What are some maternal factors that trigger 5

labor? What is effacement?

Maternal factors  It is the thinning and shortening of the

cervix that occurs during labor
 ◦Stretched uterine muscles & release of  At 100% effacement, the cervix is paper-
prostaglandins thin
 ◦pressure on cervix stimulates nerve
plexus → oxytocin
 ◦> estrogen → stimulates uterus to
6
contract
What is dilatation/dilation?
 ◦Withdrawal of progesterone = <
quieting
It is the widening of the cervical external os
 ◦> release of oxytocin + prostaglandins
from less than 1 cm, to full dilatation (approx.
= inhibit CA binding → contractions
10 cm) to allow birth of a full term fetus
activated
 ◦Surge of oxytocin → contractions

2 7
What are some fetal factors that trigger labor? What is a placenta previa?

 Placental aging → triggers contractions
 Fetal membranes synthesize
prostaglandins → contractions
 ↑Fetal cortisol (adrenal glands) → <
progesterone → > prostaglandins →
contractions
3
What are the premonitory signs of labor?
 Low-lying placenta may cause the baby
to assume a transverse lie
 Placenta previa can be associated with
breech presentation, this increases the
chances of being in a breach
 May also impede descent of a vertex
baby

 Lightening 8
 Braxton-Hicks (will go away when During the intrapartum period what would you
walking) vs. true labor contractions observe for in the cervix and vagina?
(they will not go away when walking)
}Cervix:
 GI changes (diarrhea, nausea,
indigestion)
◦Cervical Scarring
 Backache
 Bloody show (brownish or blood tinged)
– LEEP, conization, biopsy
 Spontaneous rupture of membranes
◦Causes firm or “purse-string” consistency
4
What are 5 factors affecting labor?
 ◦Prolonged effacement period followed
by rapid dilatation once tissue softens
1.Powers (the contractions)
}Vagina:
2.Passage (the pelvis)
 ◦Obstructions
3.Passenger (the fetus)  ◦“Tissue Dystocia”

4.Psyche (the response of woman) 9

What is a fetal "lie" and what are the different
5.Position (maternal postures and physical types?
positions to facilitate labor)
Definition: the relationship of the fetal long 12
axis to the long axis of the mother What is fetal position and what are the
different types?
Types:
Definition: the relationship of the presenting
 Vertical/Longitudinal (normal)
part to the specific area of the woman’s pelvis
o head first
 Vertical/Longitudinal (variation)
o breech
 Perpendicular (abnormal)
Types:
o Transverse (spines make a T )
o oblique
 Right (R) or Left (L) of maternal pelvis
 Occiput (O), Mentum (M), or Sacrum (S)
of fetus
10  Anterior (A), Posterior (P), or Transverse
What is fetal presentation and what are the (T) of maternal pelvis
different types?
Definition: the leading or most dependent
portion of the fetus. 13
What are some position and presentation
Types:
issues with labor?
1. Cephalic
Position: Occiput Posterior “sunny side up”
 Vertex, Brow, Face
 Longer labors
2. Shoulder
 Spontaneous or assisted rotation to OA
3. Breech
 Some feel that sedentary behavior in
Mom ↑ this
 Frank (feet up), Complete (both feet +
sacrum), Footling (just a foot/feet)

Compound Presentation: more than just a

head….
11
What are some options of a breech at term?  1:700 deliveries
External Cephalic Version  Associated with umbilical cord prolapse
15% to 20% of cases
Turning the fetus  More than just a head comes out of the
Requirements: mother, increased risk of an umbilical
cord prolapse --> Emergency (lift
 Normal fetus with reassuring FHR
presenting part off of cord)
tracing
 Adequate amniotic fluid
14
 Not in labor What are sutures?
 Presenting part not engaged
 They are the meetings of the bones of
Default option: cesarean delivery the fetal skull
}Manipulating the fetus in order to turn it to  Covered by a membrane
head first
}Procedure: IV, ultrasound, terbutaline (to relax 15
uterus), Rhogam (if Rh-negative), provide for What are fontanelles?
emergency C-S.
}Risk: separation of the placenta, uterine  Fontanelles are the space where two
rupture, fetal-maternal hemorrhage, failure. sutures meet
}Very painful for the mother  Covered by a membrane
  You never want to put a scalp electrode 22
on his scalp What is "engagement"
Occurs when the biparietal diameter is at or
below the inlet of the true pelvis
Cabit = fluid
23
What are the physiological changes of labor?
16
a.> BP, Increased cardiac output, Fluid and
What is fetal attitude?
electrolyte loss, Diaphoresis, Hyperventilation
Definition: posturing of the joints and the & Elevated temperature
relationship of the fetal body parts (chest, chin,
24
arms) to each other.
What are the mechanisms of labor?
}Flexion - normal fetal attitude when labor
begins 1. Engagement
}Extension increases diameters 2. Descent
} 3. Flexion
17 4. Internal rotation
What are primary "powers" (involuntary)? 5. Extension
6. External rotation
Primary (involuntary) Contractions: 7. Expulsion

 Frequency (Beginning of one to the 25

beginning of another)
 Duration (beginning from one to end of
it)
 Intensity (How strong it is)
 resting tone (Important because of
oxygenation to baby)
18
What are secondary (voluntary) contractions?
maternal bearing-down efforts
19
Describe the frequency of contractions
Timed from the START of one contraction to
the START of the next
20
Describe the duration of contractions
What is the decent of labor?
26
What is the flexion of labor?
Chin to chest to < diameter
27
What is the internal rotation of labor?
c. Process of alignment of fetal long axis
to
maternal long axis
28
What is the extension of labor?
a. presenting part pivots beneath symphysis
pubis with the birth of the head
29
What is the expulsion of labor?

Timed from the START of the contraction to the 30

END of that contraction What is labor and how many stages are there?

21 Labor is the process in which the fetus,

What are some losses experienced in labor? placenta, and membranes are expelled
spontaneously
 Privacy
 Control of Situation
 Control over Bodily Functions 4 Stages of labor
 Loss of Current Family Constellation
31
 Couples become parents, parents of one
When does stage 1 of labor occur?
become parents of two, etc
  Begins with onset of labor and ends with
complete cervical dilation
 Has 3 phases, latent, active, and
transition phase
32
Describe the active phase of the 1st stage of
labor
 Average dilation 1.2 cm/hr depending
on gravida
 Dilation progresses 4–7 cm, 40–80%
effacement
 Fetal descent
 Intense contraction q 2–5 min, lasting
40–60 sec
 Increase in pain
 Medical interventions
 Nursing actions
33
Describe the latent phase of the 1st stage of
labor
 ◦Cervix 0–3 cm dilation, 0–40%
effacement
 ◦Contraction every 5–10 min, mild
intensity, lasting 30–45 sec
 ◦Discomfort described as feelings of
strong menstrual cramps
 ◦Medical interventions
 ◦Nursing actions
34
Describe the transition phase of the 1st stage
of labor
 Dilation from 8 to 10 cm, 100%
effacement
 Contractions intense, q 1–2 min lasting
60–90 sec
 Exhaustion, difficulty concentrating
 Bloody show
 N/V, backache, diaphoresis, and
trembling
 Strong urge to bear down
 Medical interventions
 Nursing actions
35
What are some medical interventions for the 3
phases during the 1st stage of labor?
 Latent phase: orders for lab tests, IV or
saline lock, intermittent fetal monitoring
 Active: ROM, FHR monitoring, apply
fetal scalp electrode or Uterine
transducer PRN, Pain management,
Evaluate labor progression
 Transition: AROM, assess fetal position
& cervix; prepare for delivery
36
When does the 2nd stage of labor occur?
Begins with complete cervical dilation and ends
with delivery of baby
37
What are some behaviors during the 2nd stage
of labor?
 Urge to bear down is strong
 Pushing feels more productive to many
mothers; they are eager to push
 Exhausted mothers may find the
exertion overwhelming
 Burning as head crowns often causes
fear of “splitting open”
 Pushing causes very intense sensations
that can frighten unprepared mothers
38
What are some characteristics of the 2nd stage
of labor?
 —Complete dilatation
 —Sudden burst of energy, improved
focus
 —Shorter duration with multips than
primips
 —Intense contraction every 2 min,
lasting 60–90 sec
 —Increase in bloody show
 —Perineum flattens, with bulging rectum
and vagina
 —Medical interventions
 —Nursing actions
 —
39
What are some nursing interventions during
the 2nd stage of labor?
 —Prepare radiant warmer for newborn -
baby blankets, labels.
 —Adjust lighting and obtain/set up table
 —Call anesthesia/ NICU if necessary
 —Inform pt of progress and events
 —When physician at bedside, position pt
 —Prep perineum as requested
  —Document delivery time & watch for
NB void
40
What is the 3rd stage of labor?
 —Period involving separation and
expulsion of placenta/membranes
 —Lasts 5–20 min
 —Medical interventions
 —Nursing actions
41
When does the 3rd stage of labor occur?
Begins after delivery of baby and ends with
delivery of placenta
42
What is the 4th stage of labor?
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 —This stage begins the postpartum
period
 —Ends 4 hr after delivery
 —Mechanism of homeostasis occurs
 —Medical intervention
 —Nursing actions
43
When does the 4th stage of labor occur?
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Begins after delivery of baby and ends with
delivery of placenta
44
What are some characteristics of the 4th stage
of labor?
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 —Beginning of physiologic readjustment
of the mother’s body
 —250-500 cc blood loss is common
 —Causes drop in systolic and diastolic
BP, tachycardia, increased pulse
pressure
o —Maternal pulse over 100 and
fainting
 —Uterus is contracted, midline and near
the umbilicus
 —Oxytocin is given after delivery of the
placenta to increase uterine contraction
and decrease bleeding
 —Bladder may be hypotonic from
anesthesia, analgesia, trauma
 —Vital signs, fundal height and
vaginal flow checked every 15
minutes X 4 (1st hour)
 —Baby should be given to mother for
bonding and to initiate breastfeeding as
soon as possible
 —Shaking/chilling is common
 —Ending of the physical exertion of
labor
 —Loss of the “heater” that is the fetus
 —Most women are hungry, thirsty and
tired
45
What would you assess for in the uterus in the
4th stage of labor?
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 —Assess fundal height and consistency,
and relation to midline
 —Should be < umbilical level and central
 —Assess bladder - encourage pt to void
 —Straight catheter if necessary
 —Record quantity of lochia (rubra)
46
Describe some characteristics of the lateral
pushing position
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 Can help rotate a fetus that is in a
posterior position.
 Can slow a precipitous birth.
 Allows the perineum to stretch gradually
47
What is the natural position for pushing during
labor?
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Squatting
48
What is directed pushing and describe it
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 Begins when mother is completely
dilated
 Patient takes one good breath, then
takes and holds a second breath.
  While holding the breath, she pulls back Study These Flashcards
her knees, bears down and pushes for a
count of 10  —Fecal and/or urinary incontinence
 Cycle of inhale, hold, push repeated X 2  —Pain in the area can persist for 6
during a single contraction months or more
 —Increased pain with intercourse
49  —Bleeding
What is an episiotomy?  —Bruising
 —Swelling
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 —Infection
Mediolateral (usually right)
—Begins in the midline of the posterior 53
fourchette (to avoid Bartholin’s gland) Describe some newborn nursing care
—Extends at a 45 degree angle downwards
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—
50  —Obtain Apgar scores at 1 min and 5
What are the different degrees of lacerations in min
an episiotomy?  —Monitor temperature, heart rate,
Study These Flashcards respiratory rate, skin color, level of
1st degree consciousness, tone, activity
 —Newborn identification
 —fourchette, perineal skin, vaginal  —Medication administration
mucous membrane  —Dry thoroughly and place cap on
head
2nd degree  —Warm, dry, stimulate
 —For persistent cyanosis of the trunk,
 —plus fascia and muscles of perineal administer blow-by O2
body  —PPV for infants not breathing OR HR <
100
3rd degree  —Chest compressions if HR < 60
 —Deep suction after 5 minutes done for
 —extends into the anal sphincter
persistent rales or rhonchi
 —Gross physical assessment for
4th degree
abnormalities
 —Label baby with identification bands
 —also involves the anterior rectal wall
(tissue of the rectum) (per hospital protocol) before it leaves
the delivery room
51  —Baby footprints and mother’s
What are the benefits of an episiotomy? fingerprint
 —Obtain cord blood samples if required
Study These Flashcards (Rh negative or Group O)
 —Obtain cord gases if indicated (i.e., low
 —Hastens delivery if there is fetal
Apgar)
distress
 —May be needed if the perineum is 54
unyielding How is an apgar scored?
 —Room for maneuvers w/ shoulder
dystocia Study These Flashcards
 —More room for use of forceps or
 —Assign APGAR scores at 1 & 5 minutes
vacuum
 —0 - 2 points are given for 5

52 observations:
What are some risks associated with an o —Appearance: color
episiotomy? o —Pulse: heart rate
 —Grimace: response to
o MAY WORSEN OVER ONE TO THREE
stimulation
o —Activity: muscle tone
o —Respiration: respiratory effort
 —Score of < 7 at 5” indicates need for
10” score and further resuscitation
55
Describe suctioning in relation to newborn care
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 —Current guidelines state there is no
evidence to support the value of the
practice of routine bulb suctioning of
the newborn.
 —Current Neonatal Resuscitation
Program (NRP) guidelines no longer
include bulb sx in the initial
resuscitation of the normal term
newborn.
 —NRP guidelines no longer (2006)
recommend mechanical sx of the
mouth and nasopharynx on perineum
with meconium present in amniotic
fluid.
 —Babies can be on their side; mouth can
be wiped PRN
 —Studies of catheter deep suctioning fail
to show a benefit in oxygenation
 —Studies recommended that the routine
and indiscriminate use of or
nasopharyngeal catheter suctioning at
birth be curtailed.
56
What is a caput?
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JUST EDEMA UNDER THE SCALP, CAUSED BY
PRESSURE OF THE CERVIX ON THE HEAD. IT
BEGINS TO SUBSIDE AS SOON AS THE BABY IS
BORN.
57
What is a CEPHALHEMATOMA?
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 IT IS BLEEDING UNDER THE
PERIOSTEUM. IT THEREFORE DOES
NOT CROSS SUTURE LINES, BECAUSE
EACH BONE HAS ITS OWN
PERIOSTEUM.
 CEPHALHEMATOMA USUALLY STARTS
AS A RESULT OF BIRTH TRAUMA, AND
DAYS BEFORE BEING REABSORBED.
58
What can lead to pain during labor and
delivery?
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 —Pain may result due to the following
factors
 —Decreased blood supply to uterus
 —Increased pressure and stretching of
the pelvic structures
 —Cervical dilatation and stretching
59
What is counterpressure?
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 Comfort measures: Counter pressure
 —Direct pressure to the sacrum or hips
to counteract stretching of ligaments
 —
60
How can breathing manage pain during labor?
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 —Important because there is a natural
tendency to hold the breath with pain
 —In general, as labor becomes active
and contractions get stronger, deeper
breathing is difficult/impossible
 —Patterned breathing also acts as
distraction
 —Panic can lead to hyperventilation
 —Tingling hands, lips
 —Breathe into cupped hands or surgical
mask
61
What are some analgesic mediactions used
during labor?
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 Meperidine
 Morphine
 Butorphanol
 Nalbuphine
 Sublimaze
62
What types of anesthesia used in labor and —Narcotics –Fentanyl or Druamorph
delivery?
—Side effects: severe itching, Nausea &
Study These Flashcards
vomiting,Burning, swelling or skin irritation at
site of injection
1. Local
2. Pudendal nerve 67
3. General Describe spinal anesthesia

63 Study These Flashcards

What is epidural?
 —drug into the
Study These Flashcards subarachnoid cerebrospinal fluid space
(CFS). The injection is usually made in
 ——Intermittent injection or continuous the lumbar region at the L2/3 or L3/4
infusion space – punctures dura
 —outside the dura mater  —Immediate action -shorter procedures
 —Solution bathes the spinal roots
68
64 What are some complications with spinal
What are some advantages and disadvantages anesthesia?
of epidural?
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Adv:  complications are related to the
techniques, resulting in systemic
 —Slower onset toxicity, or to the effects of the block,
 —Titrate level and duration rather than to the drugs used.
 —< hypotension  —Cardiovascular: seizures or
 —Awake client convulsions, arrhythmias, cardiac arrest
 —High Block = nasal stuffiness,
Dis: respiratory distress or arrest
 —Total spinal =
 —Placement takes time
 —Post-dural Puncture Headache
 —Systemic toxicity
o —Blood patch (10 – 15 ml blood
 —Large placental transfer
injected into dural space)
 —> incidence of inadequate block
 —Maternal hypotension
 —Fetal bradycardia
69
65 What are some adverse reactions to spinal
Describe the epidural procedure for labor anesthesia?

Study These Flashcards Study These Flashcards

 —Consent forms after full explanation —

 —Establish IV and adminisiter fluid bolus 70
 —Ready equipment: O2, fetal monitor, What are the nurse's responsibilities of spinal
epidural equipment, IV fluids anesthesia?
 —Help position patient in side-lying or
sitting position – attach BP cuff Study These Flashcards
 —Assist anesthesiologist with procedure
 —Assist anesthesiologist
66  —Maintain IV site
What are some medications used for continued  —Be prepared for emergency situations
epidural and what are the side effects? if occur

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71  Labor progress
What is dystocia?  cause of dysfunction
 Hydrate
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 Pain meds
difficult labor or childbirth
 Sedation
72
What is Cephalopelvic disproportion (CPD)? 78
What are hypotonic arrest disorders?
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—disparity between the size of the maternal 79
pelvis and the fetal head What is a secondary arrest of dilation?
73 Study These Flashcards
What is asynclitism?
80
Study These Flashcards What is a constriction ring and describe it
malposition of the fetal head Study These Flashcards
74
What are some risk factors for dystocia?  Develops around a depression in the
fetus
Study These Flashcards  Related to hyperstimulation of the
uterus
 Congenital abdnormal uterus bicorniate
 Keeps the fetus from descending
uterus
o Ring may be felt abdominally &
 Mal presentation: (i.e. occiput posterior,
doesn’t move
or face)
o Uterus below the ring is often
 Ceohlo-pelvic disproportion (CPD)
loose and floppy
 Tachysystole of uterus (with [pitocin)
o Head does not move down at all
 Maternal fatigue & dehydration
with contractions
 Administration of analgesia or
 Uterus becomes tender but will not
anesthesia early labor
rupture
 < maternal fear or exhaustion →
 Labor does not progress
catecholamine release & interference
 May occur in any stage of labor
with labor
81
75
What is a precipitous birth?
What is dysfunctional labor?
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Labor < 3 hours from onset to birth
Abnormal contractions that prevent expected
progress of cervical dilation or descent of fetus 82
What are some nursing interventions with a
precipitous birth?
Protraction disorders = slower than normal
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Arrest disorders = complete cessation of UC
 Call light, call for help!
76  Try to turn on the warmer, O2, suction
What are the 2 types of contractions?  Get gloves on, if you can
Study These Flashcards  If perineum is bulging, just keep
77 hands near to control the head, use
How would you care for a women with counter pressure
hypertonic uterine dysfunction?  NEVER TAKE YOUR EYES OFF HER
BOTTOM!
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  Keep a hand near the urethra, hold the Study These Flashcards
baby’s head to slow it down and also The artificial stimulation of labor that began
push down a bit to protect the urethra spontaneously but has progressed abnormally
89
83
What would indicate and induction or
What is shoulder dystocia?
augmentation of labor?
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Occurs when the fetal spine is vertical to the
maternal pelvis
 Pre-eclampsia/Eclampsia
84  PROM/ PPROM
What does the helperr mnemonic mean in  Chorioamnionitis
relation to shoulder dystocia?  Isoimmunization
 Maternal medical issues
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 Postdate pregnancy
H:help- call for extra nurses, NICU
 Oligohydramnios
E:evaluate for episiotomy; empty bladder  Fetal growth restriction
 Fetal demise
L:legs back and open in McRoberts
 Logistic factors
P:pressure over the pubis towards the  Prior loss

baby’s face
E:entry maneuvers Rubin and Wood’s Screw 90
What are some contraindications of inducing or
R:remove posterior arm
augmentin labor?
R:roll patient- The Gaskin Maneuver
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85
What would you evalute before inducing labor  Placenta previa
maternally?  Transverse fetal lie
 Prolapsed umbilical cord
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 Breech presentation
1. confim indication for induction  Prior classical cesarean incision
2. review contraindications to labor and  Major uterine surgery
or/vaginal delivery  Active herpes simplex
3. perform clinical pelvimetery to assess
91
pelvic shape and adequacy of bony
What is the criteria for inducing labor?
pelvis
4. Assess cervical condition (assign bishop Study These Flashcards
score)
5. Review risks, benefits, and alternatives of  Engaged presenting part
induction of labor with patient  No previous classical C/S incision
 No fetopelvic disproportion
86  Reassuring FHR pattern
What would you evalute before inducing labor  No placenta previa
fetally?  No major bleeding from abruptio
placentae
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87 92
What is induction of labor? What are some risks for inducing labor?
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the process of starting labor artificially
 Fetal distress
88
 Placental abruption
What is augmentation of labor?
  Increased needs for pain medications
 Edema R/T Pitocin, IVF, hydration w/
epidural
 Prolapsed umbilical cord or infection w/
amniotomy
 Uterine rupture
 Cesarean delivery
 §Induction of nulliparas results in 40%
C/S rate
93
What are the benefits for inducing labor?
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 Ability to schedule other events in family
w/birth
 Prevention of precipitous birth
 With known anomalies, ability to have
proper staff/NICU in attendance
 Birth with chosen provider
 Completion of pregnancy that is too
physically stressful for mother
94
Describe oxytocin (pitocin) induced labor
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 Pitocin rate depends on assessment of:
 §uterine activity
 §fetal response
 §cervical effacement and dilation
 The primary concerns are tachysystole,
tetanic ctx & fetal bradycardia
 VBAC patient > risk of uterine rupture
 Nursing care ratio 1:1
 Admit as usual labor patient
 Documented fetal position, lie, cephalic
presentation within previous 24 hours
 MD with C/S privileges < 10 min away
 Mainline IV of LR 1,000mL @ 125 mL/hr
via 18 gauge cannula
 I&O
 Continuous FHR monitoring
 —Dilute 20 Units Pitocin in 1,000mL NS
IVPB
 —Give via pump starting at 1-2
milliunits/ min (3-6 mls/hour).
 —Insertion site is in the most proximal
port.
 —Increase Pitocin rate by 1-2 milliunits q
15-20 minutes until adequate ctx
pattern.
 —Take BP with every increase.
 —Continuous monitoring of ctx
frequency, duration, intensity, resting
tone.
 —Adjust total IV fluid intake to 125mL/hr

95
What are some interventions for fetal distress?
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 —Reposition in lateral recumbent
 —Increase IV mainline fluid (LR)
 —Apply FSE and assess cervix and
station
 —Assess for S & S of placental abruption
 —Turn Pitocin off
 —Administer O2 @ 8-10 L/min via NRB
 —Call physician
 —Be prepared to administer Brethine
 —Prepare for C-S if FHR still no better.
96
What is forceps delivery?
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Forceps assist the birth of a fetus by providing
traction or a means to rotate the fetal head to
an occiput-anterior position
97
What are the different types of forcepts
delivery?
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Types: Outlet, Low
§Mid-forceps (rarely used)
Outlet Forceps
§fetal skull has reached the perineum. Scalp is
visible between contractions
Low Forceps
§fetal skull is at +2 station or more
98
What are the requirements for using
forceps/vacuum?
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 Known position and presentation
 Empty maternal bladder
 Cervix fully dilated
 Membranes ruptured
 Adequate anesthesia
 Expertise
  Feasibility
 Cesarean section availability

99
What are some risks associated with forceps
delivery in the neonate and mother?
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Neonate

 Cephalohematoma
 Transient facial paralysis and bruising
 Facial edema
 Cerebral edema

Mother

 Perineal swelling
 Bruising
 Hematoma
 Hemorrhage
 Postpartum infection

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

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