MODULE 2 INTRAPARTUM PROCESSES OF LABOR AND BIRTH

MODULE 2 INTRAPARTUM PROCESSES OF LABOR AND BIRTH

• KEY FACTORS RELATED TO PROGRESS OF LABOR • FORCES OF LABOR • INTRAPARTAL ASSESSMENT AND CARE OF MOTHER AND FETUS • CARE OF MOTHER AND INFANT IN LABOR, DELIVERY, AND IMMEDIATE POST PARTUM • BIRTH RELATED PROCEDURES

MODULE 2 PART 1 KEY FACTORS RELATED TO PROGRESS OF LABOR THE PASSAGE

KEY FACTORS RELATED TO PROGRESS OF LABOR • • • PASSAGEWAY (BIRTH CANAL) PASSENGER (FETUS) POSITION OF THE MOTHER AND FETUS PHYSIOLOGICAL FORCES OF LABOR PSYCHOSOCIAL CONSIDERATIONS

BIRTH PASSAGE • • SIZE OF PELVIS TYPE OF PELVIS CERVICAL DILATATION, EFFACEMENT ABILITY OF VAGINA AND INTROITUS TO EXPAND

BIRTH PASSAGE • FOUR CLASSIC PELVIC TYPES • GYNECOID • ANDROID • ANTHROPOID • PLATYPELLOID

Figure 15– 1 Comparison of Caldwell-Moloy pelvic types.

BIRTH PASSAGE CERVICAL DILATATION AND EFFACEMENT • DILATATION—MEASURED IN CENTIMETERS FROM 0 TO 10 – 0 CM—CERIVX CLOSED – 10 CM—FULL DILATATION • EFFACEMENT—MEASURED IN PERCENTAGE 0 TO 100%

Figure 15– 11 a Effacement of the cervix in the primigravida. Beginning of labor. There is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid.

Figure 15– 11 b Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head.

Figure 15– 11 c Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic fluid exerts hydrostatic pressure.

Figure 15– 11 d Complete effacement and dilatation.

UTERINE AND CERVICAL CHANGES • UPPER UTERINE SEGMENT THICKENS AND PULLS UP • LOWER SEGMENT EXPANDS AND THINS OUT • EFFACEMENT • CAUSES OF UTERINE CHANGES – ESTROGEN STIMULATES MUSCLE CONTRACTIONS – COLLAGEN IN CERVIX BROKEN DOWN – INCREASED WATER CONTENT OF THE CERVIX

MODULE 2 PART 2 THE PASSENGER (FETUS)

• FETUS –SIZE OF FETAL HEAD –FETAL ATTITUDE –FETAL LIE –FETAL PRESENTATION –IMPLANTATION SITE OF PLACENTA

PASSENGER • FETAL HEAD • SUTURES – FRONTAL – SAGITTAL – CORONAL – LAMBOIDAL – MOLDING – FONTANELLES

Figure 15– 2 Superior view of the fetal skull.

PASSENGER LANDMARKS OF FETAL SKULL • MENTUM • SINCIPUT • ANTERIOR FONTANELLE (BREGMA) • VERTEX • POSTERIOR FONTANELLE • OCCIPUT

Figure 15– 4 a Typical anteroposterior diameters of the fetal skull. When the vertex of the fetus presents and the fetal head is flexed with the chin on the chest, the smallest anteroposterior diameter (suboccipitobregmatic) enters the birth canal.

Figure 15– 6 a Cephalic presentation. Vertex presentation. Complete flexion of the head allows the suboccipitobregmatic diameter to present to the pelvis.

Figure 15– 6 c Brow presentation. The fetal head is in partial (halfway) extension. The occipitomental diameter, which is the largest diameter of the fetal head, presents to the pelvis.

PASSENGER FETAL LIE AND PRESENTATION • FETAL LIE-- Relation of long axis of fetus to long axis of the mother – Longitudinal – Transverse • FETAL PRESENTATION—the body part of the fetus that first enters the pelvis

PASSENGER (PRESENTATION) CEPHALIC PRESENTATION (95%) • VERTEX—SUBOCCIPTOBREGMATIC • MILITARY--OCCIPITOFRONTAL • BROW--OCCIPITOMENTAL • FACE--SUBMENTOBREGMATIC

PASSENGER (PRESENTATION) BREECH PRESENTATION (3%) • COMPLETE—HIPS FLEXED, KNEES FLEXED • FRANK—HIPS FLEXED, KNEES EXTENDED • FOOTLING—HIPS & FEET EXTENDED, FEET, FOOT PRESENT TO MATERNAL PELVIS • KNEELING—HIPS EXTENDED, KNEES FLEXED

PASSENGER (PRESENTATION) SHOULDER (TRANSVERSE) PRESENTATION (2%) • TRANSVERSE LIE—SHOULDER IS USUAL PRESENTING PART • COMPOUND—USUALLY ARM OR HAND PRESENTING ALONG PRESENTING PART

MODULE 2 PART 3 POSITION OF MOTHER AND FETUS

POSITION OF FETUS IN RELATION TO MOTHER’S PELVIS ENGAGEMENT • WHEN THE WIDEST DIAMETER OF THE PRESENTING PART HAS REACHED OR PASSED THE PELVIC INLET • ENGAGMENT USUALLY CORRESPONDS TO O STATION • FLOATING—WHEN PRESENTING PART IS ENTIRELY OUT OF THE PELVIS AND FREELY MOVABLE IN THE INLET

Figure 15– 8 Measuring the station of the fetal head while it is descending. In this view the station is 22/23.

POSITION STATION • RELATIONSHIP OF FETAL PRESENTING PART TO THE LEVEL OF THE ISCHIAL SPINES – THE ISCHIAL SPINES ARE O STATION – ABOVE THE SPINES IS A NEGATIVE VALUE – BELOW THE SPINES IS A POSITIVE VALUE

FETAL POSITION IN RELATION TO MOTHER’S PELVIS • RIGHT OR LEFT SIDE OF MATERNAL PELVIS • ANTERIOR (A), POSTERIOR (P), OR TRANSVERSE (T) DETERMINES

• WHETHER LANDMARK IS IN FRONT, BACK OR SIDE OF PELVIS • LANDMARK OF FETAL PRESENTING PART: – (O) OCCIPUT, (M) MENTUM, (S) SACRUM, (A) ACROMION PROCESS

Figure 15– 9 Categories of presentation. Source: Courtesy Ross Laboratories, Columbus, OH.

MODULE 2 PART 4 A PHYSIOLOGICAL FORCES OF LABOR

PHYSIOLOGIC FORCES OF LABOR • PRIMARY FORCES—UTERINE MUSCLE CONTRACTIONS – CONTRACTION PHASES---INCREMENT, ACME, DECREMENT – DESCRIBED WITH FREQUENCY, DURATION, AND INTENSITY SECONDARY FORCES—ABDOMINAL MUSCLES USED IN PUSHING

PHYSIOLOGIC FORCES OF LABOR • FREQUENCY, DURATION, INTENSITY OF CONTRACTION • EFFECTIVENESS OF MATERNAL PUSHING • DURATION OF LABOR

CAUSES OF LABOR UNCLEAR • POSSIBLE CHANGES IN PROGESTERONE AND ESTROGEN LEVELS • RESEARCH ON POSSIBLE CAUSES – FETAL MEMBRANES, DECIDUAS – PROGESTERONE WITHDRAWAL, PROSTAGLANDIN – CORTICOTROPHIN-RELEASING HORMONE

LABOR • FORCES OF LABOR • FREQUENCY, DURATION, INTENSITY (STRENGTH) • THREE PHASES OF CONTRACTIONS – INCREMENT – ACME – DECREMENT

Figure 15– 10 Characteristics of uterine contractions.

SIGNS OF LABOR • • LIGHTENING BRAXTON HICKS CONTRACTIONS CERVIAL CHANGES BLOODY SHOW RUPTURE OF MEMBRANES SUDDEN BURST OF ENERGY WEIGHT LOSS N&V, DIARRHEA, BACKACHE

TRUE LABOR/FALSE LABOR • TRUE • CONTRACTIONS REGULAR, INCREASE IN DURATION & STRENGTH • INTERVAL SHORTENS • DILATATION & EFFACEMENT PROGRESS • INTENSITY INCREASES WITH WALKING • FALSE • CONTRACTIONS IRREGULAR, NO CHANGE IN DURATION, STRENGTH • INTERVAL IRREGULAR OR NO CHANGE • NO DILATATION OR EFFACEMENT • WALKING LESSENS OR HAS NO EFFECT ON CONTRACTIONS

MODULE 2 PART 4 B STAGES OF LABOR

• FIRST STAGE OF LABOR –STARTS WITH BEGINNING OF REGULAR CONTRACTIONS TO FULL DILATATION • FIRST STAGE IS DIVIDED INTO THREE PHASES: LATENT, ACTIVE, AND TRANSITION

PHASES OF LABOR—FIRST STAGE • LATENT---0 --3 CENTIMETERS, CONTINUING EFFACEMENT • ACTIVE---4 --7 CENTIMETERS, COMPLETE EFFACEMENT • TRANSITION 8 --10 CENTIMTERS ENGAGEMENT

CONTRACTION CHARACTERISTICS • LATENT PHASE – MILD— 10 -30 MIN. LASTING 20 -40 SECONDS – MODERATE— 5 -7 MIN. LASTING 30 -40 SECONDS • ACTIVE PHASE – MODERATE TO STRONG— 2 -3 MIN. LASTING 40 -60 SECONDS • TRANSITION – STRONG— 1 -1/2 -2 MIN. LASTING 60 -90 SECONDS

PSYCHOLOGIC ADAPTIONSTO LABOR: LATENT PHASE • FEELS ABLE TO COPE WITH DISCOMFORT • MAY BE RELIEVED THAT LABOR HAS FINALLY STARTED • USUALLY ABLE TO TALK THROUGH CONTRACTION • IS ABLE TO RECOGNIZE AND EXPRESS FEELING OF ANXIETY

PSYCHOLOGIC ADAPTIONSTO LABOR: ACTIVE PHASE • • ANXIETY INCREASES FEARS LOSS OF CONTROL MAY HAVE DECREASED ABILITY TO COPE LESS TALKATIVE

PSYCHOLOGIC ADAPTIONS TO LABOR: TRANSITION PHASE WITHDRAWS INTO HERSELF DOUBTS ABILITY TO COPE APPREHENSIVE AND IRRITABLE TERRIFIED OF BEING ALONE DOES NOT WANT ANYONE TO TALK TO HER OR TOUCH HER • DIFFICULT TO CONCENTRATE ON TASK • • •

SECOND STAGE OF LABOR –BEGINS WITH COMPLETE CERVICAL DILATATION AND ENDS WITH THE BIRTH OF THE INFANT

THIRD STAGE OF LABOR BEGINS WITH BIRTH OF INFANT AND ENDS WITH THE DELIVERY OF THE PLACENTA

FOURTH STAGE OF LABOR • BEGINS WITH DELIVERY OF PLACENTA TO 4 HOURS AFTER

LABOR REVIEW • DESCRIBE THE FIVE CRITICAL FACTORS THAT INFLUENCE LABOR IN THE ASSESSMENT OF A MOTHER’S AND FETUS’ PROGRESS IN LABOR AND BIRTH

MODULE 2 PART 5 MATERNAL PHYSIOLOGIC ADAPTION TO LABOR

• CARDIAC OUTPUT INCREASES • WBC CAN INCREASE TO 25, 000 mm • BP INCREASES • ACID/BASE BALANCE—MAY SEE > Ph EARLY IN LABOR

• RENAL -- >IN RENIN, PLASMA RENIN ACTIVITY, ANGIOTENSIN • VOIDING CAN BE AFFECTED BY EDEMA, DISPLACEMENT • GI—DECREASED MOTILITY, DELAYED STOMACH EMPTYING

INTRAPARTAL NURSING ASSESSMENT • HISTORY – PERSONAL DATA – HX PREVIOUS ILLNESS – PROBLEMS IN PRENATAL PERIOD – PREGNANCY DATA – INFANT FEEDING METHOD CHOSEN – ANY PRENATAL EDUCATION ? – BIRTH PLAN

MATERNAL PSYCHOSOCIAL HISTORY • • POVERTY NUTRITION PRENATAL CARE CULTURAL BELIEFS ENVIRONMENT USE OF DRUGS/ALCOHOL DOMESTIC VIOLENCE

MATERNAL PSYCHOSOCIAL ISSUES • • • EMOTIONAL STATUS SOCIOCULTURAL BELIEFS PREVIOUS CHILDBIRTH EXPERIENCE SUPPORT MENTAL AND PHYSICAL PREPARATION

INTRAPARTAL ASSESSMENT-- STAGE ONE • • VITAL SIGNS WEIGHT LUNGS FUNDUS EDEMA HYDRATION PERINEUM

INTRPARTAL ASSESSMENT STAGE ONE • • LABOR STATUS FETAL STATUS LAB VALUES CULTURAL INFLUENCES RESPONSE TO LABOR CHILDBIRTH PREPARATION ANXIETY SUPPPORT

• PALPATION • ELECTRONIC MONITORING OF CONTRACTIONS – TOCO—EXTERNATION ASSESSMENT OF CONTRACTIONS – IUPC—INTERNAL ASSESSMENT OF CONTRACTIONS

LABOR EVALUATION METHODS • CERVICAL ASSESSMENT – VAGINAL EXAM • DILATATION • EFFACEMENT • STATION

Figure 16– 2 To gauge cervical dilatation, the nurse place the index and middle fingers against the cervix and determines the size of the opening. Before labor begins, the cervix is long (approximately 2. 5 cm), the sides feel thick, and the cervical canal is closed, so an examining finger cannot be inserted. During labor, the cervix begins to dilate, and the size of the opening progresses from 1 cm to 10 cm in diameter.

FETAL ASSESSMENT • FETAL POSITION – PALPATION—LEOPOLD’S MANEUVER – INSPECT SIZE AND SHAPE OF WOMAN’S ABDOMEN – VAGINAL EXAM TO DETERMINE PRESENTING PART – FETAL HEART RATE – ULTRASOUND

A B C D Figure 16– 3 a Palpating the presenting part (portion of the fetus that enters the pelvis first). Left occiput anterior (LOA). The occiput (area over the occipital bone on the posterior part of the fetal head) is in the left anterior quadrant of the woman’s pelvis. When the fetus is LOA, the posterior fontanelle (located just above the occipital bone and triangular in shape) is in the upper left quadrant of the maternal pelvis.

Figure 16– 4 Top: The fetal head progressing through the pelvis. Bottom: The changes that the nurse will detect on palpation of the occiput through the cervix while doing a vaginal examination. Source: Myles, M. F. (1975). Textbook for midwives (p. 246). Edinburgh, Scotland: Churchill-Livingstone.

Figure 16– 5 d Fourth maneuver: Facing the woman’s feet, place both hands on the lower abdomen and move hands gently down the sides of the uterus toward the pubis. Note the cephalic prominence or brow.

MODULE 2 PART 7 A FETAL HEART RATE(FHR) MONITORING

• DOPPLER • ELECTRONIC FETAL HEART RATE MONITOR • BASELINE RATE— 120 -160 BPM • FETAL TACHYCARDIA, BRADYCARDIA

EXTERNAL MONITORING • EXTERNAL—ULTRASONIC TRANSDUCER – HIGH FREQUENCY SOUND WAVES REFLECT MECHANICAL ACTION OF FETAL HEART • DIFFICULT TO OBTAIN CONTINUOUS, ACCURATE RECORD

Figure 16– 8 Electronic fetal monitoring by external technique. The tocodynamometer (“toco”) is placed over the uterine fundus. The toco provides information that can be used to monitor uterine contractions. The ultrasound device is placed over the area of the fetal back. This device transmits information about the fetal heart rate. Information from both the toco and the ultrasound device is transmitted to the electronic fetal monitor. The fetal heart rate is displayed in a digital display (as a blinking light), on the special monitor paper, and audibly (by adjusting a button on the monitor). The uterine contractions are displayed on the special monitor paper as well.

INTERNAL FHR MONITORING – MEMBRANES MUST BE RUPTURED – CERVIX SUFFCIENTLY DILATED – PRESENTING PART LOW ENOUGH FOR PLACEMENT – SMALL ELECTRODE ATTACHED TO PRESENTING PART – MOST ACCURATE APPRAISAL OF FETAL WELL-BEING IN LABOR

Figure 16– 9 a Technique for internal, direct fetal monitoring. Spiral electrode.

Figure 16– 9 b Attaching the spiral electrode to the scalp.

FHR MONITORING • VARIABILITY – BEAT TO BEAT CHANGES IN FETAL HEART RATE – INDICATION OF AN INTACT CNS – SHORT TERM (STV) – LONG TERM (LTV)

FHR MONITORING

Figure 16– 10 Normal fetal heart rate pattern obtained by internal monitoring. Note normal FHR, 140 to 158 beats/min, presence of long- and short-term variability, and absence of deceleration with adequate contractions. Arrows on bottom of tracing indicate beginnings of uterine contractions.

Figure 16– 11 a Short- and long-term variability. Increased LTV; STV present.

Figure 16– 11 b Average LTV; STV absent.

Figure 16– 11 c Absent LTV; STV present.

Figure 16– 11 d Absent LTV; STV absent.

FHR MONITORING • ACCELERATIONS • DECELERATIONS – EARLY – LATE – VARIABLE

Figure 16– 12 Types and characteristics of early, late, and variable decelerations. Source: Hon, E. (1976). An introduction to fetal heart rate monitoring (2 nd ed. , p. 29). Los Angeles: University of Southern California School of Medicine.

FETAL ASSESSMENT • SCALP STIMULATION • FETAL BLOOD SAMPLING (FBS) • NORMAL SCALP p. H > 7. 25, 7. 20 -7. 25 BORDERLINE, <7. 20 NONREASSURING – MEMBRANES MUST BE RUPTURED – CERVIX DILATED 2 -3 CM – PRESENTING PART -2 STATION OR LOWER

MODULE 2 PART 8 NURSING INTERVENTIONS IN FIRST AND SECOND STAGES OF LABOR

FIRST STAGE-- LATENT PHASE – DILATATION, EFFACEMENT, STATION – MEMBRANE ASSESSMENT – COMFORT LEVEL – VS, FHR – UTERINE CONTRACTIONS EVERY 30 -60 MIN. – TEACHING

LATENT PHASE – ENCOURAGE AMBULATION – ENCOURAGE VOIDING Q 2 H – COMFORT MEASURES – NUTRITION OFFER FLUIDS – PAIN ASSESSMENT – EPIDURAL MONITORING – IDENTIFY AND OBSERVE SUPPORT PERSON(S)

FIRST STAGE-- ACTIVE PHASE – ENCOURAGE TO VOID Q 1 -2 HOURS – AUSCULTATE FHR Q 15 -30 MIN. – PALPATE CONTRACTIONS Q 15 MIN. – VAGINAL EXAMS TO ACESS PROGRESS – EPIDURAL MONITORING, VS Q 15 -30 MIN. – START IV INFUSION IF UNABLE TO TOLERATE FLUIDS – ACCESS COLOR AND ODOR OF AMNIOTIC FLUID

FIRST STAGE-- TRANSITION • PALPATE CONTRACTIONS Q 15 MIN. • STERILE VAGINAL EXAMS TO ACCESS LABOR PROGRESS • ASSESS FHR EVERY 15 -30 MIN. , DEPENDING ON RISK FACTORS • ASSIST WITH BREATHING • KEEP WOMAN FROM PUSHING UNTIL 10 CM. • STAY WITH PATIENT!

INTRAPARTAL NURSING INTERVENTIONS SECOND AND THIRD STAGE OF LABOR • • SECOND AND THIRD STAGE OF LABOR ENCOURAGMENT, ASSIST WITH PUSHING, DO NOT LEAVE PATIENT – ASSIST WITH DELIVERY – DELIVERY OF PLACENTA – APGAR SCORE, IMMEDIATE CARE OF NEWBORN – PITOCIN INFUSION

MODULE 2 PART 9 INTRAPARTUM NURSING INTERVENTIONS THE DELIVERY

• THE DELIVERY –PUSHING –BIRTHING POSITIONS –LABOR SUPPORT

Figure 15– 13 Mechanisms of labor. A, B, Descent. C, Internal rotation. D, Extension. E, External rotation.

INTRAPARTAL NURSING CARE: THE THIRD STAGE • DELIVERY OF THE PLACENTA – SCHULTZ MANUEVER – DUNCAN MANUEVER PLACENTA ACCRETAINED PLACENTA

INTRAPARTAL NURSING CARE: THE FOURTH STAGE – VS – FUNDUS – LOCHIA – PERINEUM/ABDOMINAL INCISION – BLADDER – COMFORT LEVEL – COMFORT MEASURES—WHAT ARE THEY?

INTRAPARTAL NURSING CARE: THE FOURTH STAGE – CONTINUE PITOCIN ADMINISTRATION ---WHY? – PAIN MEDICATION – DIET – HEMODYNAMIC CHANGES • CULTURAL CONSIDERATIONS

ADAPTION TO EXTRAUTERINE LIFE • IMMEDIATE CARE OF THE NEWBORN – RESPIRATORY ASSESSMENT – CIRCULATORY ASSESSMENT – THERMOREGULATION—HOW WOULD YOU ACHIEVE THIS?

• • IMMEDIATE CARE OF THE NEWBORN APGAR SCORE MAINTAIN RESPIRATIONS PROVIDE AND MAINTAIN WARMTH UMBILICAL CORD CARE CORD BLOOD COLLECTION HANDS OFF ASSESSMENT NEWBORN IDENTIFICATION FACILITATE ATTACHMENT

MODULE 2 PART 10 MATERNAL ANALGESIA AND ANESTHESIA

MATERNAL ANALGESIA & ANESTHESIA • PAIN PERCEPTION AFFECTED BY: – PREVIOUS EXPERIENCE – CULTURAL EXPECTATIONS, BELIEFS – FATIGUE, FEAR, ANXIETY – ENVIRONMENT – SUPPORT SYSTEM

MATERNAL ANALGESIA • STADOL • DEMEROL • MORPHINE • OPIATE ANTAGONIST—NARCAN • REGIONAL ANALGESIA

MATERNAL ANESTHESIA • REGIONAL ANESTHESIA – EPIDURAL – CONTINUOUS EPIDURAL – SPINAL

A B C D Figure 18– 3 c Tip of needle in epidural space. Source: Bonica, J. J. (1972). Principles and practice of obstetric analgesia and anesthesia (p. 631). Philadelphia: Davis.

Figure 18– 4 Levels of anesthesia for vaginal and cesarean births. Source: Reprinted with permission of Ross Laboratories, Columbus, OH. From Clinical Education Aid No. 17.

MATERNAL ANESTHESIA • LOCAL INFILTRATION • PUDENDAL • GENERAL

ANALGESIA AFTER DELIVERY • EPIDURAL NARCOTIC ANALGESIA (DUROMORPH) – CONTRAINDICATIONS – SIDE EFFECTS – DOSAGE

MODULE 2 PART 11 A BIRTH RELATED PROCEDURES

BIRTH RELATED PROCEDURES • AMNIOTOMY –ARTIFICIAL RUPTURE OF MEMBRANES (AROM – SPONTANEOUS RUPTURE (SROM)

AMNIOTOMY AFTER 3 CM MAY SHORTEN LABOR (AROM) CAN BE A STIMULATION OF LABOR FHR ASSESSED BEFORE AND AFTER AROM—WHY?

BIRTH RELATED PROCEDURES • LABOR INDUCTION—STIMULATION OF UTERINE CONTRACTIONS • INDICATED INDUCTION • ELECTIVE INDUCTION

BIRTH RELATED PROCEDURES • ELECTIVE INDUCTIONS – INCREASE IN LAST 10 YEARS – CONTROVERSY, CONTROVERSY!!!!!!! – RISKS – EVIDENCE BASED PRACTICE—LATE PRETERM NEWBORNS-- 34 -37 WEEKS

BIRTH RELATED PROCEDURES • LABOR INDUCTION: STRIPPING OF MEMBRANES ADVANTAGES: LABOR USUALLY OCCURS WITHIN 24 HOURS DISADVANTAGES: CAN BE PAINFUL UTERINE CONTRACTIONS BLOODY DISCHARGE

BIRTH RELATED PROCEDURES LABOR INDUCTION/AUGMENTATION RISKS: • HYPERSTIMULATION OF THE UTERUS • UTERINE RUPTURE • WATER INTOXICATION • NONREASSURING FETAL HEART RATE PATTERNS

BIRTH RELATED PROCEDURES • CERVICAL RIPENING—PROSTAGLANDIN E 2 – RISKS • UTERINE HYPERSTIMULATION • NONREASSURING FETAL STAUS • HIGHER INCIDENCE OF POSTPARTUM HEMORRHAGE • UTERINE RUPTURE

BIRTH RELATED PROCEDURES • CERVICAL RIPENING – ADVANTAGES • SHORTER LABOR • LOWER REQUIREMENTS FOR OXYTOCIN IN LABOR • VAGINAL BIRTH IS USUALLY ACHIEVED WITHIN 24 HOURS • INCIDENCE OF CESAREAN BIRTH IS REDUCED

• VERSION – EXTERNAL • EXTERNAL MANIPULATION – INTERNAL • USED TO DELIVER SECOND TWIN DURING VAGINAL BIRTH IF NOT DESCENDING OR IN DISTRESS-RARE

MODULE 2 PART 11 B BIRTH PROCEDURES

BIRTH RELATED PROCEDURES • VACUUM EXTRACTION – SUCTION CUP PLACED ON FETAL OCCIPUT – PUMP IS USED TO CREATE SUCTION – TRACTION IS APPLIED – FETAL HEAD SHOULD DESCEND WITH EACH CONTRACTION

INDICATIONS FOR VACUUM EXTRACTION – PROLONGED SECOND STAGE OF LABOR – NONREASSURING FETAL HEART RATE PATTERN – USED TO RELIEVE PUSHING EFFORT (MATERNAL FATIGUE) – WHEN ANALGESIA INTERFERES WITH ABILITY TO PUSH EFFECTIVELY – BORDERLINE CPD (CEPHALO-PELVIC DISPROPORTION)

BIRTH RELATED PROCEDURES • VACCUM EXTRACTION –MATERNAL RISKS –NEONATAL RISKS

EPISIOTOMY • SURGICAL INCISION OF PERINEUM TO ENLARGE OUTLET • RESEARCH—EVIDENCE BASED PRACTICE • PREVENTATIVE MEASURES • TWO TYPES: – MEDIAN – MEDIOLATERAL

BIRTH RELATED PROCEDURES • INDICATIONS FOR CESAREAN BIRTH – CPD – PLACENTAL ABRUPTION – ACTIVE GENITAL HERPES – UMBILICAL CORD PROLAPSE – FAILURE TO PROGRESS IN LABOR – PROVEN NONREASSURING FHR PATTERN – COMPLETE PLACENTA PREVIA

BIRTH RELATED PROCEDURES • INDICATIONS FOR CESAREAN BIRTH • BREECH PRESENTATION • PREVIOUS CESAREAN BIRTH • MAJOR CONGENITAL ANOMALIES • CERVICAL CERCLAGE • NON-REASSURING FHR PATTERNS

BIRTH RELATED PROCEDURES • CESAREAN BIRTH SKIN INCISIONS • TRANSVERSE (PFANNENSTIEL) • VERTICAL • UTERINE INCISIONS –TRANSVERSE –SELHEIM (LOWER UTERINE SEGMENT) –CLASSIC (UPPER SEGMENT OF CORPUS)

BIRTH RELATED PROCEDURES • PREPARATION FOR C-BIRTH – MAJOR SURGERY – SPINAL ANESTHESIA – MANY TIMES PARENTS HAVE LITTLE TIME TO PREPARE PSYCHOLOGICALLY

BIRTH RELATED PROCEDURES • AMNIOINFUSION – INCREASES FLUID VOLUME IN UTERUS BY INSTILLATION OF NORMAL SALINE INTO THE UTERUS – DECREASES PRESSURE ON THE CORD— VARIABLE DECELERATIONS – PROMOTES INCREASED PERFUSION TO FETUS – CAN DILUTE HEAVY MECONIUM FLUID – USED IN PRETERM LABOR WITH PPROM

BIRTH RELATED PROCEDURES • VBAC (VAGINAL BIRTH AFTER CESAREAN) • CRITERIA: – PREVIOUS C-BIRTH, LOW TRANSVERSE UTERINE INCISION – AN ADEQUATE PELVIS – NO OTHER UTERINE SCARS OR PREVIOUS UTERINE RUPTURE – AN IN HOUSE PHYSICIAN AND ANESTHESIOLOGIST