What are some maternal factors that trigger labor?

6
What is dilatation/dilation?
Maternal factors
It is the widening of the cervical external os from
 ◦Stretched uterine muscles & release of less than 1 cm, to full dilatation (approx. 10 cm) to
prostaglandins allow birth of a full term fetus
 ◦pressure on cervix stimulates nerve plexus
→ oxytocin
 ◦> estrogen → stimulates uterus to contract 7
 ◦Withdrawal of progesterone = < quieting What is a placenta previa?
 ◦> release of oxytocin + prostaglandins =
inhibit CA binding → contractions activated  Low-lying placenta may cause the baby to
 ◦Surge of oxytocin → contractions assume a transverse lie
 Placenta previa can be associated with
2 breech presentation, this increases the
What are some fetal factors that trigger labor? chances of being in a breach
 May also impede descent of a vertex baby
 Placental aging → triggers contractions
 Fetal membranes synthesize prostaglandins
→ contractions
 ↑Fetal cortisol (adrenal glands) → < 8
progesterone → > prostaglandins → During the intrapartum period what would you
contractions observe for in the cervix and vagina?

3 }Cervix:
What are the premonitory signs of labor?
◦Cervical Scarring
 Lightening
 Braxton-Hicks (will go away when walking) – LEEP, conization, biopsy
vs. true labor contractions (they will not go
away when walking)
◦Causes firm or “purse-string” consistency
 GI changes (diarrhea, nausea, indigestion)
 Backache  ◦Prolonged effacement period followed by
 Bloody show (brownish or blood tinged) rapid dilatation once tissue softens
 Spontaneous rupture of membranes
}Vagina:
4
What are 5 factors affecting labor?  ◦Obstructions
 ◦“Tissue Dystocia”
1.Powers (the contractions)
9
2.Passage (the pelvis) What is a fetal "lie" and what are the different
types?
3.Passenger (the fetus)
Definition: the relationship of the fetal long axis to
4.Psyche (the response of woman) the long axis of the mother
Types:
5.Position (maternal postures and physical
positions to facilitate labor)  Vertical/Longitudinal (normal)
o head first
5
 Vertical/Longitudinal (variation)
What is effacement?
o breech
 It is the thinning and shortening of the  Perpendicular (abnormal)
cervix that occurs during labor o Transverse (spines make a T )
 At 100% effacement, the cervix is paper- o oblique
thin

10
What is fetal presentation and what are the What are some position and presentation issues
different types? with labor?
Definition: the leading or most dependent portion
Position: Occiput Posterior “sunny side up”
of the fetus.
Types:  Longer labors
1. Cephalic  Spontaneous or assisted rotation to OA
 Some feel that sedentary behavior in Mom
 Vertex, Brow, Face ↑ this

2. Shoulder
3. Breech
Compound Presentation: more than just a head….
 Frank (feet up), Complete (both feet +
 1:700 deliveries
sacrum), Footling (just a foot/feet)
 Associated with umbilical cord prolapse
15% to 20% of cases
 More than just a head comes out of the
11 mother, increased risk of an umbilical cord
What are some options of a breech at term? prolapse --> Emergency (lift presenting part
off of cord)
External Cephalic Version
Turning the fetus 14
Requirements: What are sutures?

 They are the meetings of the bones of the

 Normal fetus with reassuring FHR tracing
 Adequate amniotic fluid fetal skull
 Covered by a membrane
 Not in labor
 Presenting part not engaged
15
Default option: cesarean delivery What are fontanelles?
}Manipulating the fetus in order to turn it to head
 Fontanelles are the space where two
first
}Procedure: IV, ultrasound, terbutaline (to relax sutures meet
 Covered by a membrane
uterus), Rhogam (if Rh-negative), provide for
 You never want to put a scalp electrode on
emergency C-S.
his scalp
}Risk: separation of the placenta, uterine rupture,
fetal-maternal hemorrhage, failure.
}Very painful for the mother
12 Cabit = fluid
What is fetal position and what are the different
types?
16
Definition: the relationship of the presenting part What is fetal attitude?
to the specific area of the woman’s pelvis Definition: posturing of the joints and the
relationship of the fetal body parts (chest, chin,
arms) to each other.

Types: }Flexion - normal fetal attitude when labor begins

}Extension increases diameters
 Right (R) or Left (L) of maternal pelvis }
 Occiput (O), Mentum (M), or Sacrum (S) of 17
fetus What are primary "powers" (involuntary)?
 Anterior (A), Posterior (P), or Transverse
(T) of maternal pelvis Primary (involuntary) Contractions:

 Frequency (Beginning of one to the

beginning of another)
13  Duration (beginning from one to end of it)
  Intensity (How strong it is) 27
 resting tone (Important because of What is the internal rotation of labor?
oxygenation to baby)
c. Process of alignment of fetal long axis to
18 maternal long axis
What are secondary (voluntary) contractions?
28
What is the extension of labor?
maternal bearing-down efforts
a. presenting part pivots beneath symphysis pubis
19
with the birth of the head
Describe the frequency of contractions
29
Timed from the START of one contraction to the What is the expulsion of labor?
START of the next
30
20 What is labor and how many stages are there?
Describe the duration of contractions
Labor is the process in which the fetus, placenta,
and membranes are expelled spontaneously
Timed from the START of the contraction to the
END of that contraction
21 4 Stages of labor
What are some losses experienced in labor?
31
When does stage 1 of labor occur?
 Privacy
 Control of Situation
 Begins with onset of labor and ends with
 Control over Bodily Functions
complete cervical dilation
 Loss of Current Family Constellation
 Has 3 phases, latent, active, and transition
 Couples become parents, parents of one
phase
become parents of two, etc
32
22
Describe the active phase of the 1st stage of labor
What is "engagement"
Occurs when the biparietal diameter is at or below  Average dilation 1.2 cm/hr depending on
the inlet of the true pelvis gravida
 Dilation progresses 4–7 cm, 40–80%
23
effacement
What are the physiological changes of labor?
 Fetal descent
 Intense contraction q 2–5 min, lasting 40–
a.> BP, Increased cardiac output, Fluid and
60 sec
electrolyte loss, Diaphoresis, Hyperventilation &
 Increase in pain
Elevated temperature
 Medical interventions
24  Nursing actions
What are the mechanisms of labor?
33
1. Engagement Describe the latent phase of the 1st stage of labor
2. Descent
3. Flexion  ◦Cervix 0–3 cm dilation, 0–40% effacement
4. Internal rotation  ◦Contraction every 5–10 min, mild intensity,
5. Extension lasting 30–45 sec
6. External rotation  ◦Discomfort described as feelings of strong
7. Expulsion menstrual cramps
 ◦Medical interventions
25  ◦Nursing actions
What is the decent of labor?
34
26 Describe the transition phase of the 1st stage of
What is the flexion of labor? labor
Chin to chest to < diameter
 Dilation from 8 to 10 cm, 100% effacement
  Contractions intense, q 1–2 min lasting 60– What are some nursing interventions during the
90 sec 2nd stage of labor?
 Exhaustion, difficulty concentrating
 Bloody show  —Prepare radiant warmer for newborn -
 N/V, backache, diaphoresis, and trembling baby blankets, labels.
 Strong urge to bear down  —Adjust lighting and obtain/set up table
 Medical interventions  —Call anesthesia/ NICU if necessary
 Nursing actions  —Inform pt of progress and events
 —When physician at bedside, position pt
35  —Prep perineum as requested
What are some medical interventions for the 3  —Document delivery time & watch for NB
phases during the 1st stage of labor? void

 Latent phase: orders for lab tests, IV or 40

saline lock, intermittent fetal monitoring What is the 3rd stage of labor?
 Active: ROM, FHR monitoring, apply fetal
scalp electrode or Uterine transducer PRN,  —Period involving separation and expulsion
Pain management, Evaluate labor of placenta/membranes
progression  —Lasts 5–20 min
 Transition: AROM, assess fetal position &  —Medical interventions
cervix; prepare for delivery  —Nursing actions

36 41
When does the 2nd stage of labor occur? When does the 3rd stage of labor occur?
Begins with complete cervical dilation and ends Begins after delivery of baby and ends with delivery
with delivery of baby of placenta
37 42
What are some behaviors during the 2nd stage of What is the 4th stage of labor?
labor?
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 Urge to bear down is strong
 —This stage begins the postpartum period
 Pushing feels more productive to many
 —Ends 4 hr after delivery
mothers; they are eager to push
 —Mechanism of homeostasis occurs
 Exhausted mothers may find the exertion
 —Medical intervention
overwhelming
 —Nursing actions
 Burning as head crowns often causes fear of
“splitting open”
43
 Pushing causes very intense sensations that
When does the 4th stage of labor occur?
can frighten unprepared mothers
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38 Begins after delivery of baby and ends with delivery
What are some characteristics of the 2nd stage of of placenta
labor?
44
What are some characteristics of the 4th stage of
 —Complete dilatation
labor?
 —Sudden burst of energy, improved focus
 —Shorter duration with multips than Study These Flashcards
primips
 —Intense contraction every 2 min, lasting  —Beginning of physiologic readjustment of
60–90 sec the mother’s body
 —Increase in bloody show  —250-500 cc blood loss is common
 —Perineum flattens, with bulging rectum  —Causes drop in systolic and diastolic BP,
and vagina tachycardia, increased pulse pressure
 —Medical interventions o —Maternal pulse over 100 and
 —Nursing actions fainting
 —
 —Uterus is contracted, midline and near the
39 umbilicus
  —Oxytocin is given after delivery of the 49
placenta to increase uterine contraction What is an episiotomy?
and decrease bleeding
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 —Bladder may be hypotonic from
Mediolateral (usually right)
anesthesia, analgesia, trauma
 —Vital signs, fundal height and vaginal —Begins in the midline of the posterior fourchette
flow checked every 15 minutes X 4 (1st (to avoid Bartholin’s gland)
hour) —Extends at a 45 degree angle downwards
 —Baby should be given to mother for —
bonding and to initiate breastfeeding as 50
soon as possible What are the different degrees of lacerations in an
 —Shaking/chilling is common episiotomy?
 —Ending of the physical exertion of labor
 —Loss of the “heater” that is the fetus Study These Flashcards
 —Most women are hungry, thirsty and tired 1st degree

 —fourchette, perineal skin, vaginal mucous

membrane
45
What would you assess for in the uterus in the 4th 2nd degree
stage of labor?
 —plus fascia and muscles of perineal body
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3rd degree
 —Assess fundal height and consistency, and
relation to midline
 —extends into the anal sphincter
 —Should be < umbilical level and central
 —Assess bladder - encourage pt to void
4th degree
 —Straight catheter if necessary
 —Record quantity of lochia (rubra)
 —also involves the anterior rectal wall
(tissue of the rectum)
46
Describe some characteristics of the lateral pushing
51
position
What are the benefits of an episiotomy?
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 Can help rotate a fetus that is in a posterior
 —Hastens delivery if there is fetal distress
position.
 —May be needed if the perineum is
 Can slow a precipitous birth.
unyielding
 Allows the perineum to stretch gradually
 —Room for maneuvers w/ shoulder
dystocia
47
 —More room for use of forceps or vacuum
What is the natural position for pushing during
labor?
52
Study These Flashcards What are some risks associated with an
Squatting episiotomy?
48 Study These Flashcards
What is directed pushing and describe it
 —Fecal and/or urinary incontinence
Study These Flashcards  —Pain in the area can persist for 6 months
or more
 Begins when mother is completely dilated
 —Increased pain with intercourse
 Patient takes one good breath, then takes
 —Bleeding
and holds a second breath.
 —Bruising
 While holding the breath, she pulls back her
 —Swelling
knees, bears down and pushes for a count
 —Infection
of 10
 Cycle of inhale, hold, push repeated X 2
53
during a single contraction
Describe some newborn nursing care and nasopharynx on perineum with
meconium present in amniotic fluid.
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 —Babies can be on their side; mouth can be
wiped PRN
 —Obtain Apgar scores at 1 min and 5 min
 —Studies of catheter deep suctioning fail to
 —Monitor temperature, heart rate,
show a benefit in oxygenation
respiratory rate, skin color, level of
 —Studies recommended that the routine
consciousness, tone, activity
and indiscriminate use of or
 —Newborn identification
nasopharyngeal catheter suctioning at
 —Medication administration
birth be curtailed.
 —Dry thoroughly and place cap on head
 —Warm, dry, stimulate
56
 —For persistent cyanosis of the trunk,
What is a caput?
administer blow-by O2
 —PPV for infants not breathing OR HR < 100 Study These Flashcards
 —Chest compressions if HR < 60 JUST EDEMA UNDER THE SCALP, CAUSED BY
 —Deep suction after 5 minutes done for PRESSURE OF THE CERVIX ON THE HEAD. IT
persistent rales or rhonchi BEGINS TO SUBSIDE AS SOON AS THE BABY IS
 —Gross physical assessment for BORN.
abnormalities
57
 —Label baby with identification bands (per
What is a CEPHALHEMATOMA?
hospital protocol) before it leaves the
delivery room Study These Flashcards
 —Baby footprints and mother’s fingerprint
 —Obtain cord blood samples if required (Rh  IT IS BLEEDING UNDER THE
negative or Group O) PERIOSTEUM. IT THEREFORE DOES NOT
 —Obtain cord gases if indicated (i.e., low CROSS SUTURE LINES, BECAUSE EACH
Apgar) BONE HAS ITS OWN PERIOSTEUM.
 CEPHALHEMATOMA USUALLY STARTS AS A
54 RESULT OF BIRTH TRAUMA, AND MAY
How is an apgar scored? WORSEN OVER ONE TO THREE DAYS
BEFORE BEING REABSORBED.
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58
 —Assign APGAR scores at 1 & 5 minutes
What can lead to pain during labor and delivery?
 —0 - 2 points are given for 5 observations:
o —Appearance: color Study These Flashcards
o —Pulse: heart rate
o —Grimace: response to stimulation  —Pain may result due to the following
o —Activity: muscle tone factors
o —Respiration: respiratory effort  —Decreased blood supply to uterus
 —Score of < 7 at 5” indicates need for 10”  —Increased pressure and stretching of the
score and further resuscitation pelvic structures
 —Cervical dilatation and stretching
55
Describe suctioning in relation to newborn care 59
What is counterpressure?
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 —Current guidelines state there is no
evidence to support the value of the  Comfort measures: Counter pressure
practice of routine bulb suctioning of the  —Direct pressure to the sacrum or hips to
newborn. counteract stretching of ligaments
 —Current Neonatal Resuscitation Program  —
(NRP) guidelines no longer include bulb sx
in the initial resuscitation of the normal 60
term newborn. How can breathing manage pain during labor?
 —NRP guidelines no longer (2006)
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recommend mechanical sx of the mouth
  —Important because there is a natural  —> incidence of inadequate block
tendency to hold the breath with pain  —Maternal hypotension
 —In general, as labor becomes active and  —Fetal bradycardia
contractions get stronger, deeper
breathing is difficult/impossible 65
 —Patterned breathing also acts as Describe the epidural procedure for labor
distraction
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 —Panic can lead to hyperventilation
 —Tingling hands, lips
 —Consent forms after full explanation
 —Breathe into cupped hands or surgical
 —Establish IV and adminisiter fluid bolus
mask
 —Ready equipment: O2, fetal monitor,
epidural equipment, IV fluids
61
 —Help position patient in side-lying or
What are some analgesic mediactions used during
sitting position – attach BP cuff
labor?
 —Assist anesthesiologist with procedure
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66
 Meperidine What are some medications used for continued
 Morphine epidural and what are the side effects?
 Butorphanol
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 Nalbuphine
 Sublimaze
—Narcotics –Fentanyl or Druamorph
62
—Side effects: severe itching, Nausea &
What types of anesthesia used in labor and
vomiting,Burning, swelling or skin irritation at site
delivery?
of injection
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67
1. Local Describe spinal anesthesia
2. Pudendal nerve Study These Flashcards
3. General
 —drug into the subarachnoid cerebrospinal
63 fluid space (CFS). The injection is usually
What is epidural? made in the lumbar region at the L2/3 or
Study These Flashcards L3/4 space – punctures dura
 —Immediate action -shorter procedures
 ——Intermittent injection or continuous
infusion 68
 —outside the dura mater
What are some complications with spinal
 —Solution bathes the spinal roots
anesthesia?
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64
What are some advantages and disadvantages of  complications are related to the techniques,
epidural? resulting in systemic toxicity, or to the
Study These Flashcards effects of the block, rather than to the
Adv: drugs used.
 —Cardiovascular: seizures or convulsions,
 —Slower onset arrhythmias, cardiac arrest
 —High Block = nasal stuffiness, respiratory
 —Titrate level and duration
 —< hypotension distress or arrest
 —Total spinal =
 —Awake client
 —Post-dural Puncture Headache
Dis: o —Blood patch (10 – 15 ml blood
injected into dural space)
 —Placement takes time
 —Systemic toxicity
 —Large placental transfer 69
What are some adverse reactions to spinal Protraction disorders = slower than normal
anesthesia?
Arrest disorders = complete cessation of UC
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76
What are the 2 types of contractions?
—
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70
What are the nurse's responsibilities of spinal 77
anesthesia? How would you care for a women with hypertonic
uterine dysfunction?
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 —Assist anesthesiologist
 —Maintain IV site  Labor progress
 —Be prepared for emergency situations if  cause of dysfunction
occur  Hydrate
 Pain meds
71  Sedation
What is dystocia?
78
Study These Flashcards What are hypotonic arrest disorders?
difficult labor or childbirth
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72
79
What is Cephalopelvic disproportion (CPD)?
What is a secondary arrest of dilation?
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—disparity between the size of the maternal pelvis 80
and the fetal head What is a constriction ring and describe it

73 Study These Flashcards

What is asynclitism?
 Develops around a depression in the fetus
Study These Flashcards  Related to hyperstimulation of the uterus
malposition of the fetal head  Keeps the fetus from descending
o Ring may be felt abdominally &
74
doesn’t move
What are some risk factors for dystocia?
o Uterus below the ring is often loose
Study These Flashcards and floppy
o Head does not move down at all
 Congenital abdnormal uterus bicorniate with contractions
uterus  Uterus becomes tender but will not rupture
 Mal presentation: (i.e. occiput posterior, or  Labor does not progress
face)  May occur in any stage of labor
 Ceohlo-pelvic disproportion (CPD)
 Tachysystole of uterus (with [pitocin) 81
 Maternal fatigue & dehydration What is a precipitous birth?
 Administration of analgesia or anesthesia
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early labor
Labor < 3 hours from onset to birth
 < maternal fear or exhaustion →
catecholamine release & interference with 82
labor What are some nursing interventions with a
precipitous birth?
75
What is dysfunctional labor? Study These Flashcards

Study These Flashcards  Call light, call for help!

Abnormal contractions that prevent expected  Try to turn on the warmer, O2, suction
progress of cervical dilation or descent of fetus  Get gloves on, if you can
  If perineum is bulging, just keep hands Study These Flashcards
near to control the head, use counter The artificial stimulation of labor that began
pressure spontaneously but has progressed abnormally
 NEVER TAKE YOUR EYES OFF HER
89
BOTTOM!
What would indicate and induction or
 Keep a hand near the urethra, hold the
augmentation of labor?
baby’s head to slow it down and also push
down a bit to protect the urethra Study These Flashcards

83  Pre-eclampsia/Eclampsia
What is shoulder dystocia?  PROM/ PPROM
 Chorioamnionitis
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 Isoimmunization
Occurs when the fetal spine is vertical to the
 Maternal medical issues
maternal pelvis
 Postdate pregnancy
84  Oligohydramnios
What does the helperr mnemonic mean in relation  Fetal growth restriction
to shoulder dystocia?  Fetal demise
 Logistic factors
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 Prior loss
H:help- call for extra nurses, NICU

E:evaluate for episiotomy; empty bladder
90
L:legs back and open in McRoberts
What are some contraindications of inducing or
P:pressure over the pubis towards the augmentin labor?
baby’s face Study These Flashcards
E:entry maneuvers Rubin and Wood’s Screw  Placenta previa
R:remove posterior arm  Transverse fetal lie
 Prolapsed umbilical cord
R:roll patient- The Gaskin Maneuver  Breech presentation
85  Prior classical cesarean incision
What would you evalute before inducing labor  Major uterine surgery
maternally?  Active herpes simplex

Study These Flashcards 91

What is the criteria for inducing labor?
1. confim indication for induction
2. review contraindications to labor and Study These Flashcards
or/vaginal delivery
3. perform clinical pelvimetery to assess pelvic  Engaged presenting part
shape and adequacy of bony pelvis  No previous classical C/S incision
4. Assess cervical condition (assign bishop  No fetopelvic disproportion
score)  Reassuring FHR pattern
5. Review risks, benefits, and alternatives of  No placenta previa
induction of labor with patient  No major bleeding from abruptio placentae

86 92
What would you evalute before inducing labor What are some risks for inducing labor?
fetally? Study These Flashcards
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 Fetal distress
87
 Placental abruption
What is induction of labor?
 Increased needs for pain medications
Study These Flashcards  Edema R/T Pitocin, IVF, hydration w/
the process of starting labor artificially epidural
 Prolapsed umbilical cord or infection w/
88
amniotomy
What is augmentation of labor?
  Uterine rupture  —Apply FSE and assess cervix and station
 Cesarean delivery  —Assess for S & S of placental abruption
 §Induction of nulliparas results in 40% C/S  —Turn Pitocin off
rate  —Administer O2 @ 8-10 L/min via NRB
 —Call physician
93  —Be prepared to administer Brethine
What are the benefits for inducing labor?  —Prepare for C-S if FHR still no better.
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96
What is forceps delivery?
 Ability to schedule other events in family
w/birth Study These Flashcards
 Prevention of precipitous birth Forceps assist the birth of a fetus by providing
 With known anomalies, ability to have traction or a means to rotate the fetal head to an
proper staff/NICU in attendance occiput-anterior position
 Birth with chosen provider
97
 Completion of pregnancy that is too
What are the different types of forcepts delivery?
physically stressful for mother
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94 Types: Outlet, Low
Describe oxytocin (pitocin) induced labor
§Mid-forceps (rarely used)
Study These Flashcards Outlet Forceps

 Pitocin rate depends on assessment of: §fetal skull has reached the perineum. Scalp is
 §uterine activity visible between contractions
 §fetal response Low Forceps
 §cervical effacement and dilation §fetal skull is at +2 station or more
 The primary concerns are tachysystole, 98
tetanic ctx & fetal bradycardia What are the requirements for using
 VBAC patient > risk of uterine rupture
forceps/vacuum?
 Nursing care ratio 1:1
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 Admit as usual labor patient
 Documented fetal position, lie, cephalic  Known position and presentation
presentation within previous 24 hours  Empty maternal bladder
 MD with C/S privileges < 10 min away  Cervix fully dilated
 Mainline IV of LR 1,000mL @ 125 mL/hr via  Membranes ruptured
18 gauge cannula  Adequate anesthesia
 I&O  Expertise
 Continuous FHR monitoring  Feasibility
 —Dilute 20 Units Pitocin in 1,000mL NS IVPB  Cesarean section availability
 —Give via pump starting at 1-2 milliunits/
min (3-6 mls/hour). 99
 —Insertion site is in the most proximal port. What are some risks associated with forceps
 —Increase Pitocin rate by 1-2 milliunits q delivery in the neonate and mother?
15-20 minutes until adequate ctx pattern. Study These Flashcards
 —Take BP with every increase. Neonate
 —Continuous monitoring of ctx frequency,
duration, intensity, resting tone.  Cephalohematoma
 —Adjust total IV fluid intake to 125mL/hr  Transient facial paralysis and bruising
  Facial edema
 Cerebral edema
95
What are some interventions for fetal distress? Mother
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 Perineal swelling
 —Reposition in lateral recumbent  Bruising
 —Increase IV mainline fluid (LR)  Hematoma
  Hemorrhage
 Postpartum infection

100
What is an amniocentesis?
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THIS IS THE PROCEDURE FOR INSERTING A NEEDLE
INTO THE UTERUS IN ORDER TO EXTRACT SOME
AMNIOTIC FLUID FOR ANALYSIS. THE RISKS
INVOLVED INCLUDE BLEEDING AND INFECTION. IN
EARLY PREGNANCY IT IS COMMONLY DONE FOR
GENETIC STUDIES; NEAR TERM IT IS USED TO
OBTAIN SAMPLES FOR DETERMINING FETAL LUNG
MATURITY PRIOR TO DELIVERY.
101
Why is an amniocentesis done when the baby is
near term?
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 Generally done to determine fetal lung

maturity from 34-38 weeks
 Due to surfactant a term specimen will
develop bubbles when shaken
 Also turbidity prevents seeing through
specimen
 L/S (lecithin/ sphingomyelin) ratio
(2:1) and phosphatidylglycerol done in lab
for FLM