Ob Study Packet

LABOR AND DELIVERY SKILLS
Bloodborne pathogens / Standard Precautions

The Center for Disease Control (CDC) defines Standard Precautions as a set of precautions designed to prevent or reduce the
risk of transmission of HIV, HBV, HCV and other blood-borne pathogens from both recognized and unrecognized sources of
infection in health-care workers (HCWs). HCWs are defined as persons, including students and trainees, whose activities
involve contact with patients or with blood or other body fluids from patients in a health-care setting. Nurses employed in
labor and delivery are exposed to blood, vaginal secretions and amniotic fluid, which are carriers of infectious diseases. Blood
is the single most important source of HIV, HBV and other bloodborne pathogens. The blood does not have to be visible to the
human eye to be capable of transmitting disease.
Handwashing
Wash the hands thoroughly, with soap and water, after contamination with blood or other body fluids, between patients and
immediately after gloves are removed. Gloves do not replace the need to wash the hands. There may be minuscule puncture
marks on the gloves that can aid in spreading infectious diseases.
Gloves
In labor and delivery, gloves must always be worn when touching body fluids that contain blood or when handling items or
surfaces with blood or body fluids what are potentially infectious. (CDC, 1999) Non sterile gloves can be used when starting
the intravenous, phlebotomy, washing used instruments, cleaning a patient before or after a vaginal delivery, obtaining various
body fluids for diagnostic purposes (peritoneal or amniotic fluids), handling the placenta and umbilical cord, and when
handling the infant after the delivery until blood and amniotic fluid is washed off. Non-sterile gloves can also be used for
procedures involving contact with mucous membranes and other non sterile examination, for example: digital examination of
mucous membranes or when performing heel sticks on infants. Sterile gloves must be used for procedures that involve contact
with normally sterile areas of the body. In obstetrics this includes the use of sterile gloves during vaginal examinations to
protect the transmission or introduction of infection into the vagina. Gloves should be changed between each patient contact.
Never wash gloves for reuse.
Protective Barriers
The Center for Disease Control (CDC) states that all health care workers who participate in invasive procedures must use
appropriate barrier precautions. (CDC, 1999).The CDC recommends that for both vaginal and cesarean deliveries gloves,
gown (with protective front), plastic disposable overshoes, eyeguard and mask be worn. Both in a vaginal or cesarean section,
the floor or ground is likely to be contaminated and when the placenta is delivered, the blood may splatter.
Human Milk
Although HIV and outer surface antigens (HBsAg) have been found in the milk of mothers infected with HIV and HBV, health
care workers do not have the same type of exposure as the infant. Therefore, universal precautions do not apply to breast milk.
Source: The Center for Disease Control (CDC) the prevention of transmission of blood-borne diseases in the health-care
setting 1999.
HISTORY AND INITIAL ASSESSMENT
As with any evaluation the first and perhaps most essential component is the history. The patient
should be specifically queried about the presence or absence of leaking or ruptured membranes
and the presence or absence or vaginal bleeding. A history of recent illnesses should be sought
and any prenatal complications should be reviewed. Finally, an inquiry should be made about the
patient's expectations and preparation for the labor and delivery process (childbirth classes,
preferred pain management, plans for infant feeding). A careful review of the prenatal record
should be supplemented by the patient interview with regard to recent illnesses and obstetrical
complications.
PHYSICAL EXAMINATION OF THE LABORING WOMAN
Steps you should take to prepare for the examination:
Ask woman to empty bladder (collect urine for testing).

Prepare to follow a logical order.
Prepare to chart logically immediately after exam (make
notes).
Remember to use all your senses during assessment.
Remember to explain everything you are doing.
Exam should be carried out immediately and as quickly as
possible.
Urine tests used during intrapartum
Ph
Measures acidity/alkalinity of the urine, Levels below normal indicate high fluid intake, levels above the norm
indicate inadequate fluids & dehydration.
Protein
Normal = Negative, Small amounts may be in urine from vaginal secretions & dehydration, Amounts of 2+ to 4+
may indicate be one indicator of possible UTI, Kidney Infection or PIH.
Glucose
Normal = Negative or + I. High levels of glucose may be one indicator of high blood sugar, gestational diabetes or
diabetes mellitus. Always ask what woman has recently eaten if her BS is high.
Ketones
Normal = Negative. Ketones are products of the breakdown of fatty acids caused by fasting. The body breaks down
fats because there are not enough carbohydrates and proteins available. Ketones may be deleterious to fetus.
Techniques to be used in performing a physical examination:
Inspection
Palpation
Auscultation...
For more information go to:
The Auscultation Assistant - Hear Breath Sounds, Heart Murmurs, Heart Sounds, and ...
Perform Examination:
General appearance:
Edema, skin color, hygiene, pain, distress, mood
Measure vital signs:

Blood pressure, pulse, respiration, temperature
Blood pressure
Take blood pressure with woman in sitting or side lying position
Compare blood pressure with prenatal blood pressure
At what point would you determine if the patient were hypertensive? What additional
assessments and interventions would you take if patient were hypertensive?
Test for proteinuria.

Assess for facial and general edema.
Test for hyperreflexia.
Ask if patient is having headaches, blurred vision, spots in vision.
Notify provider of any pathologic results
Pulse
Rate: 60 - 90
Increased pulse can be dehydration, anxiety.
Always question possibility of cardiac problems.
What is the most common cardiac problem in a young female?
Respiration
Don’t count during a contraction
Temperature
Think about infection and dehydration
Abdominal examination
An abdominal examination should include a measurement of fundal height as well as an

assessment of fetal size (estimated fetal weight), presentation and position using Leopold's
maneuvers.
Inspect: Scars, linea, striae, symmetry
Palpate: fundal height, fetal position
Osculate: fetal heart tones
Determine and palpate contractions
Inspect and palpate lower extremities
Press firmly with thumbs about 5 seconds over shin

If any signs of elevated blood pressure, elicit DTR
If reflexes are hyperactive, check for clonus
Measuring fundal height
Place the zero line of the tape measure on the

anterior border of the symphysis pubis and stretch
tape over midline of abdomen to top of fundus.
The tape should be brought over the curve of the
fundus.
The height of the fundus in centimeters equals the
number of weeks gestation plus or minus 2.
After 32 weeks the relationship is less accurate.
Perform Leopold maneuver.
Leopold's Maneuver
Abdominal Examination for Position and Presentation and Size
Hands have an acute sense of touch especially when attached to a well-trained mind. You should
always assess for position, presentation, engagement and size by abdominal examination. With
warm hands and gentle pressure palpate the abdomen for soft consistency, fluctuating amniotic
fluid, indefinite outlines and baby’s small knobby parts.
Leopold's maneuvers are used to determine the

orientation of the fetus through abdominal palpation.
1. Palpation of the uterine fundus to determine which fetal
pole "head or breech" is present in the fundus. Using
two hands and compressing the maternal
abdomen, a sense of fetal direction is obtained
(vertical or transverse).
2. The lateral sides of the fundus are palpated to

determine the position of the fetal back and small
parts.. The fetal spine will palpate as firm, flat and linear.
The fetal extremities are palpable by their varying contour
and movements. The purpose of this maneuver is to
determine whether the fetal back is left or right.
3. The purpose of this maneuver is to determine the pelvic

position of the presenting part. The presenting part
(head or breech) is palpated above the symphysis
and degree of engagement determined. The
examiner uses the thumb the fingers of one hand in the
suprapubic region (similar to palming a basketball) and
attempts to move the presenting part from side to side. If
little movement occurs or only the fetal neck is palpable
the presenting part is engaged.
4. The fetal occipital prominence and flexion of the

vertex is determined. If the fetal vertex is flexed, the
cephalic prominence may be palpable on a same side as
the fetal small parts. If a distinct cephalic prominence is
noted on the same side as the spine and head the vertex
is not very well flexed.
Use Leopold's to locate fetal back and as a reason to "lay hands" on your patient.
slowly “walk” fingers over the abdomen looking for the resistance of baby’s back, which may be in
the center of the abdomen or deflected off to either side. Palpating the fundus (top) of the
abdomen along with the symphysis pubis area (bottom) of the abdomen, the hands will be feeling
for the firm irregular buttocks of baby or baby’s even firmer regular and smooth head as you
‘visualize’ the size of baby.
While locating fetal position and heart tones, talk to the patient. Assess abdominal
tenderness as well as contractions and ascertain fetal movement. Sometimes just
taking those few minutes to touch, talk to and listen to the patient goes a long way to
establishing the tone of the whole labor. The monitors are great but do remove that
human touch. Always remember there is a human being attached to that monitor
and treat her as such. She has a lot of information to impart if you ask the right
questions and make astute observations
Leopold's maneuvers just are a part of a whole-person assessment. Develop a skill for this by
practicing and learn it well. It CAN help you determine a lot of things and help establish a warmer
relationship with a mom-to-be---especially if you provide her with the information you find. It just
makes it all much more personal. Technology is a wonderful thing but NEVER takes the place of
this touch and YOUR assessment skills.
Monitoring the Mother and Fetus During Labor
• A 20 minute fetal monitor strip is done for all patients on admission. As long as the patient is
healthy, the presentation normal, the presenting part well engaged, and the fetus in good
condition, the woman may walk about or be in bed as she wishes.
• The patient's condition and progress is checked periodically. FHT's are checked q 30 min in latent
phase, q 15min. in active phase, and q 5min. in second stage. The maternal temp is taken q 4 hrs.,
q 2 hours if ROM. Variations to this timing depend on the maternal-fetal situation.
• The progress of labor is followed by abdominal or vaginal examination to note the position of the
baby, the station of the presenting part, and the dilatation of the cervix. These examinations should
be done only often enough to ensure the safe conduct of labor, i.e., to determine that the rate of
dilatation is within the normal range or to evaluate the patient if she is requesting medication.
• Over distension of the bladder is obviated by urging the patient to void every few hours. If she is
not able to do so, catheterization may be necessary, since a full bladder impedes progress.
• Adequate amounts of fluids and nourishment are essential. If the patient is unable to take enough
orally, a intravenous of Lactated Ringers solution may be given.
• During the first stage, the patient should be impressed with the important of relaxing with the
contractions. Help the couple as much as possible to work with the contractions and compliment
them for a good job.
• The passage of meconium stained fluid in a cephalic presentation is a possible sign of fetal distress
and if present, the patient should be continually monitored during active labor.
Ausculate fetal heart tones.

ROA is best heard in mother's right lower quadrant.
ROP or LOP is best heard in mother’s left side.
Should Women be Given a Choice About Fetal Assessment in Labor?
MCN, The American Journal of Maternal/Child Nursing September / October 2003

Abdominal Examination for Contractions
An initial abdominal examination is carried out on admission by laying a hand on the uterus and
palpating, noting the degree of hardness during a contraction and timing its length. This should be repeated
at intervals throughout labor in order to assess the length, strength and frequency of contractions and the
descent of the presenting part. The uterus should always feel softer between contractions.
The monitor should never be relied on; the mother’s abdomen should be regularly palpated by hand.
Uterine contractility can be quantified subjectively by palpation or objectively by the use of an

external tocodynamometer or an intrauterine pressure catheter (IUPC). The external
tocodynamometer can generally provide reliable information about the frequency of uterine
contractions and their approximate duration.
The actual amount of intrauterine pressure generated with each contraction must be measured by
internal devices, such as the intrauterine pressure catheter. The traditionally used measure of
uterine work is called the Montevideo method. Montevideo units are calculated by totaling the
peak uterine pressures (in mm/Hg) minus the baseline pressures over a ten minute period. at
least 200 Montevideo units are required before the forces of labor can be considered adequate
(i.e., when a protraction or arrest disorder is noted measures should be taken to ensure that
contractions at least 200 Montevideo units exist before a cesarean delivery is undertaken).
Uterine Contractions
Vaginal examination
A fetal heart check and an abdominal palpation for fetal position and presentation
should always precede initial vaginal examination.
The vulva should be carefully inspected for lesions (e.g., herpes, etc), some assessment of the
superpubic angle, prominence of the iliac spine and size of the pelvis in relation to the fetal head
should be made. Purpose of exam is to assess the status of membranes, fetal
presentation and position, engagement, effacement, cervical dilatation and station.
Lie and presentation

Lie and Presentation
Engagement
Engagement
Effacement
Effacement
Station
Station
http://cats.med.uvm.edu/cats_teachingmod/ob_gyn/teaching_modules/normal_delivery/movies/expulsion1.dcr
Procedure
Prepare client the same way as for a speculum examination. Lubricate index and
middle finger of examining hand generously.
Separate the labia with gloved fingers. Inspect vaginal opening (introitus). Observe
for:
Amount of bloody show: advanced labor

Ruptured membranes
Discharge that is malodorous
Discharge that is deep yellow or greenish brown: Meconium
Ulcerated areas on perineum: Herpes, Syphilis
Examinations are done with aseptic technique (sterile gloves and antiseptic solution). You insert two
fingers into the vagina and feel the cervix and the top of the baby’s head to gather information about the
dilation and the presentation of the baby. This may be uncomfortable, especially during a contraction.
There is no place for routine vaginal examinations in any labor. Vaginal examination should only be
done when there is doubt about the clinical situation or symptoms, and the information gathered is
necessary or likely to be of use in making a clinical decision.
Excessive vaginal examinations carry with it the risk of increased infection. You should rely on behavior
and emotional responses and physical sensations rather than vaginal exams.
Reasons to defer or avoid digital vaginal examination:
The vaginal examination should be avoided or deferred in certain circumstances. In most of these
situations a careful speculum examination is acceptable: (1) Significant vaginal bleeding of
unknown etiology (delay examination until placenta previa has been ruled out by
ultrasonography), (2) Presence of placenta previa, (3) Ruptured membranes in patients who are
not in labor and for whom immediate induction of labor is not anticipated, (4) Presence of active
HSV lesions in a patient with ruptured membranes.
Dilatation chart (actual size)
Cervical dilation: 1 finger represents aprox 1.5 cm.
Questions to ask yourself as you perform a Vaginal Examination
Status of amniotic membranes:
Are they intact. Bulging through the cervix?
Status of cervix:
Is it soft or firm (the cervix must be soft before it can efface and dilate), anterior
or posterior? (the cervix must be anterior before it can really start to dilate)
How much effacement?
0%/long and thin to 100%/completely thinned out.
How much dilation?
0 (closed) to 10 cm. (dilation complete).
Fetal presentation:
What is the presenting part? (head, breech, other fetal part)

What is the fetal position? (left/right, anterior/posterior/transverse)
Fetal station:
What is the presenting part in relation to the ischial spines?
Engagement:
Is the presenting part engaged and well applied to the cervix? stabilized in the
middle of the pelvis below the level of the ischial spine [zero station].
How to palpate presenting part:

Palpate the hard skull; palpate for sagital suture; follow to anterior or posterior
fontanel
If what you feel is soft it may be breech or face.
Assessing Cervical effacement
Cervical effacement: Palpate degree of thickness; normal cervix about 1 inch thick
How to determine station:

Station is the relationship of the presenting part to the ischial spines.
Locate the lowest portion of presenting part, then sweep the fingers deeply to one
side of pelvis to feel for ischial spines.
To determine station estimate in centimeters, the tip of presenting part is above the
ischial spine.
Tell the mother your findings.
Speculum examination
A speculum examination will be necessary in cases of suspected "leaking" or ruptured

membranes. The presence of "leaking" or ruptured membranes can be confirmed by performing a
nitrazine test, inspecting the posterior fornix for pooling of fluid and by obtaining a sample of the
fluid with a sterile applicator and applying the fluid to a glass slide. The glass slide is allowed to
air dry and is subsequently inspected for an arborization pattern ("ferning").
Procedure:
Select speculum
Speculum is made of 2 blades and a handle
There is a thumb piece attached to top blade
The bottom blade is fixed
The top blade is hinged and thumb piece controls movement
Comes in both metal and plastic
Explain what you will do.

Have client empty bladder.
Assist client to bend legs, feet resting either flat on table or in stirrups.
Place pillow under her head and under her hip.
Drape client’s legs.
Place a minimum amount of lubricant on speculum. Sterile water may be used as
lubricant.
Using dominant hand, place 2 fingers just inside the introitus and gently press down
on base of vagina.
With other hand, introduce the closed speculum past your fingers at about 45-degree
angle downward.
Keep a downward pressure on blade to avoid upward pressure on sensitive bladder
and top of vaginal wall.
After speculum in vagina, remove finger.
Turn blades into a horizontal plane while keeping moderate downward pressure.
Move your thumb to the thumb piece and press to open blades so that the cervix is in
view.
Sweep the blades upward and gently press on the handle.
When cervix in view, tighten the thumbscrew to keep blades open.
If membranes are ruptured, you will see fluid leaking from cervix.
Place sterile cotton tipped applicator in pool of fluid.
Touch applicator to nitrazine paper or glass slide.
Release thumb screw.
Hold blades apart by pressing on thumb piece and begin withdrawing the speculum
until cervix is released.
Release pressure on thumb piece and allow blades to close.
Rotate the blades to a sideways position; exert downward pressure.
Gently and slowly remove.
Fern testing for ruptured membranes

Amniotic fluid contains a high amount of salt. If drops of fluid are spread on glass
slide, allowed to dry and examined through microscope, a characteristic fern pattern
can be seen.
Mechanisms of Labor
The following definitions must be mastered to be able to discuss and understand the mechanism of
labor:
Attitude. This refers to the posturing of the joints and relation of fetal parts to one another. The normal
fetal attitude when labor begins is with all joints in flexion.
Lie. This refers to the longitudinal axis of the fetus in relation to the mother's longitudinal axis; i.e.,
transverse, oblique, or longitudinal (parallel).
Presentation. This describes that part on the fetus lying over the inlet of the pelvis or at the cervical os.
Point of Reference or Direction. This is an arbitrary point on the presenting part used to orient it to the
maternal pelvis [usually occiput, mentum (chin) or sacrum].
Position. This describes the relation of the point of reference to one of the eight octanes of the pelvic inlet
(e.g., LOT: the occiput is transverse and to the left).
Engagement. This occurs when the biparietal diameter is at or below the inlet of the true pelvis.
Station. This references the presenting part to the level of the ischial spines measured in plus or minus
centimeters.
Normal mechanisms of labor/Cardinal Movements - Occiput anterior positions
• Definition: A mechanism of labor is a series of passive, adaptive movements of the fetal head and
shoulders through the birth canal.
• Related factors
o Passage: Size and morphology of the pelvis
o Passenger: Size of the baby and moldability of the fetal skull
o Powers: Quality (efficiency) of uterine contractions and voluntary expulsive forces and
quality and direction of soft tissue resistance, especially of the levator ani muscles
o Psyche: Mom’s attitude
Cardinal Movements of Labor
o Engagement: Mechanism by which the greatest transverse diameter of the head in vertex
(biparietal diameter) passes through the pelvic inlet (usually 0 station). The head usually enters the
pelvis in the transverse or oblique - the inlet is a transverse oval.
o Descent: This occurs intermittently with contractions and is brought about by one or more forces:
Pressure of the amniotic fluid, direct pressure of the fundus upon the breech, contractions of
abdominal muscles (2nd stage) and extension and straightening of the fetal body.
o Flexion: As soon as the vertex meets resistance from the cervix, walls of the pelvis or the pelvic
floor, flexion results. The chin is brought into contact with the fetal thorax and the resenting
diameter is changed from occipitofrontal to suboccipitobregmatic (9.5 cms.)
o Internal Rotation: After engagement, as the head descends, the lowermost portion of the head
(usually the occiput) meets resistance from one side or the other of the pelvic floor and is rotated
about 45 degrees anteriorly to the midline under the symphysis. Internal rotation brings the AP
diameter of the head in line with the AP diameter of the pelvic outlet.
o Extension: With further descent and full flexion of the head, the nucha (the base of the occiput)
becomes impinged under the symphysis. Upward resistance from the pelvic floor causes the head
to extend, with the bregma, brow, nose, mouth and chin being born successively.
o Restitution: When the head is free of resistance, it untwists, causing the occiput to move about 45
degrees back to its original left or right position. The sagittal suture has now resumed its normal
right angeled relationship to the transverse (bisacromial) diameter of the shoulders.
o External Rotation: While the head has been descending to the pelvic floor, the shoulders have
entered the pelvis and engaged with the bisacromial diameter in the transverse or in an oblique
diameter. With the descent, the leading (anterior)shoulder meets the resistance of the side of the
pelvic floor and is rotated anteriorly toward the midline under the symphysis. This movement
brings the long axis of the shoulders in line with the long axis of the pelvic outlet. The movement
of the shoulders causes the occiput to rotate another 45 degrees, to the transverse position.
o Expulsion: Delivery of the anterior shoulder, posterior shoulder, and the rest of the body.
Expulsion
The Six Steps of Labor Progression
Labor can be defined as regular, painful uterine contractions that result in progressive cervical
change. The diagnosis of labor progression may be dependent upon the patient's history of
uterine contractions as well as information gathered from abdominal palpation and vaginal
examination. Evidence of progressive cervical effacement and/or dilation is necessary in order to
distinguish true labor from false labor.
Labor progresses in six ways and all are equally important. Frequency, duration and intensity of
contractions cannot be relied upon as measures of progression in labor.
• Cervical dilatation and fetal descent are the only indicators that labor is progressing.
Cervical Ripening The cervix ripens or softens. As a woman’s body gets ready to labor it produces
prostaglandin. This causes the cervix to soften from the consistency of rubber to
something that feels like a marshmallow.
Cervical Position The cervix moves from a posterior to an anterior position. During most of the
pregnancy, the cervix points toward the back (posterior), but during the last few
weeks of pregnancy or in early labor, it moves forward (anterior). The uterus may
contract for several days intermittently before true labor begins to accomplish these
first two things, softening the cervix and bringing the cervix from the back of the
vagina to the front of the vagina.
Cervical Effacement The cervix effaces About two inches in length is average size, but in early
labor, the cervix begins to get shorter and thinner (effacement). By the active
part of labor the cervix will be completely effaced and be paper-thin.
It is vital to understand that when the cervix has not undergone the first
three steps (ripening, effacement, and anterior movement of the cervix),
significant dilation (beyond 3-4 cm in the nullipara, more in the
multipara) rarely occurs), but that pre-labor contractions are accomplishing
the important job of pre-paring the cervix to dilate.
Cervical Dilatation The cervix dilates and active labor begins. Not much dilatation can occur until
the cervix has completed the above three processes. Remember the cervix needs
to get very soft, move to an anterior position and get paper-thin before it will dilate
much past 3-4 centimeters.
Fetal Head Rotation, Flexion The fetal head rotates, flexes, and molds. The head begins to change shape to fit
and Molding through the pelvis. Remember, this is called molding. Rotation, flexion, molding,
and descent of the fetal head take place in active labor and second stage
Fetal Descent and The fetus descends and is born. Descent occurs as the baby lowers itself into your
pelvis. Remember, descent is measured in terms of "stations."
Birth
Stages of Labor Chart
The first stage of labor begins when uterine contractions of sufficient frequency, intensity and
duration result in effacement and dilation of the cervix. The first stage is completed when the
cervix reaches 10 cm. The second stage involves descent of the fetus and its eventual expulsion
from the vagina. It begins with complete cervical dilation (10 cm) and ends with delivery of the
infant. The third stage of labor involves delivery of the placenta. It begins with the completion of
the infants' delivery and ends with delivery of the placenta and membranes.
LATENT-EARLY ACTIVE LABOR TRANSITION SECOND STAGE THIRD STAG

LABOR LABOR LABOR Delivery of th
FIRST STAGE (4-8 cm.) Placenta
LABOR
LATENT
(0-3 cm.) (8-10 cm) (10 cm. -Birth)
Pre-labor
♥ Ripening and Contractions: Contractions: Contractions: Contractions: Contractions:

effacement of
the cervix ♥ 5-20 minutes ♥ 2-5 minutes ♥ 1 -2 minutes ♥ 3-5 minutes apart ♥ Irregular
apart apart apart
♥ 60-120 seconds long ♥ A feeling of

♥ 30-45 seconds ♥ 45-60 seconds ♥ 45-90 seconds fullness and
long long long cramping as
placenta sepa
♥ Less aware of
contractions,
♥ Mild, feel like ♥ Stronger and ♥ The strongest
cramps, back more intense they will get more aware of urge ♥ A time for mo
pain, pressure to push and fullness to hold and en
in vagina as baby baby.
moves down
Diagnosis of Abnormal Labor
Review Friedman Curve
Cervical dilation usually follows a sigmoid curve over time. In the 1970s, Friedman (Friedman EA
1978, labor: clinical evaluation and management. Appleton and Lange, E. Norwalk, CT) plotted
the labor curves of over 10,000 normal pregnant women. In addition to noting that cervical dilation
progressed on a sigmoid curve, he noted that labor progressed faster in parous women. Patients
whose labor is excessively long in duration or slow in rate of progress require special attention
and may be treated with various forms of intervention aimed at improving the progress of labor.
Friedman Curve
Diagnosis of Abnormal Labor
Prolonged or Protracted Latent Phase: A prolonged latent phase is present when the active phase
of labor is not achieved after 14 hours in multiparous patients and 20 hours in nulliparous
patients. This diagnosis may be difficult to make since the onset of labor is very often dependent
upon the patient's perception of when labor actually began. There are two basic methods for
prolonged latent phase, narcotic analgesia or oxytocin augmentation of labor. In cases where the
fetal heart rate tracing is normal and the patient is at low risk a large dose of narcotic plus
antihistamine may be administered in order to allow the patient to rest for several hours. Typically,
when the parturient awakens she will either find that she has entered the active phase or the
contractions will completely dissipate during the hours of sleep. In the later case, false labor
would be diagnosed and the patient would be subsequently discharged to home.
Prolonged or Protracted Active Phase A protracted active phase is defined as progression at less
than 1.2 cm an hour in nulliparous patients and less than 1.5 cm and hour in parous patients
during the active phase. This disorder is associated with a higher incidence of occiput posterior
and occiput transverse fetal positions. It may also be indicative of true cephalopelvic disproportion
or it may result from inhibitory effects of narcotics anagelsia. Generally this condition is treated by
first assessing the adequacy of labor (i.e., placing an intrauterine pressure catheter and
determing the number of Montevideo units). Additionally, the size of the fetus in relation to the
pelvis must also be determined. When addressing active phase labor abnormalities most
Obstetricians refer to "the three P's". The power refers to the adequacy of labor, passenger refers
to the size and attitude of the fetus and the pelvis refers to the size and shape of the maternal
boney pelvis. In most instances the laboring patient has a relatively normal pelvis d fetus but
uterine contractile forces are found to be inadequate. In these cases labor augmentation with
oxytocin is indicated. Most center's begin oxytocin at 1-2 mL per minute and increase the dose by
1/2 to 1 mL every 20-40 minutes.
Active Phase Arrest: This is the most common abnormality of labor in women who are ultimately
delivered by cesarean section. It is defined as a lack of cervical progress over 2 or more hours,
despite adequate uterine contractions (> 200 Montevideo units). As with Protracted Active Phase,
the three P's must be assessed and in most cases a trial of oxytocin augmentation given.
Second Stage Disorders: The average primigravida can expect to spend one to two hours in the
second stage of labor while the multiparous women will typically have a second stage of 30
minutes duration or less. These times may be significantly increased in patients who have
epidural anesthesia. In the presence of an epidural anesthetic the second stage may last as long
as three hours in a nulliparous patient and as long as 1-1/2 hours in a parous patient.
Protracted Descent: Common causes of protracted descent include poor maternal expulsive effort
and excessive fetal size relative to the maternal pelvis. A common management approach to
protracted descent is to simply allow a longer period of time for the patient to push. Alternatively,
in a patient with epidural anesthesia who has poor effort initially, expectant management can be
undertaken while the patient is allowed to relax for the first 1 to 1-1/2 hours after becoming
completely dilated (laboring down). When the fetal vertex reaches a +2 station or more a forceps
or vacuum delivery may be used.
Arrested Descent: Arrested Descent occurs when there is no advancement of the presenting part
for more than an hour. The criteria are the same in both the nulliparous and multiparous patients.
The reasons for this disorder are the same as Protracted Descent. Reducing the level of maternal
epidural anesthesia may be helpful in some cases. Additionally, changes in maternal position
such as having the mother assume the "squatting" position may be helpful.
Fluids
As part of the altered anatomy and physiology during pregnancy, laboring women are considered to have a
full stomach. The enlarged gravid uterus physically obstructs gastric emptying and increases intragastric
pressure. Pregnancy hormones decrease intestinal motility and gastroesophageal barrier pressure, as
evidenced by the common complaints of constipation and acid reflux or heartburn. The policy of NPO
(nothing by mouth) is, regrettably, a well-established routine in many hospitals. Reducing the risk of
maternal morbidity and mortality by reducing stomach contents, thus eliminating the acidic contents for
pulmonary aspiration, is given as the rationale. However, surveys of literature from anesthesia and
obstetrics show no compelling scientific basis for maintaining NPO policies (although aspiration can be a
complication of inadvertently high spinal or epidural blocks).
Choices for fluids in labor include water or ice, juices (less acidic are preferable; may be frozen in ice
cubes), popsicles, and hydrating fluids such as Gatorade.
Intravenous Hydration
IV fluids (usually dextrose and water or lactated Ringer's solution) are indicated when the mother is NPO
status and should be run at a rate of 125 mL per hour, which ensures that the mother receives 1,000 mL of
fluid every 8 hours.
IV therapy is not needed routinely, especially in the first hours of labor. A normal healthy woman, who
already has approximately 2 L of stored body water in extravascular spaces. Routine IV fluid
administration can induce fluid overload, hyperglycemia in the fetus, and hypoglycemia in the newborn,
and can alter plasma sodium levels.
Comfort Measures for the Laboring Woman.
Do not leave alone in active labor.

Change soiled and damp linen promptly.
Provide mouth care.
Ice chips, lubricate lips.
Keep room cool, uncluttered, quiet and privacy.
Promote participation of coach.
Therapeutic Choices for the Discomforts of Labor
Journal of Perinatal and Neonatal Nursing, October / December 2003
Slow-Paced Breathing
Every woman beginning labor should be taught this simple technique for coping with labor. The use of a
specific breathing pattern during labor contractions has two objectives: Helping the woman relax by
distracting her from the intense contraction sensations. Ensuring a steady, adequate intake of oxygen.
Begin the Breathing Technique

This technique is done only during contractions. Rest and sleep between contractions is important. Instruct
the laboring woman to do the following:
Assume a comfortable position.
Try to maintain a relaxed state throughout the contraction.
Close her eyes or
Concentrate on a focal point while doing the breathing (e.g., a pretty picture, a button on someone's shirt).
Cleansing Breath
Begin and end each breathing technique with a cleansing breath. This is simply a deep quick breath, like a
big sigh. Inhalation is through the nose; exhalation is through slightly pursed lips.
Slow-Paced Breathing
This technique can be used in early labor and for as long as the mother is comfortable with it. For some
women, this may last throughout the entire first stage of labor.
1. Take a cleansing breath as soon the contraction begins.
2. Breathe slowly and deeply in through the nose and out through slightly pursed lips or the nose
over the duration of the contraction.
3. Maintain a steady rate of approximately 6 to 9 breaths during a 60-second contraction (the
cleansing breaths do not count).
AWHONN Clinical Position Statement

Professional Nursing Support of Laboring Women
Epidural Anesthesia
Pain management options for woman in labor have changed dramatically over the last decade. Systemic
analgesia and dense-motor-blockade regional analgesia/anesthesia have become less common for childbirth
while the use of newer neuraxial and regional techniques, with minimal motor blockade, have become more
popular. Neuraxial analgesia is defined as intrathecal or epidural administration of opioids and/or local
anesthetics for treatment of postoperative pain or other acute pain problems. Neuraxial analgesia includes
epidural, spinal and combined spinal-epidural techniques.
Patients receive a 1000cc Lactated Ringers IV bolus (unless on a fluid restriction), and an oral antacid
(Bicitra) prior to the placement of the epidural. The fluid bolus potentially alleviates any precipitous drops
in the patient’s blood pressure. L&D RN's assist with patient positioning during the procedure. Blood
pressures are recorded prior to the start of the epidural, when a test dose is administered, when a bolus dose
is administered, and q 5-15 minutes until stable per the RN's and anesthesiologists discretion. The
anesthesiologist gives BP parameters to be notified if abnormal. After one hour of stable BP's, BP's can be
recorded q 30 min until delivery. FHR and contractions are recorded at these intervals also. Patients are
kept NPO or ice chips only after placement.
Education and certification of nurses. A standardized educational program should

be established for initial training and certification of nurses caring for patients
receiving neuraxial analgesia and for maintenance of competence. Nursing
personnel should understand
• The risk of respiratory depression, including delayed respiratory depression

when hydrophilic opioids are used
• Assessment and management of respiratory depression
• Assessment of motor and sensory blockade
• Assessment and management of hypotension in patients receiving neuraxial
analgesia
• Signs and symptoms of the rare, but catastrophic, complications of neuraxial

analgesia.
Nursing Responsibilities in Preventing, Preparing for, and Managing Epidural Emergencies
Journal of Perinatal and Neonatal Nursing, January/March 2003
The Role of the Registered Nurse (RN) in the Care of Pregnant Women Receiving
Analgesia/Anesthesia by Catheter Techniques (Epidural, Intrathecal, Spinal, PCEA Catheters)
Guidelines for the Epidural Procedure
Adapted from the AWHONN's Evidence-Based Clinical Practice Guideline, Nursing Care of the
Woman Receiving Regional Analgesia/Anesthesia in Labor.
The purpose of these guidelines is to provide principles of management, so that neuraxial

analgesia is provided in a fashion that maximizes its benefit-risk ratio. Adequate nursing
support is essential to the safe provision of an epidural. Evidence is lacking regarding the
safety of nurses administering bolus medications during labor. However, the significance
of potential side effects has necessitated standards that preclude this activity from nursing
functions currently.
The AWHONN position statement maintains that the insertion of epidural catheters and
injection or rebolus of regional analgesic/anesthetic agents remains within the scope of the
licensed, credentialed anesthesia care provider.
During the first stage of labor, anesthetic dosages are given to limit the block to the lower
thoracic (T10) and upper lumbar segments. This allows perineal tone to be maintained to
avoid interfering with internal rotation of the fetal head to the occiput anterior position.
When Stage II labor is reached, the block can be extended to the sacral area to promote
perineal relaxation, delivery, and episiotomy repair.
Special techniques include the following:
• Patient-controlled epidural anesthesia (PCEA): allows the patient to self-titrate

periodic amounts of anesthetic
• So called walking epidural: patients who have intentional motor function and
semi-mobility with a bolus or continuous infusion via an indwelling epidural
catheter preceded by an injection of local anesthetic into the subarachnoid space.
Actions Before the Procedure Remarks

Consult with anesthesia and obstetric providers The physician, anesthesiologist, or nurse-
when epidural anesthesia is requested by client anesthetist is responsible for explaining
complications.
Document informed consent by the woman The nurse clarifies and elaborates on information
regarding the purpose, the desired effect, possible
side effects, the procedure itself, and recovery.
Note contraindications, such as maternal fear Sympathetic blockade worsens some of these.
or refusal, local infection at the injection site,
coagulation defects, and maternal hypotension
or shock.
Move the crash cart to an area nearby. This provides for any emergency.
Obtain maternal baseline BP, pulse rate, Anesthetic effects include vascular vasodilatation,
respiratory rate, and fetal baseline heart rate decreased BP, and possible fetal heart rate
and variability. Confirm a reassuring fetal heart accelerations that could exacerbate a preexisting
tracing before the procedure. problem.
Have the woman void before the procedure. The epidural block can reduce or eliminate
bladder sensation.
Administer an IV fluid bolus of 500 to 1,000 ML A preprocedure bolus will help prevent
balanced saline or lactated Ringer's solution 10 hypotension caused by vasodilatation from the
to 30 minutes before the epidural procedure. anesthetic.
NOTE: IV glucose solutions are not

recommended because of the potential impact of
fetal hyperglycemia with subsequent and rebound
newborn hypoglycemia.
Assist the woman to a side-lying position with This promotes moderate spinal flexion to assist in
legs slightly flexed or to a sitting position with locating the appropriate site.
the mother's head flexed forward, elbows
resting on her knees, and feet supported on a
chair.
Support the mother throughout the procedure Breathing techniques appropriate to the phase of
of local infiltration and catheter threading. labor can be encouraged to promote relaxation.
A high-pressure volumetric pump is required for This is important to overcome catheter resistance.
continuous epidural infusion. Check frequently
to ensure that the proper hourly rate is accord-
ing to the prescribed orders. Ensure that all
connections along the epidural route are
secure.
Note maternal BP and pulse rate before and Epinephrine is added to the test dosage. If the
after the test dosage. Repeat at least every 5 catheter is misplaced and is in the dilated epidural
minutes throughout administration of the vein, maternal pulse rate will increase 20% to
anesthetic dose and for 15 minutes afterwards. 30%. A normal rate reflects that the drug was not
injected intravascularly.
Thereafter, record BP, pulse, and respiration Systolic drops below 90 mm Hg are considered
rate regularly based on institutional protocol inadequate to maintain uterine blood flow for fetal
and patient's status. oxygenation.
Never leave a mother unattended during the first 20 minutes following administration
of the initial anesthetic or any bolus dose.
Actions Following the Procedure Remarks
You need to reassure the mother if she feels a This is a normal preanesthetic effect.
warm tingling sensation down her legs when
the initial bolus loading dose is given.
Avoid maternal hypotension by promoting Promote and maintain uterine displacement.

uterine displacement with a pillow/wedge or Avoid the supine position.
placing the mother in a full lateral position or in
a supine position, with the head of the bed
elevated.
Assist the mother in turning every hour. This allows the drug to defuse bilaterally.Avoid
excessive pressure in one area.
Evaluate the mother's bladder every 30 The woman can lose the sensation to void. A full
minutes. bladder not only is subject to trauma but also can
impede descent of the fetus.
Periodically assess for level of anesthesia This is important to avoid potentially high levels of
before administration of any bolus dose. anesthesia.
(One way to do this is to move an ice cube This is also done to assess the fading of
from the mother's groin area upward. Mark with anesthesia.
a skin marker the level at which the mother
becomes aware of the cold; repeat on other
side.)
Determine the level of pain relief using Avoid anesthesia receding too far bfore a (bolus
institutional pain assessment scales. dose) is needed.
Continually monitor for maternal complications. Nausea, vomiting, itching, and urinary retention
are possible. Nausea and vomiting can occur in
up to 50% of women having epidural anesthesia.
Can be rapidly reversed by administering

naloxone hydrochloride (Narcan).
Document the following per institutional policy: This documentation is placed on the fetal monitor
strip and becomes part of the medical record.
Times, types, and amounts of anesthetic
Maternal BP and pulse rates

Document the same information in the nursing
Position changes notes, including description of the following:
Oxygen administration The woman's responses to the procedure
IV rate changes Any complications
Maternal response
Use of oxygen
Other supportive interventions, should they be

necessary
During Stage II of labor, in preparation for A semi-upright position allows the anesthetic to
delivery, assist the mother to a semi-upright migrate into the sacral area.
position, an upright position, or a sidelying
position. If fetal heart rate decelerations occur, a lateral
position optimizes blood flow to the fetus.
Under the influence of epidural anesthesia,
Stage II of labor is sometimes delayed. The
American College of Obstetricians and
Gynecologists (ACOG) defines a prolonged
Stage II as being greater than 3 hours in a
nullipara with regional anesthesia and greater
than 2 hours without regional anesthesia. For
the multipara, a prolonged Stage, II is greater
than 2 hours with regional anesthesia and
greater than 1 hour with anesthesia.
Continue to monitor for maternal complications and evaluate and document maternal pain
levels using standard assessment tools such as visual and verbal analog scales
Actions to Respond to Complication Remarks

Maternal Hypotension
Maternal hypotension is defined as a systolic Maternal hypotension may result in a fetal

blood pressure less than 100 mm Hg or a 20% hypotensive response showing fetal bradycardia
decrease from preanesthesia levels. and/or late decelerations.
Place the mother in a full lateral or upright

position.
Give oxygen by face mask

These supportive measures are intended to
Give 250 to 500 ML IV bolus of non-glucose- restore uterine blood flow.
balanced saline solution.
This is the vasopressor of choice because it
If vasopressors are needed, 5 to 10 mg IV targets cardiac muscle, thus increasing uterine
ephedrine is recommended. blood flow by enhancing cardiac output.
Pruritus
Pruritus is a common and mild reaction to
anesthetic, usually begins within 10 to 30
minutes of epidural initiation and medication The use of opioids may increase the risk of
administration. pruritus by 40% to 90%. Less than 20% of women
require medication to alleviate it.
Diphenhydramine or naloxone is used for

treatment. Usually, the pruritus resolves within
an hour of onset.
Urinary retention
Urinary retention is a side effect of epidural
anesthesia in a large percentage of women. Assessment of bladder status is critical to avoid
overdistension of the bladder, which the mother
cannot feel.
Urinary catheterization will be necessary in Urinary displacement relieves pressure on the

some women vena cava and aorta, promoting better venous
return to the heart.
High Spinal
Prevailing symptoms: Inadvertent intravenous catheter placements can

occur in up to 5% of pregnant women.
Profound motor and sensory block within 1 to 5
minutes of the epidural injection
Severe hypotension
Cessation of respirations
Cardiac arrest
Take steps to do the following:
Establish a patent airway.
Give 100% oxygen at a high flow rate.
Intubate if necessary.
Administer vasopressors.
Manually push the gravid uterus to one side.

Intravascular Injection of Local Anesthetic
Signs of this include the following: Inadvertent dural punctures occur in

approximately 2% of pregnant women.
Change in maternal heart rate (tachycardia or
bradycardia)
Maternal hypertension
Dizziness, tinnitus, or metallic taste
Loss of consciousness.
Intravascular injection of a local anesthetic may

result in seizure or cardiac arrest and requires
an immediate response, including
cardiopulmonary resuscitation, 02 administra-
tion, and assisted ventilation.
Spinal Headaches
If the dura is accidentally punctured, women Headaches develop in 1% to 3% of women who

may experience spinal headaches 24 to 48 receive epidural anesthesia.
hours after the puncture.
Conservative treatment involves:
Maintaining a flat position, hydration, and an

abdominal binder and administering As cerebrospinal fluid is lost, pressure is
analgesics. diminished throughout that compartment and the
brain descends somewhat, especially when the
A blood patch is used to seal the puncture site, mother is in an upright position.
using 15 mL of the patient's unanticoagulated
blood. As the blood clots, it "patches" the area,
usually affording quick relief
Actions During Recovery From Remarks

Epidural/Delivery
During the mother's recovery, keep the side
rails up and the bed in a low position.
Remove the catheter once the placenta has

been delivered and the mother begins her The maternal position increases the intervertebral
recovery period. A registered nurse with space.
training may remove the catheter.It is
preferable to remove the catheter with the
mother in the same position used during
placement.
Inspect the catheter carefully to make sure it is

intact. If you suspect breakage, alert the
anesthesiologist immediately. Always save the
catheter for the anesthesiologist's inspection.
Assess for motor and sensory return by asking

the mother to move her legs up and down and
side to side; perform plantar flexion and
dorsiflexion of the feet. The mother must be
able to support her knees in an upright
position, as in a standing position.
Actions to Respond to Neonatal Remarks

Complication
Neonatal respiratory depression as a result of Monitor all neonates for signs of neurobehavioral
opioids can be treated with narcotic antagonists change associated with the use of epidurals
i.e. Narcan
American Family Physician
The Nature and Management of Labor Pain: Part II. Pharmacologic Pain Relief [2003]
The Nature and Management of Labor Pain: Part I. Nonpharmacologic Pain Relief
[2003]
Contemporary OB/GYN
Do epidurals increase risk of C/S? Yes. [2003]

Do epidurals increase risk of C/S? No. [2003]
Epidural analgesia: 2002 update [2002]

Cochrane Reviews
Types of intra-muscular opioids for maternal pain relief in labour (Cochrane Review)
[2004]
Spinal versus epidural anaesthesia for caesarean section (Cochrane Review) [2004]
Prophylactic intravenous preloading for regional analgesia in labour (Cochrane

Review) [2004]
Epidural versus non-epidural analgesia for pain relief in labour (Cochrane Review)
[2004]
Complementary and alternative therapies for pain management in labour (Cochrane

Review) [2004]
Combined spinal-epidural versus epidural analgesia in labour (Cochrane Review)

[2004]
Amnioinfusion
Guidelines for the Amnioinfusion Procedure

Adapted from the AWHONN's Evidence-Based Clinical Practice Guideline, Nursing Care of the
Woman Receiving Amnioinfusion in Labor.
• Obtain informed consent, including purpose, risks, and benefits, and explain the procedure to the mother.
• With the mother's permission, perform a vaginal examination to rule out cord prolapse. Determine cervical
dilatation, effacement, station, status of membranes, and presentation.
• Ask the woman to position herself on her side. With the mother's consent, insert a fetal scalp electrode and
an intrauterine pressure catheter.
New-generation pressure catheters are equipped with dual lumens, internal transducers, and amnioports (sites for
injecting the amnioinfusion fluid). Connect the catheter to the amnioinfusion system. Double-lumen uterine
catheters permit monitoring of uterine activity while amnioinfusion is being performed. Otherwise, use a separate
uterine catheter to monitor uterine activity throughout the procedure.
• Prepare the infusion (an initial bolus of normal saline or lactated Ringer's), by either gravity flow or an
infusion pump.
NOTE: A literature survey revealed no demonstrable benefits using infusion pumps or solution warmers during
amnioinfusion. Warming is accomplished by using a standard blood-warming unit. Extremes of temperature should
be avoided. Do not use a microwave oven to warm the fluid
• Infuse the stipulated infusate at the rate determined by protocols and by primary care provider orders.
Infusion rates vary among recent reports in the literature. An initial bolus of 250 to 600 mL and an hourly
maintenance rate of 150 to 180 mL has been suggested. Recent studies show initial bolus ranges from 250 to 600
mL followed by a maintenance infusion rate of 150 to 180 mL per hour.
• Observe for fluid return; if 250 mL infuses with no evidence of return, discontinue the infusion and wait to
see fluid.
• Continue the infusion until either the variable decelerations cease or 800 mL of normal saline or lactated
Ringer's infuse.
Resolution of variable decelerations might not occur. The woman's primary care provider should be contacted if
resolution is not achieved within the time frame stipulated in nursing protocols.
• Reduce the infusion rate to the hourly maintenance rate designated by nursing and institutional protocols.
• Carefully monitor uterine activity throughout the procedure.
• Watch uterine resting tone.
Artificially increased uterine resting pressures higher than the preinfusion baseline can occur. A resting baseline
pressure of less than 25 mm Hg should be maintained.
• Carefully calculate fluid output during the amnioinfusion.

Fluid output can be evaluated by comparing a dry-weight item with a wet-weight item; 1 mL of fluid is equal to 1 g
of weight. Therefore, all vaginal fluid should be captured in whatever padding is kept under the mother.
• Document the procedure on the fetal monitor tracing and in nursing progress notes.
• Be attentive to other possible complications associated with amnioinfusion.
Iatrogenic polyhydramnios can occur if the fetal head is pressed closely against the cervix. Too much retained
fluid may result in maternal symptoms of shortness of breath, hypotension, or tachycardia.
Abruptio Placentae. Signs and symptoms of abruptio placentae include a hard, board like abdomen; vaginal
bleeding; and pain. NOTE: Vaginal bleeding does not always occur with abruptions of the placenta.
Umbilical cord prolapse can occur if the cord is carried down with fluid output.
Intrauterine Resuscitation
What is intrauterine resuscitation? Interventions undertaken to attempt to change the relationship of the
uterus, placenta, cord, and fetus to improve placental and fetal oxygenation. These are empirically designed
to overcome uteroplacental insufficiency or to decrease cord compromise.
These include the following:
• Positioning the mother to right/left side lying recumbent or knee-chest to improve blood flow to
the uterus
• Repositioning the mother to alleviate cord compression
• Discontinuing oxytocin
• Tocolysis with subcutaneous Terbutaline to decrease/moderate uterine activity and improve blood
flow
• Increasing intravenous (IV) fluids to enhance maternal blood flow volume
• Administering oxygen to the mother in an effort to promote oxygen flow across the placental
membrane
• Performing amnioinfusion-fluid instillation into the amniotic cavity through a catheter; usually
performed transcervically during the intrapartum period.
Fetal Pulse Oximetry
Current techniques for evaluating fetal status in labor are limited in their ability to predict outcome. Fetal
oxygen saturation monitoring
provides a continuous measure of fetal oxygenation and is used to evaluate peripheral tissue perfusion to
provide additional information when a nonreassuring fetal heart rate pattern occurs and a management
decision cannot be made without benefit of additional information regarding fetal oxygenation.
Procedure
A sensor is inserted into the uterus and placed next to a fetal vascular bed (e.g., temple, cheek, forehead).
Measurements are based on a fraction that represents the rate of hemoglobin that is oxygenated
(oxyhemoglobin), as measured by differences in light absorption, and are displayed on the electronic fetal
monitoring strip providing continuous real-time data.
The normal range of fetal oxygenation in labor is between 30% and 70%. Values greater than 30% provide
reassurance.
Indications
Single fetus at term
Vertex presentation
Nonreassuring fetal heart rate pattern
Ruptured membranes
Cervix dilated at least 2 cm with station -2 or below
Contraindications
Placenta previa
Nonreassuring fetal heart rate pattern necessitating immediate delivery
Infectious diseases that preclude internal fetal heart rate monitoring (e.g., HIV; active herpes virus; hepatitis
B, C, and E)
Amniotomy
Artificial rupture of membranes is a commonly used practice in obstetrics performed at or beyond

3 cm dilation. The technique involves perforation of the fetal membranes with a sterile plastic
instrument (amnihook) or by applying a fetal scalp electrode through the membranes onto the
fetal scalp. Amniotomy results and local release of arachidonic acid from the membranes and the
subsequent prostaglandin formation is thought to be one of the mechanisms responsible for labor
augmentation and induction. The procedure may be associated with changes in the fetal heart
rate (e.g., accelerations or bradycardia) secondary to prolonged uterine contraction, secondary to
release of a large quantity of fluid or in some cases prolapse of the umbilical cord.
Amniotomy and Placement of Internal Fetal Spiral Electrode
Amniotomy and Placement of Internal Fetal Spiral Electrode through Intact Membranes
Induction of Labor
Induction of labor is the deliberate starting of uterine contractions before they begin on their own.
Augmentation is the administration of synthetic oxytocin to enhance existing labor.
Methods for Cervical Ripening and Induction of Labor
http://www.aafp.org/afp/20030515/2123.html
http://www.aafp.org/afp/20030515/editorials.html
Indications
The benefits of delivering the fetus at a specific point in time must outweigh the benefits of permitting the
pregnancy to continue. Induction is appropriate when delivery is indicated but immediate delivery by
cesarean is not necessary
Indications include.
Pregnancy induced hypertension (PIH)
Fetal demise
PROM, with or to prevent chorioamnionitis
Suspected fetal jeopardy
Macrosomia
Relative contraindications include.
Previous classical uterine incision
Placenta previa
Active genital herpes
Fetal malposition; abnormal lie
Cephalopelvic disproportion
Invasive cervical carcinoma
Pre-requisites
Accurate estimation of gestational age
Favorable Bishop score
Available personnel and resources for observation and immediate intervention
Methods
Cervical ripening
Hygroscopic dilators
Prostaglandin gel
Amniotomy
Oxytocin
Oxytocin Pharmacology
Posterior pituitary hormone/ Half life = 3-6 minutes /Causes uterine contractions/Antidiuretic/Causes milk
ejection reflex
Policy and prerequisites
Physician availability
Nursing personnel
Monitoring
ACOG guidelines
Induction Procedure
Intravenous LR infusion
Use volumetric pump
Piggy back oxytocin solution
Dosage
Induction -start at 0.5-1.0 mU/min, increasing every 15-4(minutes by 1-2 mU/min
Augmentation- start at 0.5 mU/min
Active management (nulliparous patients) -start at 4.0-6.0 mU/min, increasing every 15 minutes by 4.0-6.0
mU/min
Indications for reducing or discontinuing oxytocin include:

Non-reassuring fetal heart rate
Uterine hyperstimulation
Persistent uterine hypertonus
Nursing responsibilities
Assess and document fetal presentation
Explain procedure to patient; obtain consent
Document maternal and fetal assessment at the time of each change in infusion rate
Notify physician of abnormal FHR, abnormal contraction pattern, or discontinuance
Monitor Intake and Output
Active management of labor
Vacuum Extraction
In vacuum extraction, a properly sized silastic cup is attached to a source of suction (manual or electric).
The physician determines the position of the fetal head, and places the cup on the head of the fetus in the
area of the posterior fontanel. The practitioner then uses gentle downward traction to deliver the fetal head.
Continuous or intermittent suction is used. Once the baby's head is delivered, the suction is discontinued
and the cup removed.
The nurse's involvement in vacuum extraction is primarily on the side of patient education. The nurse is
responsible for assessing the patient's level of pain, assisting the physician and reassuring the patient
throughout the procedure.
Additionally, the nurse must be prepared to resuscitate the newborn if necessary and explain any
marks that may be caused by either forceps delivery or vacuum extraction.
Vacuum Extraction
Shoulder Dystocia
Most of the time, an infant's shoulders present in the proper alignment across the mother's pelvic outlet.
However, occasionally the shoulders present transverse to the pelvic outlet. As a result, shoulder dystocia
may occur.
In shoulder dystocia, the baby's shoulder becomes lodged under the mother's symphysis pubis, making
delivery difficult. In such cases, the nurse-midwife or obstetrician will require assistance. When the
physician identifies a shoulder dystocia, the nurse's first response is to call for additional assistance. The
nurses help the physician with either the McRobert's maneuver or applying suprapubic pressure, if required.
The McRobert's Maneuver
First try the McRobert's maneuver. In this maneuver, one nurse stands on each side of the patient and help
her to hyperflex her legs. If possible, the patient must keep her knees bent back to her abdomen. When the
patient's legs are hyperflexed, the birth canal opens to its maximum, facilitating the delivery of her baby's
anterior shoulder.
Suprapubic Pressure
In applying suprapubic pressure, the nurse must feel the infant's shoulder above the symphysis pubis and
press directly down on it with the heel of her hand. This action can help to dislodge the baby's shoulder to
facilitate easier delivery of the baby.
Perineal Skin Prep
Crowning and birth of the baby and placenta

Father or SO Cuts the Cord
Hand baby to mom: if baby is stable
Management of the Third Stage of Labor
Newborn Management
Review of Newborn ABC Management

When the head is delivered, the mouth is suctioned first and then the nose to reduce
A Airway the risk of aspiration. The caregiver will inspect to see if the umbilical cord is
wrapped around the neck. If the cord is around the infant’s neck, it is loosened, and
slipped over the infant’s head. If it is impossible to slip the cord over the head, the
cord is clamped in two places and cut between the clamps. Then the body of the baby
is delivered and the mouth and nose are suctioned again.
If breathing is not spontaneous, the caregiver gently rubs the baby’s back with a towel
B to stimulate breathing.
Breathing
Dry the baby, cover, and put in a warm environment. If baby is stable placing the
C infant on the mother’s abdomen is a warm and appropriate place. Determine the
Circulation Apgar score at delivery and then again 5 minutes after delivery.
Apgar Score
0 1 2
Blue limbs, pink
Appearance Blue Pink
body
Pulse Absent < 100 beats/min. > 100 beat/min.
Grimace Limp Some flexion Good flexion
Activity Absent Some motion Good motion
Respiratory Absent Weak cry Strong cry
Assign a score to appearance, pulse, grimace, activity, and respiratory. Add
them together. A score 7 to 10 is good; 4 to 6 is depressed; 0 to 3 is severely
depressed.
When the cord has stopped pulsating, the caregiver clamps the cord in two places, and
C Clamp cut between the clamps.
the Cord
Continue to dry the baby, cover and keep warm, again if baby is stable the mother’s
C Cover abdomen is a warm and appropriate place, encourage the mother to breastfeed
the infant. Breastfeeding stimulates the uterus to contract.. If the baby is not
stable the baby must be transferred to the radiant warmer.
Continue the assessment. Reassess the airway. If the airway is not clear, suction the
C Continue nose and then the mouth, reposition the newborn, and perform a slight chin lift. Do
not hyperextend the neck. If breathing is absent or heart rate is < 80 beats/min. begin
the
resuscitation.
assessment
CPR Provide oxygen, establish effective ventilation with a bag-valve mask or endotracheal
Neonatal intubation, and perform chest compressions. Medications are infrequently needed. A
blood glucose level of 40 mg/dl is critical in a newborn. Administer a 25% solution at
Resuscitation 0.5 g/kg.
Obstetrical Complications
Breech
Breech presentations are categorized into three types:
A complete breech is presentation with the infant’s knees and hips flexed.
An incomplete breech is presentation with one or both of the infant’s feet or knees first.
A frank breech is presentation with the infant's hips flexed and the legs extended.
Breech Presentation
Abruptio placentae
Abruptio placenta is premature separation of the placenta. The cause is unknown. Symptoms may include
vaginal bleeding and abdominal pain or contractions. Diagnostic tests include hemogram and crossmatch of
4 units of PRBC. Management includes fluid resuscitation with normal saline, fetal monitoring, and STAT
C-section.
Ultrasound of Placental Abruption
Abruptio placentae: Fetal tracing
Abruptio Placentae
Gross: abruptio placenta
Microscopic: abruptio placenta
Abruptio placenta
Characteristic findings of placental abruption (list)
Risk factors for placental abruption (list) .
Amniotic fluid embolism
An amniotic fluid embolism is amniotic fluid that leaks into the mother’s vascular system and is associated
with abruptio placentae, placenta previa, and cases of fetal demise. Symptoms may include profound
hypotension, cardiopulmonary comprise and/or cardiac arrest. Management may include rapid endotracheal
intubation, mechanical ventilation, fluid resuscitation with normal saline and blood products, and
evaluation of coagulopathy.
Cord prolapse
There are three variations of cord prolapse:
• The cord is compressed by the fetus and not visible externally.

• The cord may not be visual but is felt in the vaginal canal.
• The cord is protruding from the vagina.
The goal is prevention of fetal anoxia. Management includes positioning the mother on the left side in
trendelenberg or in a knee-chest position and administering 100% oxygen. If the cord is exposed, cover it
with saline moistened sterile gauze. STAT C-section is performed.
Umbilical Cord Complications
"Velamentous" insertion of the umbilical cord
Placenta previa
Placenta previa is a disorder where the placenta presents before the fetus. The amount of coverage of the os
is used to determine the type of placenta previa: total completely covers the os, partial partially covers the
os, and marginal is beside the os. Symptoms may include hemorrhage not accompanied by labor.
Diagnostic tests may include hemogram, type and crossmatch for four units of PRBC, clotting studies, and
ultrasound. Management may include fluid resuscitation with normal saline, blood replacement, and
transfer to labor and delivery. Pelvic examination is contraindicated.
Placenta Previa
Total Placenta previa: schematic of complete placenta previa
Total Placenta previa: placenta accreta in uterine specimen
Partial placenta previa
Low lying posterior placenta previa

Pre-Eclampsia/Eclampsia
Cardinal signs of pre-Eclampsia are elevated blood pressure, sudden weight gain with generalized edema,
decreased urine volume, and proteinuria. Eclampsia symptoms may include seizures and coma. Signs and
symptoms usually occur in the third trimester, but can occur up to two months post delivery. Treatment
includes oxygen, intravenous access, and fetal monitoring. Magnesium sulfate is used to control seizures.
Hydralazine and nitroprusside sodium may be used to control hypertension. The problem commonly occurs
in primagravida women and is associated with diabetes, hypertension, and renal disease.
Obstetrical Accidents Involving Intravenous Magnesium Sulfate: Recommendations to Promote

Patient Safety
MCN, The American Journal of Maternal/Child Nursing, May/June 2004
Eclampsia
Edema
Risk factors for preeclampsia (table)
PIH is a multi-organ pathologic state with various subsets: (list)
Signs and symptoms of mild and severe pregnancy induced hypertension (table)
Cesarean Section
In the case of severe obstetric emergencies, the time from decision to delivery is ideally within 30
minutes
Cesarean Delivery
Nursing Responsibilities in the O.R.
• The labor and delivery nurse is responsible for informing the physician of complications and
calling the anesthesiologist. If the physician is present, he will order the C-section. If he is not
present, the nurse phones the physician, who confirms the necessity of the C-section. The
anesthesiologist is then called.
• Notifying the pediatrician and resuscitation team (usually an RN from the nursery and a
respiratory therapist). If the C-section is not immediate, the resuscitation team may arrive in the
OR after the patient is taken to the OR.
• Informed consent must be obtained. The JCAHO states that this is to be obtained by the physician,
who is also responsible for explaining the procedure as well as the risks and benefits. The labor
and delivery nurse witnesses the patient's signature and asks the patient if she understands what
the physician has told her. The nurse also answers questions the patient may have about the
procedure at this point. The nurse can then prepare the patient appropriately.
• Inserting a Foley catheter. This may occur before leaving the birthing room or when patient arrives
at the OR, according to emergency and timing. If the patient has had an epidural, she may already
have a Foley in place.
• Administering ordered meds.
• Take patient to the OR and transfer to the operating table.
• Positioning the patient with a wedge under the patient's right hip to keep the weight of the uterus
off of her large blood vessels. This occurs as soon as the patient arrives at the OR.
• Assuring Infant resuscitation equipment is present and in good operating condition prior to
delivery. In preparing equipment for delivery, the nurse turns the infant warmer on, as well as the
sources for oxygen and suction.
• Obtaining a fetal heart rate (unless the C-section is a critical emergency).
• Placing a grounding pad under her thigh and attaching the electrocautery unit. The grounding pad
or return electrode for the electrocautery unit must be placed on the patient's thigh and attached to
the unit before being turned on. It is important not to place the grounding pad over a wet surface.
The nurse must be careful to assure that the prep solution does not run down over the area where
the pad will be placed.
• Prepping the patient's abdomen for surgery. Abdominal prep varies from institution to institution
and from physician to physician. Under normal circumstances, the area directly over and
immediately surrounding the surgical site is shaved or clipped. Then, one of several types of prep
solutions is applied. Although these solutions differ, their application process is consistent.
Working from the side of the patient tilted toward the nurse, the nurse starts at the incision site and
works outward (cleanest area to dirtiest) in a circular motion, never going back over a previously
prepped site with a used applicator. In a crash C-section, the prep does not include a shave and the
solution is poured over the belly, or sprayed.
• Counting instruments, sponges and sharps prior to surgery. The circulating nurse is responsible for
making sure the counts of these items are accurate. The scrub tech or nurse and circulating nurse
counts the instruments together. It is important for the circulating nurse and scrub tech to count
instruments aloud and simultaneously. The number of each item must be determined with utmost
certainty. At the end of each count, the circulating nurse informs the physician of the results, and
the physician verbally acknowledges this information. These counts occur at the beginning of the
surgery, when a body cavity is closed, and prior to skin closure. During emergency surgeries, as in
a crash c-section, the instrument count is forgone, while attempts are usually made to count
sponges and needles. A post op x-ray is then taken to confirm the absence of any instrument or
foreign body left in the abdominal cavity.
• Providing patient education, explaining to the patient what is happening to the extent that time
allows just prior to emergency surgery. It is important to remember that an emergency C-section
can be very frightening for the patient and her birth partner. That's why, even while preparations
are being made, it is imperative for the nurse to explain what is happening and reassure the patient
as much as possible.
• Once preparations are complete, the surgeon(s) and anesthesiologist are called to the O.R.
Common Areas of Litigation Related to Care During Labor and Birth: Recommendations to Promote
Patient Safety and Decrease Risk Exposure
Journal of Perinatal and Neonatal Nursing, April/June 2003
CRITICAL THINKING: Labor and Delivery
• IV Nubain/Stadol is ordered for pain to the mother in active labor. What measures do you
need to take before giving pain medication to a laboring woman?
• When should an IV medication be given in relation to her contractions?
• List four possible causes of fetal tachycardia.
• List three possible causes of fetal bradycardia.
• What should you do if you discover fetal bradycardia?
• What are common causes of early decelerations?
• What are common causes of late decelerations?
• What are common causes of variable decelerations?
• What are the nursing responsibilities for a patient receiving Terbutaline?
CRITICAL THINKING: Labor and Delivery
• A childbirth coach can sometimes feel "in the way". How can you make the coach feel
more welcome and comfortable?
• Take a minute and draw a fetus inside a uterus. Draw the fetus in a longitudinal lie,
cephalic lie, extended attitude.
CRITICAL THINKING: Unknown Obstetrical Complication
Mary, G3, P0 presents to L&D complaining of vaginal bleeding and abdominal pain. She appears
reluctant to answer questions. She is 38 weeks pregnant with a history of no prenatal care. Her
fundal height measures 30cm. Her monitor pattern reveals fetal heart rate of 180 and decreased
variability. Her abdomen is rigid and a hypertonic pattern appears on the monitor. BP 100/60, P
120, R 24. Mary is slow to respond to questions and appears weak and diaphoretic.
Describe Mary’s obstetrical history?

What emergency obstetrical complication do you suspect Mary has?
Support your choice with clinical findings.
What data support your suspicion that Mary is a substance abuser?
What common pain meds should be avoided in drug addicted persons?
CRITICAL THINKING: Labor

Mary has an emergency cesarean section for abruptio placenta. She is in the
recovery room and you notice bloody urine in the Foley catheter and a 2cm area of
bright red blood on her abdominal dressing.
What should you do, and what serious complication would Mary be at risk for?
Mary’s baby weighs 3 pounds and is severely growth restricted.

Explain why these babies are prone to hypothermia, hypoglycemia and hyperbilirubinemia.
What symptoms will you look for in Mary’s baby due to Mary’s use of drugs?
CRITICAL THINKING: Labor
Sarah is at 42 weeks’ gestation. Her physician has ordered a biophysical profile (BPP). She is
very upset and tells the nurse: "All my doctor told me is that the test will see if my baby is O.K. I
don’t know what is going to happen next and if it will be painful to me or harmful to my baby."
Sarah receives a score of 8 for the BPP.
Describe how you would be respond to Sarah’s concerns.
List the factors that were evaluated to obtain this score.
Specify the meaning of Sarah’s test result of 8.
Thermoregulation Using a Radiant Warmer
Assessment
• Assess infant's axillary temperature. If below 36.4176C (97.5° F), may lead to cold stress.
• Assess skin integrity.
Implementation
• Prewarm the radiant warmer to between 36° and 37° C (96.8° and 98.6° F).
• Remove shirt from infant, leaving a diaper on.
• Place infant under the heater
• Place thermal skin probe on the abdomen and attach by an aluminum heat deflector
patch.
• Set the radiant warmer controls according to agency protocol.
Evaluation
• Evaluate axillary temperature to verify stability between 36.4° and 37.2° C (97.5° and 99°
F).
• Inspect infant's skin for absence of redness and irritation.
• Assess infant's axillary and skin probe temperature every 30 minutes or according to
agency protocol.
• As the infant's temperature stabilizes, prewarm blankets.
• When the infant's temperature reaches 37° C (98° F), dress and wrap in prewarmed
blankets with a dry cap on head.
• Place in an open crib.
• Recheck axillary temperature in 1 hour.
Identify Unexpected Outcomes and Nursing Interventions …Report and

Record
• Temperature of infant before and after warming.

• Length of time under the warmer.
• Temperature of infant 1 hour after removing from the warmer.
• Condition of skin after warming process
Infant Bathing
|| TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary |

Extremities |
Assessment
• Assess the infant's skin for dryness, peeling, or signs of infection.

• Assess the site of the umbilical cord for redness, drainage, drying, and intactness.
• Assess the infant's temperature if at high risk for hypothermia.
• Shampooing infant's hair:
• Wrap the infant in the blanket using a swaddling technique.
• Hold the infant in a "football" hold over the washbasin, or leave infant in crib and gently
pick up head, supporting it in one hand.
• Lather scalp with a small amount of mild soap. A soft washcloth may be used to wash the
scalp if there is excess soiling.
• Rinse the scalp thoroughly by pouring water from a small cup over the infant's scalp into
the washbasin.
• Dry thoroughly with a towel. Comb or brush infant's hair gently.
• Replace the damp blankets.
• Implementation
• Prepare washbasin with warm water at about 36.6° to 37.8° C (98° to 100° F), which is
comfortably warm.
• Place infant in crib or bassinet with sides and have all supplies within reach. Use clean
gloves for first newborn bath or if in contact with body secretions during any bath.
• Keep infant covered with a blanket to maintain warmth.
• Cleanse the eyes with plain water from the inner to the outer canthus, using a clean
portion of the washcloth with each wipe. Apply a moistened washcloth for 1 to 2 minutes
before cleansing to soften crusts if present.
• Cleanse the external ears with plain water and a twisted end of the washcloth.
• Cleanse the face and neck with plain water, with attention to areas behind ears and
creases in neck. A small amount of soap may be used for soiled creases, rinsing well
after washing.
• Dry face and neck with a towel using a gentle patting motion.
• With fresh washcloth dampened with plain water, cleanse the infant's mouth, including
inside lips, cheeks, dorsal surface of tongue, roof of mouth, and along upper and lower
gum pads.
• Cover infant's lower body with blanket.
• Cleanse infant's upper body with soap and washcloth. Quickly rinse soap from the
infant's hands.
• Thoroughly rinse the rest of the upper body and dry completely by using a patting motion.
• Cleanse the abdomen around the umbilicus with soap and water, keeping the cord dry.
Dry the area. Apply cord care product according to agency protocol until area is healed.
• Cover the upper body with a dry towel or blanket.
• Cleanse the legs and outer buttocks with soap and water. Rinse and dry thoroughly.
• With a fresh washcloth, cleanse the genitalia with plain water.
• For a female infant: Gently retract labia and wash from front to back toward the anus.
Use separate portions of the washcloth for each wipe. Wash the other portions of the
labia and the folds in the groin.
• For an uncircumcised male infant: Wash from the urethra outward and down toward the
scrotum. Wash scrotum and folds of the groin. In uncircumcised newborns, the foreskin
may be adhering to the glans and should not be retracted.
• In a circumcised newborn, circumcision care is done. Assess area for bleeding. Cleanse
the area gently with warm tap water and cotton gauze or cotton balls. Place sterile gauze
dressing with sterile petroleum jelly added between the penis and diaper. Change this
dressing with each diaper change.
• Cleanse anal area with soap, rinse, and dry.
• Apply clean diaper.
Identify Unexpected Outcomes and Nursing Interventions

Record and Report
• Temperature on the graphic sheet.

• Description of skin condition.
Parent Teaching and Evaluation
Communication Tip: Assess parents' knowledge of how to give a bath and any
cultural deviations that may alter the care of the infant. Incorporate specific bathing
techniques important to their family or culture.
• Evaluate parents' ability to bathe, handle, and dress the infant during a return
demonstration.
• Observe parents' interactions with infant in relation to sensory and social stimulation.
• Document parent teaching and response.
Infant Feeding

Extremities |
Assessment
• Assess for feeding readiness cues

• Determine when the infant was last fed, and the quality of that feeding time.
• Assess physical development of infant and suck reflex.
• Assess for tolerance of last feeding of formula.
Implementation
• Identify the infant using identification bracelet.

• Prepare the infant by providing clean diaper and clothing and wrap snugly.
• Encourage mother to implement thorough hand washing before infant feeding.
Assisting with Breast-Feeding

• Assist the mother to a comfortable position supported with pillows in the bed or chair.
• Assist the mother to position the infant in one of four positions (The football hold; The
cradle hold; Across the lap; Lying down) and encourage her to to use a variety of
positions
• Assist the baby to latch on effectively.
• Have the mother support the breast in one hand with the fingers underneath and the
thumb on top.
• Have the mother lightly touch the baby's lower lip and the tip of the tongue with her
nipple.
• When the mouth is open wide and the tongue is down, have the mother pull the baby
quickly to the breast, bringing the baby to the breast and not the breast to the baby.
• Evaluate for a proper latch on.
• The mother feels a firm tug on her nipple and no pinching or sliding sensation.
• Ask if nursing hurts after the first few sucks. If there is pain, have her release the suction
with her finger and remove the infant from the breast and start over.
• Assess for the following evidence of success:
• After the milk comes in at least one breast softens with each feeding.
• The baby has bursts of 10 or more sucks and swallows at the beginning and slows down
to 2 to 3 sucks and swallows as the breast softens. The swallowing can be heard.
• As the let-down reflex occurs, there may be leaking from the other breast.
• After the breast has softened, encourage the mother to burp the infant and, if possible or
desired, continue nursing on the opposite breast. Encourage the mother to begin
feedings on the opposite breast each time.
Assisting with Formula Feeding
• Identify and prepare the appropriate type and amount of formula.

• Position the infant: cradle head in one hand or on one arm, support body on the other.
• Place bib or small cloth under infant's chin.
• Touch the corner of infant's mouth with nipple.
• Insert nipple into mouth and hold bottle so that nipple is completely filled with formula.
• Allow infant to suck, observing for suck-swallow-breathe reflex.
• Observe for choking, gagging, or regurgitation during feeding.
• Burp infant about halfway through feeding. Place infant in prone position across lap and
gently pat infant's back.
• Observe infant's face for signs of choking or vomiting. The infant may also be placed on
the shoulder of the caregiver or in a sitting position.
• Continue to feed remainder of formula.
• Burp infant at the end of the feeding.
• Check diaper and change if needed. Place infant in bed on right side, never on the
abdomen.
• Observe for choking, gagging, or regurgitation after feeding.
• Dispose of bottle and unused formula in an appropriate container.
Evaluation
• Evaluate the amount of formula or, if breast-feeding, the time in minutes and note if infant
softens at least one breast each feeding.
• The infant is content for at least 2 to 2½ hours between feedings.
• The infant has at least six wet diapers and two bowel movements each 24 hours by 4
days of age.
• The infant regains birth weight in 7 to 10 days and doubles the birth weight in 6 months.

Record and Report
• Amount of formula infant drank.

• Length of feeding.
• How infant sucked.
• Infant's tolerance of formula.
• Positive/negative bonding response of parents.
Newborn Exam
Physical Assessment of the Newborn

Extremities |
Measure and record height, weight, and head circumference. If the infant appears premature or is
unusually large or small, perform a Dubowitz/Ballard exam to assess gestational age (see
Dubowitz/Ballard scoring grid). The exam is divided into two parts: an external characteristics
score, which is best done at birth, and a neuromuscular score, which should be done within 24
hours after birth.
SKIN
Color
• Pallor - associated with low hemoglobin

• Cyanosis - associated with hypoxemia
• Plethora - associated with polycythemia
• Jaundice - Elevated bilirubin
• Slate grey colour - associated with methemoglobinemia
Lesions
• Milia - pinpoint white papules of keratogenous material usually on nose,

cheeks and forehead, last several weeks.
• Miliaria - obstructed eccrine sweat ducts. Pinpoint vesicles on forehead scalp
and skinfolds. Clear within 1 week.
• Transient neonatal pustular melanosis - small vesicopustules, generally
present at birth, containing WBCs and no organisms.
• Erythema toxicum - Most common newborn rash. Variable, irregular macular
patches. Lasts a few days.
• Cafe au lait spots - suspect neurofibromatosis if there are many large spots.
• Junctional nevi - if large numbers suspect tuberous sclerosis, xeroderma
pigmentosus, generalized neurofibromatosis.
NEUROLOGICAL EXAM

Extremities |
State of alertness
Check for persistent lethargy or irritability.
Posture
In term infant, normal position is one with hips abducted and partially flexed and with knees
flexed. Arms are adducted and flexed at the elbow. The fists are often clenched, with fingers
covering the thumb.
Tone
Support the infant with one hand under his chest. The neck extensors should be able to hold the
head in line for 3 seconds. Should not have more than 10% head lag when moving from supine to
sitting position.
Reflexes
Reflexes must be symmetrical.
Biceps jerk test C5 and C6
Knee jerk tests L2-L4
Ankle jerk tests S1, S2
Truncal incurvation reflex tests T2 through S1
Anal wink test S4, S5
Other primitive reflexes include the Moro, palmer and planter grasps, sucking and rooting
reflexes, and the asymmetric tonic neck reflex (ATNR).
Neonatal Primitive Reflexes
Newborn and infant reflex tests and behaviors.

BABINSKI BABKIN DOLL'S EYE
Baby's foot is stroked When both of baby's While manually
from heel toward the palms are pressed, turning baby's head,
toes. The big toe should her eyes will close, his eyes will stay
lift up, while the others mouth will open and fixed, instead of
fan out. her head will turn to moving with the head.
one side.
**** ****
****
Absence of reflex may While normally
suggest immaturity of vanishing around one
the CNS, defective Absence of this reflex month of age, if it
spinal chord, or other or if it reappears after reappears later, there
problems. Reflex may vanishing around 3-4 may be damage to the
be seen up to age one, mos., it may signify a CNS.
then reaction will be malfunctioning CNS.
reversed with the toes
curling downward.
PALMAR
GALANT MORO
GRASP
While stroking Baby is held horizontally, then swiftly By pressing
baby's back to lowered a few inches, or the head may just one of
one side, her be lowered a few inches, or a loud baby's palms,
spine and trunk sudden noise will make baby's arms fingers should
will arch toward fling out and then come together as grasp the
that side. hands open then clutch. object.
**** **** ****
Absence may Absence or weakness of this reflex may Absence or

indicate spinal suggest a severely disturbed CNS. weakness of
injury or this reflex
depression of could reflect an
the CNS. injured spinal
chord or
depressed
CNS.
PEREZ PLANTERS GRASP STEPPING
Firmly stroking Pressing thumbs Holding baby upright with
baby's spine from against the balls of feet touching a solid
tail to head, will baby's feed will make surface and moving him
make her cry out his toes flex. forward should elicit
and head will rise. stepping movements.
****
**** ****
Absence of this reflex

If this reflex does may indicate damage to After 3-4 months, this reflex
not vanish in 4-6 the spinal chord. should vanish. If it
months, baby's reappears, there may be an
CNS may be injury of the upper spinal
severely chord.
depressed.
SUCKING ROOTING WITHDRAWAL

A finger or nipple When baby's cheek is A pinprick to the sole of
placed in baby's stroked at the corner of her baby's foot will make
mouth will elicit mouth, her head will turn baby's knee and foot flex.
rhythmical toward finger and she will
sucking. make sucking motions. ****
**** **** Absence of this reflex

could indicate a damaged
sciatic nerve.
Depressed If this reflex doesn't vanish
sucking may be in 3-4 months, the CNS
due to may be malfunctioning.
medication given
during childbirth
When reflexes appear and disappear:
Reflex Appears Disappears

Moro Newborn 3 months
Grasp Newborn 3 months
LE crossed
Birth 1 month
extensors
Extensor plantar Newborn 8-12 months
Placing/stepping Birth 1-2 months
ATNR Newborn 3 months
HEAD AND NECK

Extremities |
Head
Check for overriding sutures, the number of fontanelles and their size. Check for abnormal shape
of head. Check for encephalocoeles. Measure the head circumference.
• Eyes
• Check for colobomas, heterochromia.
• Cornea - Check for cloudiness.
• Conjunctiva - Inspect for erythema, exudate, edema, jaundice and
hemorrhage. Silver nitrate prophylaxis can cause a chemical conjunctivitis.
Check for pupillary size and reactivity to light.
• Red Reflex - Hold the ophthalmoscope 6-8" from the eye. Use the +10 diopter
lens. The normal newborn transmits a clear red colour back to the observer.
Black dots may represent cataracts. A whitish color may be suggestive of
retinoblastoma.
Ears
Check for asymmetry, irregular shapes. Look for auricular or pre-auricular pits, fleshy
appendages, lipomas, or skin tags.
Nose
Look for flaring of the alae nasi as a sign of increased respiratory effort. Look for hyper- or hypo-
telorism. Check for choanal atresia (CA) as manifested by respiratory distress (neonates are
obligate nose breathers). A soft NG tube should be passed through each nostril to confirm
patency if choanal atresia is suspected.
Palate
Check for cleft lip and palate.
Mouth
• Observe the size and shape of the mouth.
• Microstomia - seen in Trisomy 18 and 21.
• Macrostomia - seen in mucopolysaccharidoses.
• Fish mouth - seen in fetal alcohol syndrome.
• Epstein pearls - small white cysts that contain keratin, frequently found on
either side of the median raphe of the palate.
• Ranulas - small bluish white swellings of variable size on the floor of the
mouth representing benign mucous gland retention cysts.
Tongue
Macroglossia - Hypothyroidism, mucopolysaccharidoses
Teeth
Natal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk of aspiration if loosely attached.
Chin
Micrognathia - occurs with Pierre-Robin syndrome, Treacher-Collins syndrome, Hallerman Streiff

syndrome.
Neck
Palpate over all muscles, palpate clavicles for possible fractures. Web neck found in Turner's and
Noonan's syndromes. Torticollis usually secondary to sternocleidomastoid hematoma. Cystic
hygromas most common neck mass. Lymph nodes are unusual at birth and their presence
usually indicates congenital infection.
CHEST AND LUNGS
Observe respiratory rate, respiratory pattern (periodic breathing, periods of true apnea). Observe
chest movements for symmetry and for retractions. Listen for stridor, grunting. Note that there
may be some enlargement of the breasts secondary to maternal hormones.
Cardiovascular System
Measure heart rate, blood pressure in upper and lower extremities, respiratory rate.
Inspection
Check baby's color for pallor, cyanosis, and plethora.
Palpation
Check capillary refill. Check pulses; note any decrease in femoral pulses or radio-femoral delay
as a sign of possible coarctation of the aorta, note character of pulses (bounding or thready).
Locate PMI with single finger on chest; abnormal location of PMI can be clue to pneumothorax,
diaphragmatic hernia, situs inversus, or other thoracic problem.
Auscultation
Note rhythm and presence of murmurs that may be pathologic.
Before birth, there is a natural opening between the aorta (the main artery to the body) and the pulmonary artery (the main artery
to the lungs) called the ductus arteriosus. This opening usually closes shortly after birth. PDA occurs when this opening fails to
close; PDA occurs in about 10% of infants. PDA is often treated initially with a medication called indomethacin. If the ductus fails
to close on its own or with indomethacin, surgery is performed. A small incision is made on the left side of the chest. The ductus is
either ligated (tied off) or cut.
Patent Ductus Arteriosis
Atrial septal defect (ASD) is a congenital heart defect. In fetal circulation there is normally an opening between the two atria (the
upper chambers of the heart) to allow blood to bypass the lungs. This opening usually closes about the time the baby is born. If
the ASD is persistent, blood continues to flow from the left to the right atria. This is called a shunt.
Atrial Septal Defect
Before a baby is born, the right and left ventricles of its heart are not separate. As the fetus grows, a muscular wall forms to
separate these lower heart chambers. If the wall does not completely form, a hole remains. This is what is known as a ventricular
septal defect, or a VSD. It is estimated that up to 1% of babies are born with this condition. In the vast majority (80-90%) of babies
born with this condition, the hole is small. They will have no symptoms, and the hole will close spontaneously as the muscular wall
continues to grow after birth. If the hole is large, then too much blood will be pumped to the lungs, leading to congestive heart
failure. These babies are often have symptoms related to the problem and may need medicine or surgery to close the hole.
Ventricular Septal Defect
ABDOMEN
Note shape of abdomen. Flat abdomens signify decreased tone, abdominal contents in chest, or
abnormalities in abdominal musculature. Note abdominal distension.
Observe for diastasis recti. Observe for any obvious malformations e.g. omphalocoele. An
omphalocoele has a membrane covering (unless it has been ruptured during the delivery)
whereas a gastroschisis does not.
Examine umbilical cord and count the vessels. Note color of cord. Palpate liver and spleen. It may
be normal for the liver to be about 2 cm below the right costal margin. The spleen is not usually
palpable; if the spleen is felt, be alert for congenital infection or extramedullary hematopoeisis.
After locating these organs (checking for situs inversus), palpate for any abnormal masses.
• Auscultate for bowel sounds.

• Examine for hernias - umbilical or inguinal.
• Inspect anal area for patency and/or presence of fistulas.
Genitourinary Exam

Extremities |
Kidneys
Examined by palpation. The kidneys should be about 4.5-5.0 cm vertical length in the full term
newborn. The technique for palpation is either a) one hand with four fingers under the baby's
back, palpation by rolling the thumb over the kidneys, or b) palpate the left kidney by placing the
right hand under the left lumbar region and palpating the abdomen with the left hand (do the
reverse for the right kidney).
Male genitalia
Term normal penis is 3.6±0.7 cm stretched length. Inspect glans, urethral opening, prepuce and
shaft. Normally difficult to completely retract foreskin. Observe for hypospadias, epispadias.
Inspect circumcised penis for edema, incision, bleeding. Full term infant should have brownish
pigmentation and fully rugated scrotum. Palpate the testes.
Female genitalia
Inspect the labia, clitoris, urethral opening and external vaginal vault. Often a whitish discharge is
present; this is normal, as is a small amount of bleeding, which usually occurs a few days after
birth and is secondary to maternal hormone withdrawal. Hymenal tags may be present normally.
Extremities and Skeletal System

Extremities |
Spine
Scoliosis, kyphosis, lordosis, spinal defects, meningomyelocoeles.

Upper extremity
Look for clavicular fracture, absence of radius or ulna. Inspect creases and fingers.
Lower extremity
See posture above. Do Ortolani maneuver to check for congenital hip dislocation. Check toes.
Problems in the Neonate
Cueing Into Infant Pain

MCN, The American Journal of Maternal/Child Nursing, March/April 2004
Newborn Behavioral and Psychological Responses to Circumcision

MCN, The American Journal of Maternal/Child Nursing, September/October 2003
Small for gestational age (SGA)

Symmetric (HC = Wt = L, all <10 %) -- 33% of SGA infants
• Genetic
o Small maternal size
o Chromosomal abnormalities (Trisomies 13, 18, 21, and Turner's
syndrome)
o Congenital abnormalities
• Intrauterine infections
o Viruses (rubella, CMV, varicella, HIV)
o Bacteria (tuberculosis)
o Spirochete (syphilis)
o Protozoan (toxoplasmosis, malaria)
• Inborn errors of metabolism
o Hypophosphatasia
o Leprechaunism
o Some amino acidurias
• Environmental
o Drugs (heroin, methadone, ethanol, diphenylhydantoin)
o X-rays (therapeutic)
o Smoking

Asymmetric (HC = L > Wt, Wt <10 %) -- 55% of SGA infants
• Uteroplacental insufficiency -- onset usually after 24 weeks

o Chronic hypertension
o Preeclampsia
o Renal disease
o Cyanotic heart disease
o Hemoglobinopathies
o Placental infarcts or chronic abruption, velamentous insertion,
circumvallate placenta, multiple gestation.
o Altitude

Combined (symmetric or asymmetric) -- 12% of SGA infants
• Environmental
o Drugs (including ethanol)
o Smoking
• Placental unit insufficiency
o Placental infarcts or chronic abruption, velamentous insertion,
circumvallate placenta, multiple gestation.
Large for gestational age (LGA)
• Infants of diabetic mothers

• Beckwith-Wiedemann syndrome
• Hydrops fetalis
• Large mother
POSTPARTUM PHYSICAL ASSESSMENT:
VS, amount of lochia, presence of edema, fundal height and firmness, status of
perineum, bladder distension
First hour: every 15 minutes

Second hour: every 30 minutes
First 24 hours: every 4 hours
After 24hours: every 8 hours
Postpartum Beliefs and Practices Among Non-Western Cultures

MCN, The American Journal of Maternal/Child Nursing, March/April 2003
KNOW YOUR PATIENT --- DELIVERY HISTORY /ADMISSION/TRANSITION

ASSESSMENT:
Gravida, parity / Time and type of delivery
Anesthesia or medications / Risk factors for PPH
Medical history / Routine medications / Allergies
Infant status / Breast/bottle
Rho (D) / Rh-? (72h) / Rubella immune?
VITAL SIGNS DAY 1 DAY 2 AND AFTER
Heart Rate 40-70 BPM Bradycardia or normal

Respiratory Normal Normal
Blood
Pressure Normal Norma
Temperature 100.4 is considered normal for first 24 hours due to muscular

exertion, dehydration .
POSTPARTUM PHYSICAL ASSESSMENT
B - breast
U - uterus
B - bowels
B - bladder
L - lochia
E - episiotomy
BREAST ASSESSMENT
Breasts – Soft, engorged, filling, swelling, redness, tenderness.
Nipples – Inverted, everted, cracked, bleeding, bruised, presence of colostrum or

breastmilk.
AWHONN Clinical Position Statements

Breastfeeding
The Role of the Nurse in the Promotion of Breastfeeding
Drugs in Nursing Mothers
FUNDAL ASSESSMENT
Location in relation to umbilicus

Degree of firmness
Midline or deviated to one side
ASSESSING THE UTERINE FUNDUS
The uterus is best evaluated with the patient in a supine position and with an empty
bladder.
The nurse should support the lower uterine segment just above the symphysis pubis
with the non-dominant hand and palpate the uterine fundus for degree of involution.
Fundal descent is measured in relationship to the umbilicus in fingerbreadths or

centimeters.
PERINEAL ASSESSMENT
Assessment of the episiotomy/perineum should occur with the woman in lateral Sims
(side lying) position.
Use the acronym REEDA (redness, edema, ecchymosis, discharge, approximation of
edges of episiotomy) to guide assessment.
Even if there is no episiotomy, the perineum should still be assessed.

Unusual perineal discomfort may be a symptom of impending infection or hematoma.
Hemorrhoids ?
LOCHIA ASSESSMENT
Assessment of lochia includes noting color, presence of clots and foul odor.
Day 1- 3 - lochia rubra
Day 4-10 - lochia serosa
Day 11- 21 - lochia alba

BLADDER ASSESSMENT
Voiding pattern, complete emptying, pain burning on urination
Record first three voids with the amount and times voided
A full bladder displaces the uterus upwards and laterally and prevents contraction of
the uterus = UTERINE ATONY = > risk of postpartum hemorrhage.
UTERINE ATONY
Normal pregnancy is associated with an increase in extracellular H20. Postpartum
diuresis is a reversal of that process and occurs post delivery. The bladder has
increased capacity and decreased muscle tone. This leads to over-distension of the
bladder, incomplete emptying of bladder, retention of residual urine and increased
risk of UTI and postpartum hemorrhage.
UTERINE INVOLUTION
–at delivery fundus at umbilicus
–1-2 hours midway between umbilicus and symphysis pubis
--12 hours 1 cm above or at umbilicus
After that the height of the uterine fundus decreases (involutes) by approximately 1
cm per day.
POSTPARTUM CESAREAN
Incision site…approximated redness swelling, discharge. If lochia indicates excessive

bleeding, combine palpation and pain management measures.
Rh Factor
The Rh factor is blood group present on the surface of erythrocytes of the rhesus monkey. It is found in
variable degrees in the human population. When the factor is present a person is designated Rh+ (positive).
A person without the factor is Rh- (negative). The blood of an Rh+ fetus can sensitize a pregnant female and
form anti-Rh agglutinin. In subsequent pregnancies, if the fetus is Rh+ the material blood may cross the
placenta and destroy fetal cells.
RhoGAM immune globulin is prepared from the plasma of a person with high Rh antibodies. It is given to
an Rh- mother within 72 hours after delivery of an Rh+ infant or if the Rh is unknown. The dose must be
repeated after each subsequent delivery. RhoGAM 300 mcg is the standard dose.
RhoGAM Rho (d) immune globulin, human
Indications Prevention of isoimmunization in Rh- females after delivery of an Rh+

infant or if the Rh is unknown.
Adult dose 1 vial IM given within 72 hours of termination of pregnancy
Onset IM onset rapid, peak and duration unknown
Side effects Irritation at injection site, fever, lethargy
Precautions Made from human plasma. Products made from human plasma may
contain infectious agents.
Postpartum Emergencies
DIC is characterized by the increase of clotting mechanisms. Clotting

Postpartum DIC factors are consumed before the liver can replace them. Hemorrhage
(disseminated ensues.
intravascular
coagulation)
Causes may include amniotic fluid embolus, fetal demise, and

abruptio placentae.
Diagnostic monitor is the fibrinogen level.
Management may include replacement of clotting factors, platelets,

fresh frozen plasma, and cryoprecipitate. Heparin may be used.
Postpartum hemorrhage is excessive bleeding of more than 1000 ml

Postpartum within 24 hours of delivery.
hemorrhage
The cause is often failure of the uterus to return to normal size,

retrained products of conception, and vaginal or cervical lacerations.
Management may include CBC, sedimentation rate, type and cross,

fluid resuscitation with normal saline and blood, vaginal examination,
diagnosis, and correction of the underlying cause.
Complete pelvic examination under anesthesia and/or surgical repair,

may be required.
Postpartum depression
The Role of the Nurse in Postpartum Depression
Postpartum depression is a nonpsychotic depressive episode that begins in the postpartum

period, includes a period of at least 2 weeks of depressed mood or loss of interest in almost all
activities, and at least four of the following symptoms: *changes in appetite or weight, sleep, and
psychomotor activity; decreased energy; feeling of worthlessness or guilt; difficulty thinking,
concentrating or making decisions; or recurrent thoughts of death or suicidal ideation, plans, or
attempts. Postpartum depression prevalence rates are estimated to be 10-15%.
STUDY GUIDE
NEWBORN EXAMINATION
Physical Assessment of the Newborn
Measure and record height, weight, and head circumference.

If the infant appears premature or is unusually large or small,
perform a Dubowitz/Ballard exam to assess gestational age
(see Dubowitz/Ballard scoring grid). The exam is divided into
two parts: an external characteristics score, which is best
done at birth, and a neuromuscular score, which should be
done within 24 hours after birth.
| Skin | Neurological Exam | Head & Neck | Chest & Lungs | Abdomen |
| Extremities & Skeletal | Neonatal Primitive Reflexes | Exam for Gestational Age |
| Physical Maturity | Maturity Rating | Administering & Enema | Urinary Catheterization |
SKIN
Color
• Pallor - associated with low hemoglobin

• Cyanosis - associated with hypoxemia
• Plethora - associated with polycythemia
• Jaundice - Elevated bilirubin
• Slate grey colour - associated with methemoglobinemia
Lesions
• Milia - pinpoint white papules of keratogenous material usually on nose, cheeks and forehead, last
several weeks.
• Miliaria - obstructed eccrine sweat ducts. Pinpoint vesicles on forehead scalp and skinfolds. Clear
within 1 week.
• Transient neonatal pustular melanosis - small vesicopustules, generally present at birth, containing
WBCs and no organisms.
Erythema toxicum - Most common newborn rash. Variable, irregular macular patches. Lasts a few
days.
• Cafe au lait spots - suspect neurofibromatosis if there are many large spots.
• Junctional nevi - if large numbers suspect tuberous sclerosis, xeroderma pigmentosus, generalized
neurofibromatosis.
NEUROLOGICAL EXAM
State of alertness
Check for persistent lethargy or irritability.
Posture
In term infant, normal position is one with hips abducted and partially flexed and with knees
flexed. Arms are adducted and flexed at the elbow. The fists are often clenched, with fingers
covering the thumb.
Tone
Support the infant with one hand under his chest. The neck extensors should be able to hold the
head in line for 3 seconds. Should not have more than 10% head lag when moving from supine to
sitting position.
Reflexes
Reflexes must be symmetrical. see below)
Head
Check for overriding sutures, the number of fontanelles and their size. Check for abnormal shape
of head. Check for encephalocoeles. Measure the head circumference.
Eyes
• Check for colobomas, heterochromia.

• Cornea - Check for cloudiness.
• Conjunctiva - Inspect for erythema, exudate, edema, jaundice and hemorrhage. Silver nitrate
prophylaxis can cause a chemical conjunctivitis. Check for pupillary size and reactivity to light.
• Red Reflex - Hold the ophthalmoscope 6-8" from the eye. Use the +10 diopter lens. The normal
newborn transmits a clear red colour back to the observer. Black dots may represent cataracts. A
whitish color may be suggestive of retinoblastoma.
Ears
Check for asymmetry, irregular shapes. Look for auricular or pre-auricular pits, fleshy
appendages, lipomas, or skin tags.
Nose
Look for flaring of the alae nasi as a sign of increased respiratory effort. Look for hyper- or hypo-
telorism. Check for choanal atresia (CA) as manifested by respiratory distress (neonates are
obligate nose breathers). A soft NG tube should be passed through each nostril to confirm
patency if choanal atresia is suspected.
Palate
Check for cleft lip and palate.
Mouth
• Observe the size and shape of the mouth.

• Microstomia - seen in Trisomy 18 and 21.
• Macrostomia - seen in mucopolysaccharidoses.
• Fish mouth - seen in fetal alcohol syndrome.
• Epstein pearls - small white cysts that contain keratin, frequently found on either side of the
median raphe of the palate.
• Ranulas - small bluish white swellings of variable size on the floor of the mouth representing
benign mucous gland retention cysts.
Tongue
Macroglossia - Hypothyroidism, mucopolysaccharidoses
Teeth
Natal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk of aspiration if loosely attached
Chin
Micrognathia - occurs with Pierre-Robin syndrome, Treacher-Collins syndrome, Hallerman Streiff

syndrome.
Neck
Palpate over all muscles, palpate clavicles for possible fractures. Web neck found in Turner's and
Noonan's syndromes. Torticollis usually secondary to sternocleidomastoid hematoma. Cystic
hygromas most common neck mass. Lymph nodes are unusual at birth and their presence
usually indicates congenital infection.
CHEST AND LUNGS
Observe respiratory rate, respiratory pattern (periodic breathing, periods of true apnea). Observe
chest movements for symmetry and for retractions. Listen for stridor, grunting. Note that there
may be some enlargement of the breasts secondary to maternal hormones.
Cardiovascular System
Measure heart rate, blood pressure in upper and lower extremities, respiratory rate.
Inspection
Check baby's color for pallor, cyanosis, and plethora.
Palpation
Check capillary refill. Check pulses; note any decrease in femoral pulses or radio-femoral delay
as a sign of possible coarctation of the aorta, note character of pulses (bounding or thready).
Locate PMI with single finger on chest; abnormal location of PMI can be clue to pneumothorax,
diaphragmatic hernia, situs inversus, or other thoracic problem.
Auscultation
Note rhythm and presence of murmurs that may be pathologic.
ABDOMEN
• Note shape of abdomen. Flat abdomens signify decreased tone, abdominal contents in chest, or
abnormalities in abdominal musculature. Note abdominal distension.
• Observe for diastasis recti. Observe for any obvious malformations e.g. omphalocoele. An
omphalocoele has a membrane covering (unless it has been ruptured during the delivery) whereas
a gastroschisis does not.
• Examine umbilical cord and count the vessels. Note color of cord. Palpate liver and spleen. It may
be normal for the liver to be about 2 cm below the right costal margin. The spleen is not usually
palpable; if the spleen is felt, be alert for congenital infection or extramedullary hematopoeisis.
After locating these organs (checking for situs inversus), palpate for any abnormal masses.
• Auscultate for bowel sounds.
• Examine for hernias - umbilical or inguinal.
• Inspect anal area for patency and/or presence of fistulas.
GENITOURINARY EXAM
Kidneys
Examined by palpation. The kidneys should be about 4.5-5.0 cm vertical length in the full term
newborn. The technique for palpation is either a) one hand with four fingers under the baby's
back, palpation by rolling the thumb over the kidneys, or b) palpate the left kidney by placing the
right hand under the left lumbar region and palpating the abdomen with the left hand (do the
reverse for the right kidney).
Male genitalia
Term normal penis is 3.6±0.7 cm stretched length. Inspect glans, urethral opening, prepuce and
shaft. Normally difficult to completely retract foreskin. Observe for hypospadias, epispadias.
Inspect circumcised penis for edema, incision, bleeding. Full term infant should have brownish
pigmentation and fully rugated scrotum. Palpate the testes.
Female genitalia
Inspect the labia, clitoris, urethral opening and external vaginal vault. Often a whitish discharge is
present; this is normal, as is a small amount of bleeding, which usually occurs a few days after
birth and is secondary to maternal hormone withdrawal. Hymenal tags may be present normally.
EXTREMITIES AND SKELETAL SYSTEM
Spine
Scoliosis, kyphosis, lordosis, spinal defects, meningomyelocoeles.
Upper extremity
Look for clavicular fracture, absence of radius or ulna. Inspect creases and fingers.
Lower extremity
See posture above. Do Ortolani maneuver to check for congenital hip dislocation. Check toes.
NEONATAL PRIMITIVE REFLEXES
| TOP | Skin | Neurological Exam | Head & Neck | Chest & Lungs | Abdomen |
Newborn and infant reflex tests and behaviors.

BABINSKI BABKIN DOLL'S EYE
Baby's foot is stroked When both of baby's While manually
from heel toward the palms are pressed, turning baby's head,
toes. The big toe should her eyes will close, his eyes will stay
lift up, while the others mouth will open and fixed, instead of
fan out. her head will turn to moving with the head.
one side.
**** ****
****
Absence of reflex may While normally
suggest immaturity of vanishing around one
the CNS, defective Absence of this reflex month of age, if it
spinal chord, or other or if it reappears after reappears later, there
problems. Reflex may vanishing around 3-4 may be damage to the
be seen up to age one, mos., it may signify a CNS.
then reaction will be malfunctioning CNS.
reversed with the toes
curling downward.
PALMAR
GALANT MORO
GRASP
While stroking Baby is held horizontally, then swiftly By pressing
baby's back to lowered a few inches, or the head may just one of
one side, her be lowered a few inches, or a loud baby's palms,
spine and trunk sudden noise will make baby's arms fingers should
will arch toward fling out and then come together as grasp the
that side. hands open then clutch. object.
**** **** ****
Absence may Absence or weakness of this reflex may Absence or

indicate spinal suggest a severely disturbed CNS. weakness of
injury or this reflex
depression of could reflect an
the CNS. injured spinal
chord or
depressed
CNS.
PEREZ PLANTERS GRASP STEPPING

Firmly stroking Pressing thumbs Holding baby upright with
baby's spine from against the balls of feet touching a solid surface
tail to head, will baby's feed will make and moving him forward
make her cry out his toes flex. should elicit stepping
and head will rise. movements.
****
**** ****
Absence of this reflex

If this reflex does may indicate damage to After 3-4 months, this reflex
not vanish in 4-6 the spinal chord. should vanish. If it
months, baby's reappears, there may be an
CNS may be injury of the upper spinal
severely chord.
depressed.
SUCKING ROOTING WITHDRAWAL
A finger or nipple When baby's cheek is A pinprick to the sole of
placed in baby's stroked at the corner of her baby's foot will make
mouth will elicit mouth, her head will turn baby's knee and foot flex.
rhythmical toward finger and she will
sucking. make sucking motions. ****
**** **** Absence of this reflex

could indicate a damaged
sciatic nerve.
Depressed If this reflex doesn't vanish
sucking may be in 3-4 months, the CNS
due to may be malfunctioning.
medication given
during childbirth
Dubowitz/Ballard Exam for Gestational Age
Neuromuscular Maturity
Posture: With the infant supine and quiet, score as follows:
• Arms and legs extended = 0

• Slight or moderate flexion of hips and knees = 1
• Moderate to strong flexion of hips and knees = 2
• Legs flexed and abducted, arms slightly flexed = 3
• Full flexion of arms and legs = 4
Square Window: Flex the hand at the wrist. Exert pressure sufficient to get as much flexion as
possible. The angle between the hypothenar eminence and the anterior aspect of the forearm is
measured and scored:
• >90 degrees = -1
• 90 degrees = 0
• 60 degrees = 1
• 45 degrees = 2
• 30 degrees = 3
• 0 degrees = 4
Arm Recoil: With the infant supine, fully flex the forearm for 5 seconds, then fully extend by
pulling the hands and release. Score the reaction:
• Remains extended 180 degrees, or random movements = 0

• Minimal flexion, 140-180 degrees = 1
• Small amount of flexion, 110-140 degrees = 2
• Moderate flexion, 90-100 degrees = 3
• Brisk return to full flexion, <90 degrees = 4
Popliteal Angle: With the infant supine and the pelvis flat on the examining surface, the leg is
flexed on the thigh and the thigh fully flexed with the use of one hand. With the other hand the leg
is then extended and the angled scored:
• 180 degrees = -1
• 160 degrees = 0
• 140 degrees = 1
• 120 degrees = 2
• 100 degrees = 3
• 90 degrees = 4
• <90 degrees = 5
Scarf Sign: With the infant supine, take the infant's hand and draw it across the neck and as far
across the opposite shoulder as possible. Assistance to the elbow is permissible by lifting it
across the body. Score according to the location of the elbow:
• Elbow reaches or nears level of opposite shoulder = -1

• Elbow crosses opposite anterior axillary line = 0
• Elbow reaches opposite anterior axillary line = 1
• Elbow at midline = 2
• Elbow does not reach midline = 3
• Elbow does not cross proximate axillary line = 4
Heel to Ear: With the infant supine, hold the infant's foot with one hand and move it as near to the
head as possible without forcing it. Keep the pelvis flat on the examining surface. Score as shown
in the diagram above.
PHYSICAL MATURITY
| TOP OF PAGE |
Sign -1 0 1 2 3 4 5
Skin Sticky, friable, Gelatinous Smooth pink, Superficial Cracking, Parchment, Leathery,
transparent red, visible veins peeling and/or pale areas, deep cracked,
translucent rash, few rare veins cracking, no wrinkled
veins vessels
Lanugo None Sparse Abundant Thinning Bald areas Mostly bald
Plantar Heel-toe 40-50 Heel-toe >50 Faint red Anterior Creases Creases over
Creases mm = -1, <40 mm, no marks transverse over entire sole
mm = -2 creases crease only anterior 2/3
Breast Imperceptible Barely Flat areola, Stippled Raised Full areola, 5-
perceptible no bud areola, 1-2 areola, 3-4 10 mm bud
mm bud mm bud
Eye & Lids fused, Lids open, Slightly Well-curved Formed and Thick
Ear loosely = -1, pinna flat, curved pinna, pinna, soft but firm, with cartilage, ear
tightly = -2 stays folded soft with ready recoil instant stiff
slow recoil recoil
Genitals, Scrotum flat, Scrotum Testes in Testes Testes Testes
male smooth empty, faint upper cannal, descending, down, good pendulous,
rugae rare rugae few rugae rugae deep rugae
Genitals, Clitoris Prominent Prominent Majora and Majora Majora cover
female prominent, labia clitoris, small clitoris, minora large, clitoris and
flat labia minora enlarging equally minora minora
minora prominent small
Maturity Rating
Add up the individual Neuromuscular and Physical Maturity scores for the twelve categories, then
obtain the estimated gestational age from the table below.
Total Score Gestational Age, Weeks

-10 20
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44
ADMINISTERING AN ENEMA
| TOP OF PAGE | Skin | Neurological Exam | Head & Neck | Chest & Lungs | Abdomen |
Assessment
1. Determine last bowel movement and presence of bowel sounds or abdominal

pain. __ ___ ___ ____________
2. Assess ability to control external sphincter. ___ ___ ___ ____________
3. Determine presence of hemorrhoids. ___ ___ ___ ____________
4. Assess abdominal pain. ___ ___ ___ ____________
5. Assess client's understanding of procedure. ___ ___ ___ ____________
6. Assess client's mobility status. ___ ___ ___ ____________
Implementation
1. Use Standard Protocol. ___ ___ ___ ____________

2. Assist client to side-lying (Sims') position with right knee flexed.
___ ___ ___ ____________
3. Place waterproof pad under hips and buttocks. ___ ___ ___ ____________
4. Cover client with bath blanket, exposing only rectal area.

___ ___ ___ ____________
5. Ensure that toilet, bedpan, or commode is available.

___ ___ ___ ____________
6. Prepackaged container:
A. Remove plastic cap from rectal tip, applying more lubricant to cap if
needed. ___ ___ ___ ____________
B. Gently separate buttocks and locate anus. Instruct client to take deep
breaths through mouth. ___ ___ ___ ____________
C. Insert lubricated tip into rectum 3 to 4 inches (adult).

___ ___ ___ ____________
D. Squeeze bottle continuously until all fluid is expelled.

___ ___ ___ ____________
7. Enema bag: Fill enema bag with 750 to 1000 ml warm tap water. Check
temperature of water. Fill tubing with solution, removing air, and clamp.
___ ___ ___ ____________
8. Add soap to water if ordered. ___ ___ ___ ____________
A. Lubricate 3 to 4 inches of tip of tubing. ___ ___ ___ ____________
B. Gently separate buttocks and locate anus. ___ ___ ___ ____________
C. Insert tip of tube slowly, pointing tip toward umbilicus, for 3 to 4 inches
(adult). ___ ___ ___ ____________
D. Hold tubing until fluid is instilled. ___ ___ ___ ____________
E. With container at hip level, open clamp and begin instillation.

___ ___ ___ ____________
F. Raise height of container to 12 to 18 inches above anus and hang on IV

pole. ___ ___ ___ ____________
G. Lower height of container if client experiences cramping.

___ ___ ___ ____________
H. Clamp tubing after solution instilled and inform client that tubing will be
removed. ___ ___ ___ ____________
9. Explain to client that a feeling of distention is expected. Ask client to retain
solution as long as possible (5 to 10 minutes). ___ ___ ___ ____________
10. Discard enema container (and tubing). ___ ___ ___ ____________
11. Assist client to use bathroom, bedpan, or commode. ___ ___ ___ ____________
12. Instruct clients with history of cardiovascular disease to exhale during defecation
(Valsalva maneuver can cause cardiac arrest). ___ ___ ___ ____________
13. Instruct client to call for nurse to inspect results before discarding.
___ ___ ___ ____________
14. Assist client with perineal care as necessary. ___ ___ ___ ____________
15. Use Completion Protocol. ___ ___ ___ ____________
Evaluation
1. Evaluate results of enema (decreased abdominal discomfort; palpate abdomen).

__ ___ ___ ____________
2. Observe characteristics of stool. ___ ___ ___ ____________
Identify Unexpected Outcomes and Intervene as Necessary

Report and Record
1. Type of enema given ___ ___ ___ ____________
2. Results (color, amount, and appearance of stool) ___ ___ ___ ____________
3. Subjective response
URINARY CATHETERIZATION: FEMALE
| TOP OF PAGE | Skin | Neurological Exam | Head & Neck | Chest & Lungs | Abdomen |
Assessment
1. Assess client's weight, age, level of consciousness, ability to cooperate, and

mobility of lower extremities. ___ ___ ___ ____________
2. Assess client's knowledge and prior experience with catheterization.
___ ___ ___ ____________
3. Palpate for bladder over symphysis pubis. ___ ___ ___ ____________
4. Inspect perineal region, observing for perineal landmarks, erythema, drainage,

or discharge. ___ ___ ___ ____________
5. Ask client the time of last voiding and to describe urine (if nurse did not
observe). Check I&O flow sheet. ___ ___ ___ ____________
6. Ask client and check chart for allergies. ___ ___ ___ ____________
7. Assess any pathological condition that may impair passage of catheter

___ ___ ___ ____________
8. Review client's medical record, including physician's order and nurse's notes.
Note previous catheterization, including catheter size, response of client, and time
of last catheterization. ___ ___ ___ ____________
Implementation
1. Use Standard Protocol. ___ ___ ___ ____________
2. Cleanse perineal area with soap and water, rinse and dry.
___ ___ ___ ____________
3. Position and drape client in dorsal recumbent position with soles of feet together
and knees abducted as far as possible. (Option: if unable to lie supine, use side-
lying position with upper leg flexed at knee and hip and supported by another
caregiver). ___ ___ ___ ____________
4. Position overhead light to illuminate perineum. ___ ___ ___ ____________
5. Place catheter kit on overbed table and open outer wrap using sterile technique.
___ ___ ___ ____________
6. Open package containing drainage system; place bag over edge of bottom bed
frame and bring tube up between siderail. ___ ___ ___ ____________
7. Put on sterile gloves. ___ ___ ___ ____________
8. Organize supplies on sterile field, maintaining sterility of gloves.

___ ___ ___ ____________
9. Prepare equipment:
A. Check bag clamp. ___ ___ ___ ____________

B. Test balloon by injecting saline solution into balloon port. Withdraw fluid
if no leakage is noted. If balloon leaks, replace with another catheter set.
___ ___ ___ ____________
C. Lubricate catheter 1 to 2 inches. ___ ___ ___ ____________
D. Open specimen container if needed. ___ ___ ___ ____________
E. Pour antiseptic solution over all but one cotton ball.

___ ___ ___ ____________
10. Draping and Cleansing:
A. Allow top edge of sterile drape to form cuff over both gloved hands.
___ ___ ___ ____________
B. Place drape on bed between thighs, ask client to lift buttocks, and slip
drape under buttocks, taking care not to contaminate sterile gloves.
___ ___ ___ ____________
C. Place sterile tray and contents on sterile drape between thighs.

___ ___ ___ ____________
D. Separate labia with fingers on nondominant hand (now contaminated).

This hand remains in this position for remainder of the procedure.
___ ___ ___ ____________
E. Cleanse labia and meatus using forceps to hold cotton balls and one
cotton ball for each stroke, moving anterior to posterior. The first stroke is
on one side of meatus, down the center, then on opposite side.
___ ___ ___ ____________
11. Holding catheter with dominant hand near tip, slowly insert catheter until urine
flows, then advance another 1 to 2 inches. ___ ___ ___ ____________
12. For straight catheterization, place end of catheter in urine tray and allow to drain
until bladder is empty. If specimen is needed, it is collected during this drainage
process. Remove catheter, pulling slowly but evenly after drainage stops.
___ ___ ___ ____________
13. For indwelling catheter, while continuing to hold catheter in place with
nondominant hand, use prefilled syringe to inflate balloon.
___ ___ ___ ____________
14. If necessary, secure catheter to drainage bag. (Some sets come pre-attached).
___ ___ ___ ____________
15. Secure catheter to inner thigh with nonallergenic tape or catheter strap, allowing
some slack to prevent tension of the balloon on the internal sphincter.
___ ___ ___ ____________
16. Position drainage bag with tubing coiled on the bed (not in dependent loops).
___ ___ ___ ____________
17. Cleanse and dry perineal area. Position for comfort. ___ ___ ___ ____________
18. Measure urine, noting color and clarity. ___ ___ ___ ____________
19. Use Completion Protocol. ___ ___ ___ ____________
EVALUATION
1. Observe urine in catheter bag for amount, color, and clarity.

___ ___ ___ ____________
2. Palpate bladder and determine client's comfort level.

___ ___ ___ ____________

Record and Report
1. Type and size of catheter inserted ___ ___ ___ ____________
2. Amount of fluid used to inflate balloon ___ ___ ___ ____________
3. Characteristics of urine and amount of urine ___ ___ ___ ____________
4. Reasons for catheterization and specimen collection

___ ___ ___ ____________
5. Client's response to procedure ___ ___ ___ ____________

Ob Study Packet

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ob Study Packet

Uploaded by

Copyright:

Available Formats

LABOR AND DELIVERY SKILLS

Bloodborne pathogens / Standard Precautions

HISTORY AND INITIAL ASSESSMENT

Steps you should take to prepare for the examination:

Ask woman to empty bladder (collect urine for testing).

Urine tests used during intrapartum

Techniques to be used in performing a physical examination:

For more information go to:

Measure vital signs:

Test for proteinuria.

An abdominal examination should include a measurement of fundal height as well as an

Inspect and palpate lower extremities

Press firmly with thumbs about 5 seconds over shin

Measuring fundal height

Place the zero line of the tape measure on the

Abdominal Examination for Position and Presentation and Size

Leopold's maneuvers are used to determine the

2. The lateral sides of the fundus are palpated to

3. The purpose of this maneuver is to determine the pelvic

4. The fetal occipital prominence and flexion of the

Ausculate fetal heart tones.

For more information go to:

Should Women be Given a Choice About Fetal Assessment in Labor?

MCN, The American Journal of Maternal/Child Nursing September / October 2003

Uterine contractility can be quantified subjectively by palpation or objectively by the use of an

Lie and presentation

Amount of bloody show: advanced labor

Dilatation chart (actual size)

Cervical dilation: 1 finger represents aprox 1.5 cm.

Questions to ask yourself as you perform a Vaginal Examination

Status of amniotic membranes:

Are they intact. Bulging through the cervix?

How much effacement?

0%/long and thin to 100%/completely thinned out.

How much dilation?

0 (closed) to 10 cm. (dilation complete).

What is the presenting part? (head, breech, other fetal part)

What is the presenting part in relation to the ischial spines?

How to palpate presenting part:

Assessing Cervical effacement

How to determine station:

A speculum examination will be necessary in cases of suspected "leaking" or ruptured

Explain what you will do.

Fern testing for ruptured membranes

Normal mechanisms of labor/Cardinal Movements - Occiput anterior positions

Cardinal Movements of Labor

The Six Steps of Labor Progression

Stages of Labor Chart

LATENT-EARLY ACTIVE LABOR TRANSITION SECOND STAGE THIRD STAG

♥ Ripening and Contractions: Contractions: Contractions: Contractions: Contractions:

♥ 60-120 seconds long ♥ A feeling of

Diagnosis of Abnormal Labor

Review Friedman Curve

For more information go to:

Diagnosis of Abnormal Labor

Comfort Measures for the Laboring Woman.

Do not leave alone in active labor.

For more information go to:

Therapeutic Choices for the Discomforts of Labor

Journal of Perinatal and Neonatal Nursing, October / December 2003

Begin the Breathing Technique

Assume a comfortable position.

Try to maintain a relaxed state throughout the contraction.