Perineal Repair Analyze baseline FHT in a 10 minute tracing Episiorraphy Normal rate (120 to 160 bpm) Abnormal rate: bradycardia and tachycardia b. Variability Long-term and short-term c. Periodic Changes 1. Accelerations Temporary normal increase in FHR (fetal movement of umbilical vein compression during contraction) 2. Early Accelerations Periodic decrease resulting from pressure on the fetal head during contractions d. Immediate Postpartum Assessment and Nursing Care 1. After repair, simultaneously remove the legs from the stirrups 2. Obtain VS every 15 mins (first hour) 3. Palpate fundus (size, consistency, position) 4. Observe amount and characteristics of lochia 5. Perform perineal care and apply perineal pad 6. Clean the area 7. Offer clean gown, warm blanket e. Aftercare (postpartal period or 4th Stage) Check the uterus MATERNAL AND FETAL ASSESSMENT DURING LABOR Immediate Assessment of a Woman in Stage 1: a. Initial Interview and Physical Examination EDB Frequency, duration and intensity of contraction Amount and character of show Membranes VS Last meal Known allergies Past and previous pregnancy history Birth plan b. Detailed Assessment During the 1st Stage of Labor 1. History Current pregnancy history Past pregnancy history Past health history Family medical history 2. Physical Examination NURSING CARE TO PROMOTE THE COMFORT OF A WOMAN Abdominal assessment DURING LABOR: Head to toe 3. Leopold’s Maneuvers 1. Reduce anxiety with explanations of the labor process 4. Assessing Rupture of Membranes Natural methods of pain relief 5. Vaginal Examination Scale pain (1 to 10) 6. Pelvic Adequacy Explain characteristics of contractions and reinstruct Sonography 2. Help woman identify coping strategies 7. Vital Signs 3. Provide comfort measures 8. Laboratory Analysis Assist woman’s support person 9. Uterine Contractions Change in position Length, intensity and frequency Ice chips, moistening lips (dry lips) Cool cloth to wipe perspiration Initial Fetal Assessment: Change rubber pads/protectors a. Auscultation of Fetal Heart Sounds Change beddings b. Electronic Monitoring Change gowns External and Internal Electronic Monitoring 4. Encourage comfortable positioning c. Telemetry (both FHR and uterine contractions) Upright, sitting, walking position  Pelvic rocking (between contractions) Late compliction: 5. Assist the woman with prepared childbirth method ○ Postpartal dural puncture Breathing exercises, distraction by focusing, headache (PDPH) or “Spinal acupressure, therapeutic touch, music therapy, headache guided imagery, self-hypnosis or combination of these Physical & Psychological Preparation of methods the Client: Massage ○ Explanation of the procedure 6. Provide pharmacological pain relief ○ Securing informed consent Analgesia: ○ Comfort & privacy (proper A. Narcotic Analgesia positioning, draping, constant Cause fetal CNS depression feedback, therapeutic touch) Common narcotics : ○ Meperidine hydrochloride POST PARTUM (Demerol) ○ Morphine Sulfate Postpartal period or Puerperium (4th trimester of Pregnancy) ○ Nalbuphine (Nubain) 6 week period after childbirth ○ Fentanyl (Sublimaze) Maternal changes: ○ Butorphanol tartrate (Stadol) a. Retrogressive (uterine and vagal involution) ○ Naloxone (Narcan) – narcotic b. Progressive (productin of milk for lactation, antagonist restoration of normal menstrual cycle, and beginning B. Intrathecal Narcotics of a parenting role) Injection into the spinal cord Catheter is introduced (Subarachnoid Physiological Changes of the Postpartal Period space) A. Reproductive System Changes Morphine or fentanyl citrate 1. Uterus Possible S/E: involution of uterus ○ intense pruritus Immediately after birth - weighs about ○ nausea and vomiting 1,000 grams C. Regional Anesthesia End of 1st week - weighs 500 grams Injection of a local anesthetic such as 6 weeks - weighs 50 grams chloroprocaine (Nesacaine) or bupivacaine 2 Main Process: (Marcaine) to block the specific nerve 1. Area where placenta was implanted is sealed off to prevent pathways bleeding Blocks sodium and potassium transport in 2. Organ is reduced to its approximate progestational size the nerve membrane Allows woman to be awake; do not depress Cause of delay uterine involution: uterine tone Birth of multiple fetuses D. Epidural Anesthesia (Peridural block) Hydraminos Anesthesia placed just inside the Exhaustion from prolonged labor or a difficult birth ligamentum flavum in the epidural space Grand multiparity Epidural space at L4-5, L3-4 or L2-3 Physiologic effects of excessive analgesia Chief concern (Epidural) ○ Hypotension 2. Lochia ○ How to reduce the risk: uteine flow, consisting of blood, fragments Combined use of of decidua, white blood cells, mucus, and fentanyl and some bacteria bupivacaine Characteristics: Proper hydration of IVF 1. Lochia Rubra (500 to 1,000 mL of red or bloody LR) discharge color Remain side lying 1-3 days post/partal (prevent SHS) day If anesthetic enters the Consists of blood, blood circulation: fragments of decidua Drowsiness, metallic and mucus state of tongue, slurred 2. Lochia Serosa speech, blurred vision, Pink or brownish in unconsciousness, color seizure leading to 3-10 days post/partal cardiac arrest day Mgt.: Composed of blood, Oxygen mucus, and invading Anticonvulsa leukocytes nt 3. Lochia Alba (Diazepam white or colorless or 10-14 days (may last 6 Theopental) weeks) IV Composed of largely Prompt mucus, leukocytes high delivery of in count the fetus 3. Cervix E. Spinal (Subarachnoid) Anesthesia After birthhh (soft and maleable) Local anesthetic is injected into the Internal and external os (open) subarachnoid space (L3 – L4) lumber End of 7 days (cervix is size of pencil space opening; cervix firm and nongravid)  Slitlike or Stellate (star shaped) after 2. Temperature rise for 2 consecutive days or more (Puerperal vaginal birth sepsis) 4. Vagina 3. Large, boddy, and painful/tender uterus (Puerperal sepsis) after birth (soft, with few rugea, greater than 4. Foul, profuse or scant lochia with characteristics inconsistent normal diameter) with the period of postpartum (Puerperal sepsis) hymen (permanently torn) 5. Poor descent of the fundus (Subinvolution) 5. Perineum 6. Swelling and redness of the breast (Mastitis) edematous and generalized tenderness 7. Pain or tenderness, redness and swelling in the calf of the leg Ecchymosis (surface) (Thrombophlebitis) Labia majora and minora (atrophic and 8. Severe post partal depression, suspiciousness and suicidal softened) tendency (Postpartal psychosis) 9. Painful urination with urgency or burning (UTI) B. Systemic Changes 1. Hormonal System NURSING CARE OF MOTHERS hormones decreases A. Safety Measures 2. Urinary System limitations of movement extensive diuresis (after birth); 3,000 mL/day (2nd - Protection from fall 5th day postpartum) Provision of adequate clothing, wound care Loss of bladder tone (full bladder) (episiotomy) Hydronephrosis or increased size of ureters (4 weeks B. Comfort Measures after birth) exercises 3. Circulatory System Limitations of lactation Assess blood loss Relief of discomfort High level of plasma fibrinogen Hygienic measures Increases in WBC Maintaining adequate nutrition 4. Gastrointestinal System C. Measures to Prevent Complications digestion and absorption (active again) ensuring adequate uterine contractions Bowel sounds are active Adequate monitoring Hemorrhoids (present) Early ambulation Prompt referral EFFECTS OF RETROGRESSIVE CHANGES D. Support for the psychological adjustment of the mother E. Health teaching needs of mother, newborn, family 1. Exhaustion F. Accurate documentation and reporting as needed 2. Weight loss weight loss of 55lb (2-4kg) 3. Vital Sign Changes temperature - slight increase during first 24 hours after birth Pulse - slightly slower than normal Blood Pressure - PROGRESSIVE CHANGES: 1. Lactation formation of breast milk Primary engagement ○ Feeling of tension in the breast on the 3rd and 4th day after delivery 2. Return of menstrual Flow 6-10 weeks after (non BF) 3-4 months (BF) - lactational amenorrhea TRANSITION PERIOD Movement or passage from one position or concept to another or a pause between what was and what is to be. PHASES OF PUERPERIUM: 1. Taking In usually sets 1-2 days after delivery Time of reflection for the woman because within the 2-3 day period, the woman is passive. Dependent 2. Taking Hold woman begins to initiate action Strong interest in taking care of her child 3. Letting Go redefines new role Gives up fantasized image of her child and accepts the real one Requires readjustment of relationships POSSIBLE COMPLICATION (POST PARTUM) 1. Rapid, thready pulse or increasing pulse rate with cold, clammy skin and signs of shock (Hypovolemic Shock)