Oakton Community College



Oakton Community College

N106- Care of the Expanding Family

 

Study Guide – Unit 2 Labor and Delivery

 

Read pages 353-370, 387, 391-403, 421, 424, 429, 433-434, and 450-454.

 

Normal Labor and Delivery

 

I. What are the five critical forces in labor p. 353

1. The birth passage (Size and Type of pelvis, Ability of the cervix to dilate and efface and ability of the vaginal canal and the external opening of the vagina to distend)

2. The fetus (Fetal head – size and presence of molding; Fetal attitude – flexion and extension of the fetal body and extremities; Fetal lie; Fetal presentation – the part of the body entering the pelvis first; Placenta – implantation site)

3. The relationship between the passage and the fetus (Engagement of the fetal presenting part) Station – within the maternal pelvis; Fetal position – presenting part to one of four quadrants of the maternal pelvis.

4. Primary forces of labor (Frequency, duration, and intensity of contractions as the fetus moves through the birth passage) Effectiveness of the maternal pushing effort; Duration of labor

5. Psychosocial considerations (Mental and physical preparation for childbirth; Sociocultural values and beliefs; Previous childbirth experience; Support from significant others; and Emotional status

 

II. The pelvis – passageway – List the four types and describe which one is the most favorable for vaginal birth and which are not. P. 355

Gynecoid - most common and favorable for vaginal birth, because all it’s diameters (inlet, midpelvis, and outlet) are adequate for childbirth

Android - hearth shaped inlet, reduced midpelvis diameters and outlet capacity; not favorable for vaginal birth, slow descent, fetal head enters transverse or posterior position, with arrest of labor frequent

Anthropoid - inlet oval, with long anteroposterior diameter; midpelvis and outlet diameters are adequate; favorable for vaginal birth

Platypelloid – inlet oval in shape, with long transverse diameters; midpelvis diameters reduced; outlet capacity inadequate; not favorable for vaginal birth, fetal head engages in transverse position, difficult descent through midpelvis, frequent delay of progress at outlet of pelvis

III . The fetus – the passenger - Define each of the following p. 356-359

 

A. Attitude – relation of fetal parts to one another; normal attitude is moderate flexion of the head, flexion of the arms onto the chest, and flexion of the legs onto the abdomen.

B. Lie – refers to the relationship of the cephalocaudal (spinal column) axis of fetus to the cephalocaudal axis of the woman; could be a longitudinal (ceph. axis of fetus is parallel to women’s spine) or transverse lie (ceph. axis of fetus is at a right angle to the woman’s spine.

C. Presentation – determined by fetal lie and part of fetus that enters the pelvic passage first (presenting part of fetus); presentation may be cephalic (most common – labor and birth likely to proceed normally); breech or shoulder (associated with difficulties during labor and it does not proceed as expected. Cephalic presentations: vertex, military, brow and face. Breech are: complete breech, Frank breech, footling breech

D. Station – an imaginary line drawn between the presenting part of the fetus and the ischial spines of the maternal pelvis. The ischial spines as a landmark are “station zero”. Negative number – if the presenting fetus is higher than the ischial spine, noting centimeters above zero station. Positive number – indicates that the presenting spine has passed the ishial spine. Station –5 is at the pelvic inlet and Station +4 is at the outlet.

E. Position – the landmark of the fetal presenting part is related to four imaginary quadrants of the pelvis: Left anterior, Right anterior, Left posterior and Right posterior. These quadrants designate whether the presenting part is directed toward the front, back, left or right of the passage. Notations: 1. Maternal pelvis - (R) right, (L) left. 2. The landmark of the fetal presenting part: (O) occiput, (M) mentum, (S) sacrum, (A) acromion process. 3. Landmarks of front, back, or side of pelvis: (A) anterior, (P) posterior, (T) transverse.

 

IV. Psychological Aspects of Birth – Review factors associated with positive birth experience – p. 361

Motivation for pregnancy, Attendance at childbirth education classes, A sense of competence or mastery, Self-confidence and self-esteem, Positive relationship with mate, Maintaining empowerment during labor, Support from mate or other person during labor, Not being left alone in labor, Trust in medical and nursing staff, Having personal control of breathing patter and comfort measures, Choosing a physician or certified nurse-midwife who has a similar philosophy of care and Receiving clear information regarding procedures.

V. Describe the hormonal changes prior to labor. P. 362

Progesterone relaxes smooth muscle tissue, estrogen stimulates uterine muscle contractions, and connective tissue loosens to permit the softening, thinning and eventual opening of the cervix. Toward the end of gestation, biochemical changes decrease the availability of progesterone to myometrial cells and may be associated with an antiprogestin that inhibits the relaxant effect but allows other progesterone actions, such as lactogenesis. With decreased availability of progesterone, estrogen is better able to stimulate contractions. CRH increases throughout pregnancy, with a sharp increase at term, and has a possible role in labor onset. Also, there is an increase in plasma CRH prior to preterm labor, and CRH levels are elevated in multiple gestation. Finally, CRH is known to stimulate the synthesis of prostaglanding F and prostaglandin E by amnion cells.

 

VI. The uterus – define p. 362-363

Effacement – in true labor, with each contraction, the muscles of the upper uterine segment shorten an exert a longitudinal traction an the cervix, causing effacement, which is the drawing up of the internal os and the cervical canal into the uterine side walls. The cervix changes progressively from a long, thick structure to a structure that is tissue-paper thin. In primigravidas, effacement usually precedes dilatation.

 

Dilatation – as the uterus elongates, the longitudinal muscle fibers are pulled upward over the presenting part; cervical dilatation is caused by this action, as well as the hydrostatic pressure from the fetus. The cervical os and cervical canal widen from less than a centimeter to approximately 10 cm, allowing birth of the fetus.

  

VII. Signs of labor – List and describe six of the signs of onset of labor p. 363-364

1. Lightening – fetus begins to settle into the pelvic inlet; the uterus moves downward and the fundus no longer presses on the diaphragm, which eases breathing.

2. Braxton Hicks Contractions – (irregular intermittent contractions that have been occurring throughout pregnancy) may become uncomfortable; pain is focused in abdomen and groin, feel of “drawing” sensation.

3. Cervical Changes – ability of collagen fibers to bind together decreases, water content of cervix increases, which results in a weakening and softening of the cervix.

4. Bloody Show – with softening and effacement of cervix, the mucus plug (the cervical barrier) is often expelled, resulting in a small amount of blood loss from the exposed cervical capillaries. Bloody show is the resulting pink-tinged secretions.

5. Rupture of Membranes (ROM) – the amniotic membranes rupture before the onset of labor and amniotic fluid may be expelled in large amounts. 80% of women experience onset of labor within 24 to 48 hours.

6. Sudden Burst of Energy – approximately 24 to 48 hours before labor. The cause of energy spurt is unknown.

 

VIII. Process of labor – Compare true and false labor p. 365

True Labor - Contractions are at regular intervals, which gradually shorten; contractions increase in duration and intensity; Discomfort begins in back and radiates around to abdomen; Intensity usually increases with walking; Cervical dilatation and effacement are progressive.

False Labor – Contractions are irregular; No gradual change in length; Usually no increase in duration and intensity; Discomfort is usually in abdomen; Walking has no effect on or lessens contractions; No change in cervical dilatation.

 

IX. Define the Stages of Labor p. 365-370

 

First stage – three phases

Latent – begins with mild regular contractions; woman able to cope with discomfort, feels talkative and exited; Uterine contractions increase in frequency, duration, and intensity. Cervix begins to dilate and effaces, although little or no fecal descent is evident. Latent stage should not exceed 14 hours. Spontaneous rupture of membranes (SROM) generally occurs at the height of an intense contraction with gush of fluid out of the vagina. Artificial rupture of membranes (AROM) is often performed (by physician with an amnihook).

  Active – woman’s anxiety tends to increase as she senses the intensification of contractions and pain. She begins to fear loss of control; Cervix dilates from about 3-4 cm to 8 cm. Fetal descent is progressive. The cervical dilatation averages 1.2 cm/hr in nulliparas and 1.5 cm/hr in multiparas.

  Transition – significant anxiety, feels restless and tired; frequently changing positions. Cervical dilatation slows as it progresses from 8 to 10 cm and the rate of fetal descent dramatically increases. There is an increase in bloody show; woman may experience hyperventilation; Generalized discomfort, including low back-ache, shaking and cramping in legs, and increased sensitivity to touch; Increased need for partner’s/nurse’s presence and support; Difficulty understanding directions; Requests for medications; Hiccupping, belching, nausea, or vomiting; Beads of perspiration on the upper lip or brow; Increasing rectal pressure and feeling the urge to bear down.

Second Stage - begins with complete cervical dilation and ends with birth of the infant; contractions – frequency of 2 min., duration of 60-90 secs. and are of strong intensity; The baby goes through Cardinal movements, including Descent, Flexion, Internal rotation, Extension, Restitution, External Rotation and Expulsion in which the infant is born.

Third Stage - about 5 mins. after birth, the placenta separates from the uterus; Signs include: 1. a globular-shaped uterus 2. a rise of the fundus in the abdomen 3. a sudden gush or trickle of blood and 4. further protrusion of the umbilical cord out of the vagina; if 30 mins. have elapsed from completion of second stage placenta is considered retained. “shiny Schultze” mechanism means placenta is delivered with the fetal (shiny) side presenting; “dirty Duncan” means placenta is delivered w/ the maternal surface first.

Fourth Stage - the time of 1 to 4 hrs. after birth in which physiologic readjustment of the

mother’s body begins; blood loss of 250 – 500ml, decreasing in BP, increasing pulse and moderate tachycardia; N/V usually cease; woman may be thirsty and hungry, may experience a shaking chill, bladder is hypotonic due to trauma and/or anesthetics, which can lead to urinary retention.

X. Describe the mechanism of labor or the cardinal movements p. 367 What does the fetus have to do to get thru the birth canal head first? P. 367-369

Descent – the head enters the inlet in the occiput transverse or oblique position

Flexion – as the fetal head descends and meets resistance from the pelvis, it’s muscles, the pelvic floor and the cervix; fetal chin flexes downward onto the chest.

Internal Rotation – head must rotate to fit the diameter of the pelvic cavity; rotates usually from left to right and the sagittal suture aligns in the anteroposterior pelvic diameter.

Extension – forward assistance of head from pelvic floor and vulva, so it passes under the symphysis pubis. With this positional change, the occiput, then brow and face, emerge from the vagina.

Restitution – shoulders enter pelvis, neck becomes twisted; once head is born and free of pelvic resistance, the neck untwists, turning the head to one side(restitution), and aligns with the position of the back in the birth canal.

External Rotation – as the shoulders rotate to the anteroposterior position in the pelvis, the head turns farther to one side (external rotation).

Expulsion – anterior shoulder is born before posterior shoulder then body follows quickly

XI. What tests are performed to confirm rupture of membranes? P. 387

If there is leakage of amniotic fluid, use a Nibrazine test tape and a Q-Tip with slide for fern test before performing the exam, to register a change in pH.

 

XII. Fetal Monitoring – Describe each of these in terms of cause for deceleration pattern, what it looks like (try to draw it) and what you would do about it. P. 400

- heart rate goes down with a contraction

A.     Early decelerations – Head compression by contraction and waveform and cerebral blood flow decreases. Onset is just prior to or early in contraction; Shape – waveform consistently uniform, inversely mirrors contraction; Lowest level – consistently at or before midpoint of contraction; Range – usually within normal range of 120-160 beats/min; Ensemble – can be single or repetitive. It is uniform shaped, which is considered benign and does not usually require intervention, but oxygen might be needed.

 

 B.     Late decelerations – caused by uteroplacental insufficiency resulting from decreased blood flow and oxygen transfer to the fetus during contraction. Shape – waveform uniform, shape reflects contraction; Onset – late in contraction; Lowest level – consistently after the midpoint of the contraction; Range – usually within normal range of 120-130 beats/min; Ensemble – occasional, consistent, gradually increase – repetitive. Is considered a nonreassuring sign, but does not necessarily require immediate delivery. Turn woman over, give oxygen, stop Potosin, increase IV’s b/c baby needs to be hydrated. C-section is needed.

 

 

 

 

 

 

 

 

C. Variable decelerations – Occurs when umbilical cord becomes compressed, thus reducing blood flow b/w placenta and fetus, increasing peripheral resistance in the fetal circulation and causing fetal hypertension. Shape – waveform variable, generally sharp drops and returns; Onset – abrupt with fetal insult, not related to contraction; Lowest level – variable around midpoint; Range – not usually within normal range; Ensemble – variable-single or repetitive. Interventions – put mom in Trendelenburg; emergency C-section.

XIII. In the chart on page 421 describe the different support measures used depending on the stages and phases of labor.

Stage I: Latent Phase – establish rapport, assess information, teach breathing techniques, orient client and family to room, equipment, etc., encourage change of positions.

Active Phase – provide a quiet environment, reassurance, support; give back rubs, cool cloth on forehead; support with pillows, give ice chips.

Transition Phase – encourage rest b/w contractions; keep couple informed of progress; provide privacy; give ice chips; encourage her to void every 1 to 2 hours.

Stage II: assist woman in pushing effort, encourage and praise her.

 

Review the chart on page 424 and describe one problem and what would be done about it.

Prolapse of Umbilical Cord – 1. releave pressure on cord manually; 2. continuously monitor FHR, watch for changes in FH pattern; 3. notify physician or CNM;

4. assist woman into knee-chest position; 5. administer oxygen

 

XIV. A baby boy is born with a heart rate of 124, respirations 24 and irregular, has flexion and movement of all extremities, has a vigorous cry when suctioned with a bulb syringe and body is pink with some acrocyanosis. What is his APGAR? p. 429

 

Her APGAR score is 8.

 

How many vessels do you anticipate in the umbilical cord and what are they?

  There are 3 vessels; 2 arteries and 1 vein

 

XV. Describe post birth danger signs for mother p. 433 and review evaluating lochia guidelines 434

Hypotension, Tachycardia, Uterine Excessive bleeding, and Hematoma

Small – smaller than a 4 in. pad stain – 10-25 ml.

Moderate – smaller than a 6 in. stain – 25-50 ml.

Large – larger than a 6 in. stain – 50-80 ml.

If more than 80ml, weight pad. 1g =1ml

 

XVI . Analgesia during labor and birth – Describe how each of the following are administered and what area will be affected. p. 450 -454

 

Epidural – to provide analgesia for 24 hrs. after birth (may be an opioid, such as morphine sulfate (Duramorph); injected through catheter into epidural space immediately after birth

Spinal block – immediate onset of a local anesthetic agent; it is injected directly into the spinal fluid in the spinal canal to provide anesthesia for cesarean birth and occasionally for vaginal birth

  Pudendal block – administered by a transvaginal method, provides perineal anesthesia for the later part of first stage of labor, the second stage (birth) and episiotomy repair; does not relieve the discomfort of uterine contractions.

Local infiltration – injection of anesthetic agent into the intracutaneous, subcutaneous, and intramuscular areas of the perineum; generally used at the time of birth, both in preparation for episiotomy and for episiotomy repair.

  General – (induced unconsciousness) – a combination of intravenous injection and inhalation of anesthetic agent, usually used for cesarean birth and for surgical intervention with some complications.

 

Childbirth at Risk p. 458, 462-463, 470, 472-481, 483-484, 489-490, 496, 506-507

 

I. Dystocia – What is the definition? And which one is the most common? p. 458

Dystocia means “difficult labor”. Most common one is dysfunctional (or uncoordinated) uterine contractions, which result in prolonged labor.

 

II. Define precipitous labor and write how it affects the mother and the fetus. p. 462

Labor that lasts less than 3 hours and results in rapid birth. Maternal risks – loss of coping ability; Laceration of the cervix, vagina, and perineum due to rapid descent and birth of the fetus; Postpartal hemorrhage due to undetected lacerations or uterine after birth. If woman had previous precipitous labor, she needs to be monitored closely in the last few weeks of her pregnancy. Fetal risks – fetal distress or hypoxia from decreased uteroplacental circulation due to intense uterine contractions; Cerebral trauma from rapid descent through the birth canal. Fetus is monitored indications for fetal distress.

 

III. Your client is a 36 year old primigravida whose last menstrual period was September 8. What is her EDC? On what date would her pregnancy be post term. What problems would you expect during labor and birth. p. 463

EDC – June 15th. Her pregnancy would be post term, past June 29th.

Expected problems: Maternal – Probable labor induction; Increased risk for large-for-gestational-age (LGA) infant; Increased incidence of forceps-assisted, vacuum-assisted, or C-section; Increased psychologic stress as the due date passes and concern for the baby increases. Fetal risks – Decreased perfusion from the placenta; Oligohydramnios (decreased amount of amniotic fluid), which increases the risk of cord compression; Meconium aspiration (aspiration of meconium-stained amniotic fluid by the fetus at the time of birth), which is more likely if oligohydramnios and thick meconium are present.

IV. Define fetal macrosomia and describe the risks involved for the infant. P. 470

Macrosomia is a newborn weight of more than 4000g at birth. Fetal-neonate implications include increased risk of: Meconium aspiration; Asphyxia; Shoulder dystocia, in which, after birth of the head, the anterior shoulder fails to deliver either spontaneously or with gently traction; Upper brachial plexus injury and fractured clavicles

 

V. What are the most common signs of fetal distress and what are the immediate interventions? P. 472-474

Most common signs are: maconium stained amniotic fluid, presence of ominous fetal heart rate pattern, such as persistent late deceleration, persistent severe variable deceleration, and prolonged deceleration

Immediate interventions: intrauterine resuscitation used to optimize the oxygen exchange within the maternal fetal circulation; begin intravenous infusion and increase the flow rate.

 

VI. Intrauterine fetal death – How is fetal demise diagnosed? P. 475

Diagnosed by an abnormal x-ray examination, which may reveal Spalding’s sign, an overriding of the fetal cranial bone. Also, maternal estrogen levels fall. IUFD is confirmed by absence of heart action on ultrasound.

 

What are the three phases of grief that are anticipated?

1. Protest – of the death of the fetus; immediate shock and numbness, followed by disbelief and denial; usually short lived and followed by distress

2. Disorganization – developing awareness of the finality of the loss; feeling of profound sadness and a deep yearning for the lost baby develop; as well as isolation, loneliness and meaninglessness manifest

3. Reorganization – the mourning process; parent slowly begin to reengage with the world; time frame varies greatly; phase may be accompanied with transitory feelings of guilt for enjoying life again in spite of the loss.

Describe what tools are used in your clinical facility for parents who have lost an infant. See page 476

 When fetal death has been confirmed before admission, inform the staff so they can avoid making inappropriate mistakes; Allow the woman and her partner to remain together as much as they wish. Provide privacy and a supportive environment.

 

VII. Write the causes of hemorrhage during the antepartal, intrapartal and postpartal periods. P 477

Antepartal – Abortion, Placenta previa, Abruptio placenta (Partial or Severe)

Intrapartal – Placenta previa, Abruptio placenta and Uterine atony in stage 3

Postpartal – Uterine atony, Retained placental fragments or Laceration of cervix or vagina

 

VIII. Define abruption placenta and describe the three types. P. 477

Premature separation of normally implanted placenta from the uterine wall.

Marginal – placenta separates at it’s edges, the blood passes b/w the fetal membranes and the uterine wall, and the blood escapes vaginally (also called vaginal sinus rupture)

Central – the placenta separates centrally, and the blood is trapped b/w the placenta and the uterine wall. Entrapment of the blood results in concealed bleeding.

Complete – massive vaginal bleeding is seen in the presence of total separation

 

IX. Describe the differences between placenta previa and placenta abruptio using criteria in key facts to remember box on page 479.

Placenta Previa Abruptio Placenta

Onset is quiet and sneaky Onset is sudden and stormy

Bleeding is external Bleeding is external or consealed

Bright red blood Dark venous blood

Anemia = blood loss Anemia > apparent blood loss

Shock = blood loss Shock > apparent blood loss

Toxemia is absent Toxemia may be present

Pain only during labor Severe and steady pain

Uterine tenderness is absent Uterine tenderness is present

Uterine tone is soft and relaxed Uterine tone is firm to stony hard

Uterine contour is normal Uterine contour may enlarge, change shape

FHTs usually present FHTs present or absent

Engagement is absent Engagement ma be present

Presentation may be abnormal Presentation - No relationship

X. Define placenta previa and describe expectant management of a pregnancy of less than 37 weeks gestation. P. 479 and 481

In placenta previa, the placenta is implemented in the lower uterine segment rather than the upper portion of the uterus. To allow fetus to mature, exceptional management is employed to delay birth, which includes; Bed rest with bathroom privileges as long as the woman is not bleeding; No vaginal exams; Monitoring blood loss, pain, and uterine contractility; Evaluating FHR with an external fetal monitor; Monitoring maternal vital signs; Complete laboratory evaluation: hemoglobin, hematocrit, Rh factor, and urinalysis; Intravenous fluid (lactated Ringer’s solution); Two units of cross-matched blood available for transfusion. If frequent recurrent, or profuse bleeding persists, or if fetal well-being appears threatened, a cesarean birth may be performed.

 

XI. Define a prolapsed umbilical cord. Describe the immediate action of the nurse if this would occur. p. 483 and 484.

Occurs when the umbilical cord precedes the fetal presenting part; pressure is placed on the umbilical cord as it is trapped b/w the presenting part and the maternal pelvis; vessels carrying blood are compressed; membranes may be ruptured. Immediate actions include, release of pressure on cord and birth needs to be facilitated. The examiner’s gloved hand needs to remain in the vagina to provide firm pressure on the fetal head (to relieve compression) until the physician or CNM arrives, if a loop of cord is discovered. The mother is given oxygen via face mask, and the FHR is monitored to determine whether the cord compression is adequately relieved. The woman assumes the knee-chest position or the bed is adjusted to the Trendelenburg position and transported to delivery or operating room in this position.

XII. Define CPD and how is it treated? P. 489

A contracture (narrowed diameter) in any of the birth passages result in Cephalopelvic disproportion, in which an abnormal fetal presentation and position occurs, as the fetus moves to accommodate its passage through the maternal pelvis. Treatment – cervical dilation and fetal descent are assessed more frequently; contraction and the fetus should be monitored frequently; the mother may be positioned in a variety of ways to increase the pelvic diameter; Sitting or squatting increases the pelvic diameter and may be effective when there is failure of or slow fetal descent; Changing from one to the other or maintaining a hands-and-knees position may assist the fetus in the occiput-posterior position to change to an occiput-anterior position.

XIII. Define the following vaginal and perineal lacerations in terms of degree p. 490

Indicated when bright-red vaginal bleeding persists in the presence of a well contracted uterus

First degree – limited to the fourchette, perineal skin, and vaginal mucous membrane

Second degree – involves the perineal skin, vaginal mucous membranes, underlying fascia, and muscles of the preineal body; it may extend upward on one or both sides of the vagina.

Third degree – extends through the perineal skin, vaginal mucous membranes, and perineal body and involves the anal sphincter; it may extend up the anterior wall of the rectum

Fourth degree – is the same as third-degree but extends through the rectal mucosa to the lumen of the rectum; it may be called a third-degree laceration with a rectal wall extension.

XIV. What assessments and nursing interventions do you perform in the care of a woman during an amniotomy? P. 496

Amniotomy is the artificial rupture of the amniotic membranes (AROM).

The nurse should assess fetal presentation, position and station. The woman is asked to assume a semireclining position and is draped for privacy. The FHR is assessed just before and immediately after the amniotomy, and the two FHR assessments are compared. The nurse should check for prolapse of the cord. Amniotic fluid is assessed for amount, color, odor, and the presence of meconium in blood. The nurse cleanses and dries the perineal area and changes the underpads; number of vaginal exams must be kept to a minimum. Also, the woman’s temperature is monitored a minimum of every 2 hours.

 

XV. After a forcep-assisted birth what complications do you assess for? P. 506-507

Immediately following birth, the newborn is assessed for facial edema, bruising, caput succedaneum, cephal-hematoma, and any sign of cerebral edema. In the fourth stage the woman is assesses for perineal swelling, bruising, hematoma, excessive bleeding, and hemorrhage. In the postpartum period it is important to assess for signs of infection if lacerations occurred during the procedure.

XVI. How does a C Section effect bonding.

Every effort should be made to assist the parents in bonding with their infant. If the mother is awake, one of her arms can be freed to enable her to touch and stroke the infant. The newborn may be placed on the mother’s chest or held in a en face position. The nurse can provide a running narrative, if physical contact is not possible. Also, she can assist with raising the mother’s head so she can see her infant immediately after birth. The parents can be encouraged to talk to the baby, and the father can hold the baby until she or he is taken to the nursery.

 

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