N 106 Labor and Delivery Female external genitals

N 106 Labor and Delivery

Female external genitals

L&D- the P’s of Labor • Power • Passenger uterine contractions lie maternal pushing attitude presentation • Passage occiput bony boundaries of pelvis brow, face softening of cartilage shoulder linking pelvic bones sacrum position – LOA, ROP • Psych

POWER Uterine muscle layers. Muscle fiber placement.

PASSAGE Pelvic types: gynecoid, android, anthropoid, platypelloid

PASSENGER Typical anteroposterior diameters of the fetal skull.

LIE • The relationship of the long axis of the fetus to the long axis of the woman • 99% the lie is longitudinal and parallel • Transverse lie – fetus is at right angle to mother Transverse lie - uncommon

ATTITUDE Flexion is normal flexed extension Fetal attitude is the relationship of fetal body parts to itself.

PRESENTATION The fetal part that first enters the pelvis Cephalic Vertex presentation. Breech presentation.

Cephalic presentations Occiput/vertex Brow Face Military

Breech presentations Full Breech Frank Breech Footling Breech

Position • Fetal position describes the location of a fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvis • Abbreviations of presenting part is “cuddled” between maternal pelvis • LOA, LOP, ROA, ROP, RSA, LMP • Occiput, Sacrum, Mentum (chin), Anterior, Posterior

Categories of presentation.

A B Quiz C D

PSYCHE • • • Preparation and information Anxiety and fear decrease coping Culture affects views Both physical and emotional experience Do not “nurse the machines”

L&D nursing responsibilities • History Antepartal weight gain fetal gest & growth risk factors present status • Obstetrical • Medical surgical • interval • Assessment maternal vital signs uterine activity bladder status I&O bloody show response to labor maternal discomfort fetal heart rate Amniotic fluid

L&D Leopold’s maneuvers • Palpate upper abdomen • Palpate opposite side in circular motion for fetal extremities • Palpate for engagement of presenting part • Palpate to identify cephalic prominence

What fetal part is in fundus

Palpate for back

Palpate for engagement of presenting part

Palpate position of head – determine descent & flexion

Location of FHR in relation to the more commonly seen fetal positions.

Location of FHR in relation to the commonly seen fetal position

Electronic fetal monitoring by external technique. The tocodynamometer (“toco”) is placed over the uterine fundus. The ultrasound device is placed over the area of the fetal back.

Intrapartum Fetal Assessment • Fetal Heart Rate • Electronic Fetal Monitoring ultrasound transducer • Response to contractions tocotransducer • Internal fetal monitoring – RBOW fetal scalp electrode intrauterine pressure catheters (IUPC)

Attached spiral electrode with the guide tube removed.

Characteristics of uterine contractions.

Normal fetal heart rate pattern obtained by internal monitoring.

Fetal Heart Rate Patterns • • • Tachycardia – greater than 160 for 10 min Bradycardia – less than 110 for 10 min Absent or minimal beat-to-beat variability Early decelerations – head compression Late decelerations – uterine placenta insufficiency • Variable decelerations – cord compression

A B Comparison of labor patterns. A) Normal uterine contraction pattern. B) Hypotonic uterine contraction pattern. .

Types and characteristics of early, late, and variable decelerations.

Nursing Interventions for Decelerations • Early • Variable Continue to observe Stop oxytocin • Late Replace IV fluids Stop oxytocin Change mothers position Replace fluids Check for prolapsed cord Change mother’s Check B/P and Pulse position Administer oxygen Check B/P and Pulse Notify the physician Administer oxygen Prepare to assist with Notify physician fetal scalp blood sample

Conditions Associated with Fetal Compromise • FHR below 100 or above 160 • Amniotic fluid Meconium-stained (greenish) Cloudy, yellowish, or foul-smelling • Contractions lasting longer than 90 seconds occurring less than 2 minutes apart • Maternal hypotension, hypertension, fever

Actions to increase oxygen to fetus • • If receiving Pitocin stop or slow rate Reposition mother Increase non-additive IV fluids Administer 100% oxygen thru snug face mask to mother at rate of 8 -10 liters/min • Keep mothers bladder empty • Change under-pads regularly

L & D true vs false labor • True labor contractions: Start in back & move wavelike toward abdomen Become more intense with walking Result in ripening of cervix, dilation & effacement • False labor contractions: Noticed primarily in abdomen Begin & remain consistent Disappear with walking No change in cervical dilation or effacement

To gauge cervical dilatation, the nurse place the index and middle fingers against the cervix and determines the size of the opening.

Measuring the station of the fetal head while it is descending

Mechanism of Labor • • Engagement / Decent Flexion Internal rotation Extension Restitution External rotation Expulsion

Mechanisms of labor.

Stages of Labor • Stage III cervical dilation to 10 cm & birth of baby to effacement to 100% delivery of placenta early/latent active • Stage IV transition 1 -4 hours after • Stage II crowning to birth of baby delivery of placenta stabilization recovery

Phases of Stage I of Labor • Early/latent - dilates - 0 -3 cm contractions q 5 min X 30 -40 sec • Active - dilates – 4 - 7 cm contractions q 25 min X 40 -60 sec • Transition- dilates – 8 -10 cm contractions q 2 -3 min apart X 60 -90 sec

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.

Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head.

Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic fluid exerts hydrostatic pressure.

Complete effacement and dilatation. End of Stage 1

Friedman Curve Predicable progression of labor for Nulliparous and Multiparous

Responsibilities during First Stage of Labor • Promote Comfort positioning, lighting temperature, cleanliness bladder, mouth care • Relieve pain breathing techniques nonpharmacologic massage, touch, pressure hydrotherapy imagery or focal point

Stage 2 From 10 cm 100% to birth of Baby • • • Assist mother with pushing Preparation of sterile delivery table Perineal cleansing Sutures for episiotomy or laceration Initial care and assessment of newborn APGAR

Effects of labor on the fetal head. Caput succedaneum formation.

Care of Infant • Maintaining cardiopulmonary function – APGAR • Supporting thermoregulation • Identifying infant • Examining for obvious anomalies and birth injuries • Medication administration

Clamp is positioned 1/2 to 1 in from the abdomen and then secured.

APGAR • • Heart rate – above 100 Respiratory Effort – spontaneous with cry Muscle tone – flexed with movement Reflex response – active, prompt cry Color – pink or acrocyanosis 0 -3 infant needs resuscitation 4 -7 Gentle stimulation – Narcan 8 -10 – no action needed

Cut cord. The one vein and two arteries can be seen.

Placenta Separation Stage 3 • • Uterus changes shape Uterus rises upward in the abdomen Cord begins to move out of the vagina Gush of blood noted from vagina

Stage III Placental separation and expulsion. Schultze mechanism.

Stage 4 of Labor • • First 1 -4 hours after delivery of placenta Palpate fundus Assess vital signs Assess lochia Ice pack to perineum Care of infant and Care of mother Identification Promoting bonding

Suggested method of palpating the fundus of the uterus during the fourth stage.

Common Intrapartum Procedures • Amniotomy • Stimulation of labor induction augmentation • Assisted delivery episiotomy forceps vacuum extractor • Cesarean delivery

Amniotomy • Artificial rupture of fetal membranes • Advantages decrease some labor assessment of fluid for meconium permits internal monitoring • Risks cord prolapse infection

Assessment of Fluid • • • Quality, Color, and Odor Greenish, meconium stained Large amount of vernix Strong order, cloudy or yellow Hydramnios Oligohydramnios

Risk during ROM Prolapse of the umbilical cord.

Induction & Augmentation of Labor During Stage 1 • Definitions • Criteria – Bishop’s scoring, 39 weeks gest. • Methods surgical – amniotomy drugs Oxytocin (Pitocin) – IV stimulate contractions Cervical ripening agents prostaglandin Misoprostol (Cytotec)- tab dinoprostone (Prostin E 2) Cervidil/Prepidil - vaginal/cervical gel

Episiotomy • Most common operation primip – 70% multip – 30% • Types midline – most common problem with 3 -4 th degree laceration mediolateral increased PP pain, more scaring Main risk – infection Complication of infection – prolonged dysparenia Prevention – perineal massage & stretching beginning at 34 weeks.

Lacerations • First degree - limited to fourchette, perineal skin, vaginal membrane • Second degree - underlying fascia and muscle of the perineal body • Third degree – involves the anal sphincter • Fourth degree – extends thru the rectal mucosa to lumen of rectum

Interventions During Stage 2 • • Forceps & Vacuum Extraction Assist with decent and rotation of fetal head Risk- trauma to maternal and fetal tissue Criteria scalp is visible at vaginal opening normal scalp ph is above 7. 25 Low forceps - station is +2 or lower Mid forceps - station 0 to +2

Forceps With correct placement of the blades, the handles lock easily.

Vacuum extractor

Risks to Mother and Infant • Mother laceration hematoma of the vagina • Infant ecchymoses facial and scalp lacerations and abrasions cephalhematoma intracranial hemorrhage • Chignon –scalp edema from vacuum extractor

Cesarean Birth • About 22% of all births • Indications – dystocia, CPD, PIH, DM, genital herpes, prolapsed cord, fetal malpresentations, placenta previa or abruptio placentae • Maternal risk same as any abdominal OR • Infant’s greatest risk is lung immaturity

Preparation for C/S • NPO, get operative permit signed • Pre-op teaching • Lab work – CBC, clotting series, type and cross match one or more units • Single IV dose of antibiotics • Famotidine (Pepcid) and citrate (Bicitra) • Shave abdomen • Insert foley catheter • Perform abdominal scrub

Incisions for C/S • Abdominal incision vertical – umbilicus to symphysis transverse or bikini – above symphysis • Uterine incisions low transverse low vertical classic • Abdominal and uterine incisions do not always match

Low transverse incision

classic uterine incision

Nursing Considerations C/S • Routine assessments q 15 min X 1 hr, q 30 min X 1 hr then hourly VS fundus for firmness, height, deviation lochia urine output abdominal dressing • Assess need for pain medication • TCDB – support incision with pillow

Intrauterine Infection • Signs Fetal tachycardia – FHT greater than 169 Maternal fever – greater than 100. 4 Foul or strong-smelling amniotic fluid Cloud or yellow appearance to amniotic fluid

Nursing Care for Infection • Prevention wash hands limit vaginal examinations keep under pads dry • Assess VS q 4 hours if ROM than q 2 hrs • Collect culture specimens

Intrapartum complications • • • Dystocia CPD – cephalopelvic disproportion Placenta previa Abruptio placenta Prolapsed umbilical cord Macrosomia - Shoulder dystocia

Dystocia • Abnormal progress of labor • Contributing factors sedation, anxiety, anesthesia, unripe cervix, supine position, cephlopelvic disproportion - CPD • Management depends on cause

Complications of Pregnancy Hemorrhage – late in pregnancy Placenta Previa Abruptio Placentae

Placenta previa • Placenta located over/near cervical opening • S&S: painless bleeding in 3 rd trimester, hemorrhage, fetal distress • Risk factor: multiparity in older women • TX: Hospitalization, bedrest, ultrasound • Care: Do not perform vag exam Monitor mother and fetus Prepare for delivery / no oxytocin

Marginal (low-lying) Placenta previa. Low placental implantation.

Total placenta previa

Abruptio Placentae • Premature separation of placenta • S&S: Concealed or apparent hemorrhage in 3 rd trimester, uterine tenderness, abd Pain, Board like abdomen, shock, fetal distress • Risk factors: PIH, multiparty, DM • TX: Replacement of blood loss, IV fluids, delivery • Care: Explain procedures, monitor mother and fetal condition, prepare for delivery

Abruptio placentae. Marginal abruption with external hemorrhage.

Abruptio placentae Complete separation with concealed bleeding.

Shoulder Dystocia • Risk factors diabetes; macrosomic infant obesity prolonged second stage previous shoulder dystocia • Morbidity • Management

Position for prolapse cord

Prolapsed Cord • Cause – increase risk - high station, AROM, poor fit, hydramnios, breech • Signs of prolapse – visible, suspect • Management – Emergency - Call Light Reduce cord compression Position hip higher than head Hold fetal part upward Give oxygen 8 -10 liters/min • Prompt delivery is the priority

Other Complications • • • Precipitous delivery Retained placenta Uterine inversion Uterine rupture Umbilical cord problems Multiple births