Finals MCN

MCN EL FINALS
Causes of onset
Multiple theories have been proposed about the mechanisms that precipitate the onset of Labor yet this
process is still not clearly understood it is likely that a combination of maternal and fetal factors
combined to initiate this process please review the possible causes of Labor onset listed on screen
Onset of Labor
Maternal factors:
o Stretching of uterine muscle.
o Pressure on the cervix.
o Oxytocin stimulation (oxytocin and prostaglandin
work together to produce uterine muscle
contractions).
o Change in estrogen/progestin ratio (estrogen
increases uterine muscle response/progestin relaxes
the uterine musculature).
Fetal factors:
o Placental aging.
o Fetal cortisol concentration (cortisol is produced by
the fetal adrenal glands and serves to increase
placental production of progestin and prostaglandin).
o Prostaglandin (originating from the fetal membranes).
In preparation for labor the pregnant woman will experience a number of physical changes that can
occur gradually over a period of weeks or in a relatively short period of time as the onset of Labor grows
near the fetus will begin to dip into the true pelvis a process known as lightning. lightning typically does
not occur in multi gravid women or women who have previously had a child or at least the process is not
as dramatic.
Lightening:
o A unique process in a primigravida (a woman having
her first baby).
o Occurs over a 10- to 14- day period.
 Does not typically occur in multigravida (a woman who
has been pregnant one or more times).
Lightening is perceived by the woman as:
o Relief from shortness of breath.
o Less diaphragmatic pressure.
o Increased pelvic pressure.
Braxton Hicks contractions sometimes known as false labor contractions are useful to tone the uterine
musculature for labor Braxton Hicks contractions also serve to promote cervical ripening it is sometimes
challenging to distinguish between true labor and false labor or Braxton Hicks contractions this table
helps outline the differences
Cervical ripening is a process whereby the cervix is softened and repaired to dilate during labor Braxton
Hicks contractions caused the cervix to thin out overtime a process known as effacement prior to labor
the cervix is typically two inches approximately 4 centimeters in length in primigravida women this
thinning must occur before the cervix can dilate multiparous women those who have given birth before
typically a face in dilate the cervix simultaneously
Preparation for Labor

o Lightening
o Braxton Hicks contractions
o Ripening of cervix
o Effacement (thinning)
o Primigravida: Effacement precedes dilation.
o Multipara: Effacement and dilation are simultaneous.
In addition to thinning and softening the cervix other factors joined to prepare the woman's cervix for
labor collectively these factors can be quantified using the Bishop pelvic scoring system the Bishop
scoring system considers cervical effacement consistency position dilation and fetal station the station
refers to the relationship of the presenting part to the level of the ischial spines this illustration shows a
fetus at station -4 which means the head is 4 centimeters above the ischial spines each of these five
criteria is evaluated on a three-point scale for women at term a bishops score of six or higher is useful in
predicting the onset of Labor within the next seven days
Preparation for Labor:

o Lightening
o Braxton Hicks contractions
Ripening of cervi
Bishop score
Bishop score considers:
o Effacement
o Consistency
o Position
o Dilation
Fetal station (relationship of the presenting partito the level of the ischial spines)
For women at term, a Bishop score of 6 or higher is a useful predictor of the onset of labor
within 7 days.
A woman presents with the following vaginal exam finding cervix is posterior moderate consistency 60%
effaced dilated 2 centimeters with the presenting part at -1 station what is her Bishop's score type your
answer in the space provided
When a effacement is complete and cervical dilation begins the pregnant woman may report a thick
tenacious pink tinged mucus discharge this is commonly known as passing the mucus plug the mucus
plug occludes the cervical canal during pregnancy and inhibits the ascension of bacteria into the gravid
uterus discharge of the mucus plug may or may not be accompanied by a bloody show indicative of
capillary rupture in the birth canal caused by pressure on the cervix by the fetus
Click on the cards to match the corresponding pairs

it is common in obstetrics to use a shorthand method of conveying the number of pregnancies a woman
has had and the outcome of each gestation gravida refers to the total number of pregnancies a woman
has had confirmed regardless of the length of gestation parity indicates the outcome of each of these
pregnancies
Parity may be further defined according to the gestation of the pregnancy and the number of living
children the woman has a full term gestation is a pregnancy lasting more than 37 weeks a preterm
gestation is a pregnancy lasting more than 20 weeks but less than 37 weeks an abortion is a pregnancy
that was confirmed but terminated prior to 20 weeks gestation regardless of the reason this includes
induced and spontaneous pregnancy terminations some professionals use the pneumonic Florida power
and light to remember the sequence of parity for example if a woman has been pregnant four times and
has had two term children one pre term child and one miscarriage her gravida and parity would be
written as G4P2113
When determining the due date of a pregnancy it is common to confuse 2 specific dates gestational age
which refers to the duration of pregnancy since the first day of the last menstrual period and
conceptional age the duration of pregnancy since the time it was conceived typically 14 days after the
first day of the last menstrual age a full term pregnancy is 40 weeks gestational age or 280 days from the
first day of the last menstrual period to allow for variations in ambulation gestational age is always stated
as ±2 weeks the due date based on gestational age is known as the estimated date of confinement or
EDC
Determining the "Due date"

o Gestational age: Based on last menstrual period (LMP).
o Conceptional age: Based on when ovum was fertilized.
A full-term pregnancy is 40 weeks gestational age, or 280 days from the first day of the last
menstrual period.
Due date is based on gestational age:
o Estimated date of confinement (EDC), or
o Estimated date of delivery (EDD)
Most medical professionals use the gestational age when dating a pregnancy gestational age can be
calculated by using a formula known as the Nagel rule to calculate the estimated due date count
backward 3 calendar months from the first day of the LMP and add seven days
Due date is based on gestational age:

o Estimated date of confinement (EDC). or
o Estimated date of delivery (EDD)
Nägele rule:
o Determine LMP (month/day).
o Subtract 3 calendar months from the LMP month.
o Add 7 days from the LMP day.
o Result of steps 2 and 3 are the month and day of the due date, respectively.
Example:
o LMP = July 13 (7/13)
o Subtract 3 calendar months (7 - 3 = 4, which is April)
o Add 7 days to the date: 13+7 = 20
o EDC = 4/20 or April 20
It is impossible to predict the ability of a woman to have a vaginal birth prior to onset of Labor
hormonally induced pelvic relaxation and soft tissue changes can have a profound impact in preparing
the birth canal to accommodate the transit of a term newborn there are however certain pre-existing
conditions that lend themselves to facilitating or impeding this process there are four primary maternal
pelvic shapes please review the types and their characteristics listed on screen
Passage or Birth Canal

Hormones and soft tissue changes influence the birth canal.
Four Primary Maternal Pelvic Shapes
Android: "Male" Pelvis
o Acute angle at arch
o Narrow outlet
Anthropoid: "Apelike" Pelvis
• Narrow transverse diameter
Gynecoid: "Normal" female pelvis
Rounded inlet
• Wide pubicarch
Platypelloid: "Flattened" pelvis
• Short anterior-posterior diameter
Each of these pelvic shapes has certain attributes that factor significantly into the birth process the
Android pelvis is heart-shaped and carries a poor prognosis for vaginal deliverythe anthropoid pelvis
occurs in approximately 25% of womenit carries a good prognosis for vaginal birththe platypus alloyed
pelvis is present in only 5% of women and carries a poor prognosis for vaginal birthoften the fetal
presenting part is unable to even engage cesarean section is very common for women with this type of
pelvisblast as its name implies the gynecoid pelvis is ideal for vaginal birthit is present in approximately
50% of women
Android Pelvis:
o Occurs in approximately 20% of women.
o Typically described as a heart shaped pelvis.
o Carries a poor prognosis for vaginal delivery.
Anthropoid Pelvis:
o Occurs in approximately 25% of women.
o Carries a good prognosis for vaginal birth.
Platypelloid Pelvis:
o Present in only 5% of women.
o Carries a poor prognosis for vaginal birth.
o Fetal presenting part is unable to engage.
o Cesarean section is very common for women with this type of pelvis.
Gynecoid Pelvis:
o Ideal for vaginal birth
o Present in approximately 50% of women
given an adequate passage the second factor to consider and labor is the passenger or the fetus the
head also known as the vertex is the largest body part of the fetus the vertex is the most common
presenting part first into the birth canal in childbirth to fit through the birth canal the vertex must enter
into the pelvis so that the smallest head diameter fits into the smaller pelvic opening and the widest
fetal head diameter fits into the widest area of the pelvis the structure of the fetal head is comprised of
eight bones that are incompletely joined the area between the bones is called fontanels this incomplete
fusion of bones allows the vertex to conform to the shape of the maternal pelvis as it moves through the
birth canal this is a process known as molding-in the vertex presentation first identify the anterior or
posterior fontanel the anterior fontanel has three suture lines extending from it the posterior funnel has
two suture lines use this information to determine the fetal position during the vaginal exam
Passenger (Fetus)
Head or Vertex:
o Largest body part.
o Most common presenting part (first into the birth canal) in childbirth.
o The smallest head diameter fits into the smaller pelvic opening, and the widest fetal
head diameter fits into the widest area of the pelvis.
o Fetal head comprised of 8 bones that are incompletely joined.
o Bones are separated by fontanelles.
o Molding: Bones conform to shape of maternal pelvis during descent.
The vertex enters the birth canal at an irregular angle the fetal head may sustain asymmetrical pressure
which results in swelling known as capput succedanum denim or a collection of blood from broken blood
vessels under the scalp known as cephal hematoma.
At times the fetus may enter the birth canal in a presentation other than vertex besides vertex others
have phallic presentations include brow face and mentum the breech position may indicate the buttocks
or feet are the first body parts in the birth canalif the fetus lies across the maternal abdomen this
presentation is known as a shoulder presentation
Variations in Presentation
Cephalic presentations:
o Vertex
o Brow
o Face
o Mentum (chin)
Breech presentation:
o Buttocks
o Feet
Shoulder presentation:
• Fetus lies across the maternal abdomen.
The presenting part is used to describe position in relation to the maternal pelvis as a guide the maternal
pelvis is divided into quadrants right and left anteriorand right and left posterior accordingly fetal
anatomy is used to describe the relationship of the presenting part to the maternal pelvis in the vertex
position the occupant posterior skull bone is the landmark if the presenting part is the fetal facethen the
chin mentum is the reference point and in a breech presentation the sacrum is the point of reference
Fetal position:
o Presenting part is used to describe position in relation to the maternal pelvis.
o The maternal pelvis is divided into quadrants:
o Right and left anterior
 Right and left posterior
Fetal anatomy is used to describe the relationship of the presenting part to the maternal
pelvis:
o Vertex presentation: Occiput (posterior skull bone) is the landmark.
o Face presentation: Mentum (chin) is the landmark.
o Breech presentation: The sacrum is the point of reference
Fetal attitude describes the degree of fetal flexioncomplete flexion helps the fetus present the smallest
skull diameter into the pelvis and causes the body to assume an Oval shape occupying the smallest
possible space incomplete flexion causes wider head diameters to enter the pelvis first possibly
inhibiting descent into the birth canalI've said trical nurses will typically use Leopold maneuvers to help
determine the position of the fetus in uteroLeopold maneuvers are a systematic way to determine fetal
position and presentation in a noninvasive manner
Fetal attitude:
Describes the degree of fetal flexion.
Complete flexion:
Fetus presents the smallest skull diameter into the pelvis.
• The body assumes an oval shape, occupying the smallest possible space.
Incomplete flexion:
- Wider head diameters enter the pelvis fidescent occurs when the fetus begins movement
through the birth canal passing through the fully dilated cervix presentation.
Fetal attitude:
- Describes the degree of fetal flexion.
Complete flexion:
o Fetus presents the smallest skull diameter into the pelvis.
o The body assumes an oval shape, occupying the smallest possible space.
Incomplete flexion:
 Wider head diameters enter the pelvis first.
o Possibly inhibits descent into the birth canal.
Leopold maneuvers:
• Method to determine fetal position and presentation.
Engagement refers to the settling of the presenting part into the pelvic inlet to the extent that it cannot
be dislodged the station refers to the relationship of the presenting part to the level of the ischial
spinesthis picture shows a fetus at station -4 which means the head is 4 centimeters above the ischial
spines when the head is at 0 station it is well engaged when the head reaches plus four the vertex is
visible at the introitus and is said to be crowning
the fetus is an active participant in the birth process and must navigate through the birth canal byThe
fetus is an active participant in the birth process and must navigate through the birth canal by keeping
the smallest diameter of the head presenting to the smallest diameter of the birth canal these
mechanics are colonial movements of Labordescent occurs when the fetus begins movement through
the birth canal passing through the fully dilated cervixflexionas the head descends pressure from the
pelvic muscles cause the head to flex so the chin rests on the fetal chestinternal rotationas the head
touches the pelvic floor the head rotates causing the occiput back of the fetal head to move to the
superior position just under the pubic synthesisthrough extension the occiput slides under the synthesis
which acts as a pivot for the rest of the headas the head extends first the occupantthen forehead face
and chin are born in successionexternal rotation also known as restitution occurs when the head is
completely emerged from the birth canal and the head turns to a line with the rest of the body
Passenger
Fetus is an active participant in the birth process.
• Navigates through the birth canal by keeping the smallest diameter of the head presenting to
the smallest diameter of the birth canal.
Cardinal movements of labor:
o Descent: Fetus passes through the fully dilated cervix.
o Flexion: Head flexes so the chin rests on the fetal chest.
o Internal Rotation: Head rotates, occiput moves to the superior position just under the
pubic symphysis.
o Extension: Occiput slides under the symphysis.
o External rotation (restitution): Head turns after completely emerged from the birth
canal.
The uterine musculature is the primary power source for labor the focal point of this power is a uterine
fundus each uterine contraction originates at the fundus and extends downward in a wave like fashion
causing the lower uterine segment to thin as the fundal area becomes increasingly thickerin this graphic
notice how the upper uterine segment is becoming thicker and the lower uterine segment is thinning
Power Source for Labor:

o Uterine musculature
o Uterine contraction originates at the fundus
The maternal psyche can play a key role in the progression of Laboranxiety uncertainty loss of
controlpast experiences attachment to support systems and multiple other psychological factors can
greatly influence the birth experiencewomen who have a poor relationship with their partner or labor
support person may experience a prolonged labor cultural expectations often contribute significantly to
the birth process those caring for laboring women cannot minimize the impact of these expectations
Maternal Psyche
Factors that may influence birth experience:
o Anxiety
o Uncertainty
o Loss of control
o Past experiences
o Attachment to support systems
o Cultural expectations
Women with a history of abuse especially sexual abuse can present one of the most challenging and
difficult situations and obstetrics sensations of Labor may precipitate flashback at the abuse helping
women stay focused on reality and minimizing anxiety can be accomplished through the care providers
awareness of the past historyand working with the woman and her partner to identify ways for her to
have maximum control and power during the labor and birthsince not all women will be able to share
such a history sensitivity to the laboring woman's anxiety level can be very revealing assisting laboring
women to feel empowered is perhaps the ultimate nursing care goal in the obstetrical setting
Maternal history of abuse presents special challenges to health care providers.

Sensations of labor may precipitate flashback of the abuse.
Strategies for care givers:
• help maintain focus on reality;
 Minimize anxiety
o Work with the woman and her partner to identify ways for her to have maximum control
and power during the labor and birth.
o Be sensitive to woman's anxiety level.
Labor and birth are traditionally divided into four stages stage one is from onset of Labor until
the cervix is fully dilated stage two is from full cervical dilation until birth stage 3 is from birth
until delivery of the placenta stage 4is from birth of the placenta until one hour postpartum
Stages of Labor and Birth

o Stage I: Labor to full cervical dilatation
o Stage II: Full cervical dilatation to birth
o Stage III: Birth until delivery of placenta
 Stage IV. First hour postpartum
Stage one is usually divided into 3 phases latent active and transition each phase can be recognized by
specific contraction patterns maternal physical sensations and maternal behavior
When caring for a woman in labor a number of factors are included in her vital signs assessment includes
blood pressure pulse respiration temperature uterine contraction pattern and fetal heart rate additional
vital information includes urinary protein and glucose cervical exam findings membrane status and fetal
movement-collectively this information helps identify risks for pregnancy complications and any
underlying disease processes timing of vital signs depends on the maternal and fetal status and stage of
Labor the fetal heart rate is most easily heard using a Doppler device
Assessments for risk/complications:

o Blood pressure, pulse, respiration, and temperature
 Uterine contraction pattern
o Fetal heart rate
Other vital information:
 Urinary protein and glucose
 Cervical exam findings (presentation, station, effacement, dilatation)
o Membrane status (intact, ruptured and if so, description)
o Fetal movement
In absence of risk factors, assess and document...
Maternal vital signs:
• 94 hor less
and...
Fetal heart rate:
o q 30 min during active labor
o q 15 min during second stage
Occasionally the maternal pulse will be heard through the Doppler the maternal or uterine souffle may
be confused with the fetal heart rate but has a slower rate
Rupture of the membranes may occur anytime prior to or during labor this may be recognized as a gush
of fluid from the vagina or as a slow but steady leaking of fluidamniotic fluid is normally clear but may
also contain flecks of vernix a thick cheesy white substance that covers the fetal skinin certain situations
amniotic fluid may also be green reddish or combinations of these variations depending on various
antenatal factors green amniotic fluid suggest passage of meconium prior to birth a concerning signred
amniotic fluid may suggest hemorrhage such as would occur with placental abruption once the
membranes have ruptured the risks for infection and cord prolapse exist
Rupture of Membranes
o May occur prior to or during labor.
o Signs: gush of fluid from vagina or steady leaking of amniotic fluid.
o Risk for infection and cord prolapse after membrane rupture.
Characteristics:
o Normally clear.
o May contain flecks of vernix.
o May be green, reddish, or combination.
o Green suggests meconium stain.
o Red suggests hemorrhage (eg, placental abruption).
Assess:
o Obtain sample of fluid perineum.
o Nitrazine paper confirms the pH is greater than 6.5 (appears blue-green).
The latent phase is primarily a time of preparationin prima Paris women this is the time when the cervix
will completely efface if it is not already done so and begin to dilate it is not unusual for multi gravid
women to skip this phase altogether or perhaps some simply overlook it or perceive this time as an
episode of Braxton Hicks contractionsmost women can continue with daily activities during this time
while becoming increasingly aware that the time for labor has arrivedI think I may be in the early stages
of Labor I lost the mucus plug yesterday so I wouldn't be surprised since this morning I've noticed more
Braxton Hicks but they just won't go away they're not that painful mostly they just feel like bad
menstrual cramps
Stage I: Latent Phase

o Cervical dilatation: 0 to 3 cm
o Duration
o Primigravida: 8.5 h
o Multipara: 5 h
o Contractions
o Mild
o Regular or irregular
o Short duration, yet persistent
Most women will continue with their daily activities even though they are aware the time for
labor has arrived.
During the active phase the principal work of dilating the cervix is accomplished for both primiparous
and multi gravid women it is very clear that labor has arrived the active phase is sometimes called the
phase of maximum slope because cervical dilation proceeds at the most rabid baseduring this
timeduring the phase of maximum slope the cervix may dilate 3.5 centimeters per hour in primigravida
women and up to 9 centimeters per hour in multiparous women this is harder than I thought these
contractions are coming really fast when they start it feels like I'm being hit by itan ocean wave I'm
struggling to keep control and my back is killing me
Stage I, Active Phase: "Phase of Maximum Slope"

o Duration
o Multipara: 2.5 h
o Contractions
o Moderate to strong
o Regular, q 2 to 5 min
o Last 1 min
o Rate of cervical dilatation
o Primigravida: 3.5 cm/h
o Multipara: 9 cm/h
As the active phase progresses some women may express an interest in assistance with pain relief non
pharmacologic strategies include emotional and physical support from partner relaxation techniques and
various cutaneous techniquesdetails are listed on screenalthough the use of intradermal sterile water
injections is not commonly used it is very effective in relieving labor pain on a short term basis typically
for up to one hour 4 small intradermal injections of sterile water are placed over the sacrum as shown in
the illustration
Stage I Nonpharmacologic Pain Relief
o Emotional and physical support from partner, family members, and birth attendants.
 Relaxation techniques including imagery, music, self-hypnosis, and patterned
breathing.
o Cutaneous techniques:
o Massage, effleurage, counterpressure, acupuncture, heat/cold, and hydrotherapy.
o Physical activity, such as walking, squatting, and use of a birthing ball.
Intradermal injections of sterile water. (Four intradermal injections of 0.1 mL of sterile water
are placed over the sacrum, leaving a fluid-filled wheal similar to a tuberculosis test)
Pharmacologic pain management options include analgesics such as sedatives and hypnotics and
parenteral opioids regional anesthesia includes local infiltration pudendal block and epiduralanalgesia
Stage I Pharmacologic Pain Management

Analgesics:
o Sedatives.
o Hypnotics may be used as a sleep agent during prolonged latent phase.
o Parenteral opioids are most commonly used during active labor.
Regional anesthesia:
o Local infiltration administered prior to episiotomy.
o Pudendal block is usually limited to second stage.
o Epidural analgesia
The cervix becomes completely dilated strong contractions occur every 1 1/2 to two minutes lasting 60
to 90 secondsI'm I'm starting to feel a lot of pressure I think my water just broke I need to lie down I
don't think I can stand it much longer this is ridiculous
Stage I, Transition Phase

o Duration
o Multipara: minutes to hours
o Contractions
o Strong
o Regular, q 1.5 to 2 min
o Last 60 to 90 seconds
The first stage of Labor can be summarized using a Friedman curve this instrument is the most
commonly used method to assess the normal progression of Labor
Those may affect the expected time frame for labor progressionthese factors include pharmacological
interventionrupture of membranesmaternal psychethe mother's chosen labor position and degree of
activity and fetal size and positionparity the number of births a woman has had plays a large role in how
fast this process progresses
Stage l
Factors that may affect labor progress:
Pharmacological intervention
• Timing of rupture of membranes
Maternal psyche
Maternal activity
Maternal position
o Fetal size
o Fetal position
Parity
Electronic fetal monitoring is a commonly used means of evaluating labor progress and fetal well-being
during laborit can be used to monitor both uterine contractions and fetal heart rate either continuously
or intermittentlymonitoring can also be accomplished through external or internal means
Stage | Assessment
Electronic fetal monitoring evaluates:
o Labor progress
o Fetal well being
Monitors:
o Uterine contractions
o Fetal heart rate
o Continuous
o Intermittent
o External
o Internal
Using an external approach senses they're placed on the maternal abdomen to transmit tension from
the uterine muscle and to document the fetal heart rate this information is printed onto graph paper
with the fetal heart rate in beats per minuteappearing on the top graph and the uterine contraction
pattern on the bottom grapheach small box indicates 10 seconds and each dark line signifies one minute
Stage I Assessment
External monitoring:
o Uterine contractions
o Fetal heart rate
o Information printed on graph paper
In this external monitor tracing the fetal heart rate is between 130 to 150 beats per minute it is normal
for the fetal heart rate to vary between 5 to 25 beats per minute and this is a reassuring signthe
contractions are occurring every two to three minutes and lasting approximately 60 to 70 secondsa
limitation of monitoring contractions externally is that the amplitude of the contractions on the graph
paper is not indicative of contraction strength or intensity it is more an indication of how tightly the
monitor belts are strapped to the maternal abdomen contraction intensity must be assessed through
palpationusing the fingertips on the fundus A mild contraction can be perceived but the fundus can be
indented with the fingertips during a moderate contraction the fundus can be slightly indented during a
firm contraction the fundus cannot be indented
Stage I Assessment
External monitoring:
• Normal tracing
Limitation of monitoring:
• Amplitude of tracing does not indicate the strength or intensity of contraction.
Assess contractions with fingertips:
o Mild: Perceived, but fundus can be indented.
o Moderate: Fundus can be slightly indented.
o Firm: Fundus cannot be indented.
In situations where a more exact measurement of fetal heart rate and contraction is necessary internal
electronic monitoring may be used using this approach a fluid filled catheter is inserted into the uterine
cavity through the cervixin this manner the contraction tracing is accurate in terms of frequency duration
and intensity with emphasis on intensity intensity is expressed in terms of millimeters of mercury much
like a blood pressure internal uterine monitoring is also useful for accurately documentinguterine resting
tone between contractionsthe fetal electrode is used to document heart rate and the tracing is reliable
for documentation of fetal heart rate variability
Stage | Assessment
Internal monitoring:
o More exact measurement of fetal heart rate and contraction with electronic fetal
monitor.
o Accurate assessment of contraction frequency, duration, intensity.
o Documents uterine resting tone.
Documents fetal heart rate and fetal heart rate variability.
Fetal heart rate variability reflects variation in the beats per minute over time. Normally this
variation is between 5 and 25 beats per minute and is considered a reliable indicator of fetal
well being.
In this tracing the fetal heart rate is between 120 and 160 beats per minute and shows excellent
variability the contractions are every 2 1/2 to 3 minutes lasting 60 seconds and are 60mm of mercury in
intensity above 50is considered moderate to strong the uterine resting tone is 10 to 20mm of mercury
which is normal
Normal Tracing
Characteristics:
o Fetal heart rate: 120 to 160/min
o Excellent variability
o Contractions: q 2:5 to 3 min
o Duration: 60 sec
o Intensity. 60 mm Hg (>50 mm Hg is considered moderate to strong)
o Uterine resting tone: 10 to 20 mm Hg (within normal limits)
The decision to use intermittent auscultation or electronic monitoring is made between the woman and
her health care provider this decision is based on many factors including risk classification hospital
policies fetal conditionand the woman's pregnancy history when used appropriately both methods are
effective in evaluating fetal well-being
Stage | Assessment (continued)

Auscultation vs. Electronic Monitoring:
o Patient history
o Fetal condition
o Risk classification
o Hospital policies and procedures
o Standard of practice
Vaginal examination should be performed in a systematic manner first explain the rationale for the exam
and the procedure to the woman ensure that the woman is minimally exposed during the exam position
her for maximum comfort commonly this is in the dorsal recumbent positionwith a slight side tilt to
avoid compression of the vena cava by the gravity uterusavoid using antiseptics such as povidone iodine
and hexachlorophene because these agents have not been shown to decrease infection and are likely to
cause local irritation and possible systemic absorption through exposed mucous membranes
Stage | Assessment
Vaginal examination:
o Use systematic approach.
o Avoid unnecessary exposure
o Position for comfort and to avoid compression of vena cava.
Avoid using antiseptics, such as povidone-iodine and hexachlorophene:
o Do not decrease infection.
o Are likely to cause local irritation.
o Possible systemic absorption.
During the vaginal exam the eskil spines may be identified by sliding the fingers down the side wall of the
vagina pressing in approximately 1 inch at 3:00 or 9:00 it is not necessary to identify both spines to
determinefetal station take care to avoid confusing the actual fetal head with capisco denimin the vertex
presentation first identify the anterior or posterior fontanel the anterior fontanel has three suture lines
leading from it the posterior fontanel has two suture lines use this information to determine the fetal
position
Stage I Assessment
Vaginal examination:
o Identify the cervix and assess:
o Consistency
o Dilatation
o Effacement
o Identify the ischial spines and determine station
o Identify anterior or posterior fontanelle to determine fetal position (vertex
presentation).
Two phases the first is from full cervical dilation to spontaneous bearing down during this phase some
women have actually been observed to take an hour long nap prior to the onset of spontaneous bearing
down effortsthe second phase is from the onset of vigorous and spontaneous bearing down efforts until
birth
Stage II: Full cervical dilatation to birth

Two phases of Stage Il:
o Phase 1: From full cervical dilatation to spontaneous bearing down.
o Phase 2: Onset of vigorous and spontaneous bearing down efforts until birth.
Once the cervix is fully dilated the fetus begins its descent down the birth canal experience labor nurses
know that as the fetal head passes through the fully dilated cervix some women may feel the urge to
vomita reaction triggered by the vagal reflex not coincidentally by vomiting the valsalva effort naturally
recruits abdominal muscles to assist in the expulsion efforts some women may perceive an involuntary
urge to push however this is not universal
Stage II: Full cervical dilatation to birth

o Cervix is fully dilated.
Fetus begins descent through birth canal.
Associated sensations:
o Urge to vomit (due to vagal reflex).
o Involuntary urge to push.
The nursing goal of the second stage should be to support the laboring woman rather than dictate to her
when and how to push there are two approaches to coaching the second stage of Labor the closed
Gladys techniqueand the open Gladys techniquethere now exists good data to suggest that the closed
Gladys technique is not only less effective but possibly harmful to the mother and fetus this technique
can cause an increase in intrathoracic pressure thereby decreasing blood return from the extremities and
eventually leading to decreased placental blood flowno data shows that the closed Gladys technique
shortens the second stage when compared with the open Gladys technique additionally data suggests
that hyperflex in the knees into the abdomen during pushing efforts can cause damage to the perineal
nerve potentially leading to numbness and tingling in the legsand possibly an inability to walkin the open
glottis or involuntary approach women were observed to hold their breath for only 6 seconds on average
while bearing downthey often took several breaths between bearing down efforts open Gladys allows a
pushing effort to occur in a more gentle fashion causing less trauma to the maternal tissues and less
compromise to uteroplacental blood flow
Coaching during Stage II

Closed glottis pushing:
o Traditional approach.
o Woman coached to hold deep breath for 10 seconds while bearing down.
o No sound is uttered with pushing efforts.
o Knees are drawn up toward abdomen.
o Associated with risks to mother and fetus.
Open glottis pushing:
o Un-coached technique:
o May occur involuntarily.
o Less impact on uteroplacental blood flow.
o Better tolerated by mother and fetus.
o Physiologic.
 Results in shorter second stage.
When women are allowed to use an upright position the duration of the second stage is shorter if
women assume a squatting position the duration is shortened an average 23 minutes for prima Paris
women and 13minutes for multi gravid women when compared with women who approached the
second stage in a recumbent position
Positioning during Stage Il

Upright position shortens second stage.
In certain situations such as when women have regional analgesia they may not perceive an urge to push
there is some evidence to support a laboring down approach whereby active pushing is delayed and the
fetus is allowed to descend through the birth canal passively A lateral position facilitates passiveit'll
descend until the mother perceives the urge to push laboring down reduces maternal fatigue and
increases the success rate of spontaneous vaginal birthby decreasing complications this approach is also
cost effectiveadditionally the duration of the second stage is not increased to a clinically significant
degree
Laboring Down
Used in situations when a woman does not perceive an urge to push (such as regional
analgesia).
o Fetus descends passively.
o Useful when urge to push is absent.
o Active pushing is delayed
o Lateral position until mother perceives the urge ta push (Ferguson reflex).
o Improves success rate for vaginal birth.
o Reduces maternal fatigue
Second stage is not significantly prolonged.
• Fewer complications.
The birth stage is relatively short but is the highlight of the labor effort as the presenting part approaches
plus forestation the mother becomes very focused on efforts to bring forth her child a variety of
positions can be used during the actual birth the goal is to allow the laboring woman to select a position
of her choosing and direct caregiver efforts to accommodate her ideally her chosen position will be one
that lessens tension on the perineum such as the lateral or Sims position semi sitting the all fours
position with squatting
Positioning during Stage Il

o Allow woman to select position.
o Positions that lessen tension on the perineum:
o Lateral
o Sims position
o Semi-sitting
All fours position
o Squatting
Two as crowning as the head emerges the birth attendant provides support so that the head is born with
the smallest diameter presenting gentle pressure on the presenting part while supporting the perineum
will facilitate a slow birth and lessen the risk of tearing
Stage II: Birth

When baby's head is visible at the introitus.
Birth attendant:
o Supports the head.
o Provides gentle pressure on presenting part
o Supports perineum to reduce risk of tearing.
Once the head is born the birth attendant will suction the nose and clear the mouth of secretions care is
taken at this point to check for the presence of an umbilical cord around the neck if such a loop is felt it
may be gently loosened and drawn over the infant's head or clamped and cut if necessary before
delivery of the shoulders once the head is delivered an external rotation or restitution has occurred the
birth attendant gently lowers the head toward the mother's ****** to facilitate birth of the anterior
shoulder once the anterior shoulder is in view the head and neck are gently raised anteriorly to allow
birth of the posterior shoulder the rest of the body is quickly born the cord may be clamped at this point
and the neonatal bonding process begins face to face
Stage II: Birth

Birth attendant:
o Suctions infant's nose and mouth.
o Checks for presence of nuchal cord (umbilical cord around neck).
After the head is delivered, external rotation (restitution) occurs.
Birth attendant:
o Lowers the head to facilitate of anterior shoulder.
 Raises head and neck to allow birth of posterior shoulder.
o Supports infant as rest of body is born quickly.
o Clamps cord.
During the third stage or placental stage there are two separate phases separation of the placenta and
placental expulsion the placenta separates from the uterine wall as the uterus contracts down causing a
shearing process as the placenta separates the maternal surface begins to bleed and facilitates the
process gentle tension on the cord may facilitate this process however strong traction is to be avoided
due to the risk of uterine inversion signs that the placenta has loosened and is ready for expulsion are
lengthening of the umbilical cord sudden gush of vaginal blood and a change in the shape of the
postpartum uterus
Stage III: Birth until delivery of placenta

Two phases of Stage III:
o Phase 1: Separation of the placenta.
o Phase 2: Expulsion of the placenta.
Phase 1: Separation of the placenta.
o As separation begins the maternal surface begins to bleed.
o Gentle tension may facilitate separation.
o AVOID strong traction.
Signs of placental separation:
o Lengthening of the umbilical cord
o Sudden gush of vaginal blood.
o Change in the shape of the postpartum uterus.
If the placenta first separates at the center then around the edges it tends to fold on itself and present it
the vaginal opening with the shiny fetal surface showing this is known as the shiny Schultz presentation if
the placenta separates at the edges first it slides along the uterine surface and appears at the introitus
with the maternal side exposed this is called a dirty Duncan presentation bleeding is a normal
occurrence with separation of the placenta when the uterus begins the involution process exposed
maternal sinuses are sealed and blood loss is minimized normal blood loss is usually less than 500
milliliters
Stage III: Birth until delivery of placenta

Phase 2: Expulsion of the placenta.
Schultze placenta
o Placenta folds on itself showing shiny fetal surface during expulsion.
o "Shiny Schultze"
Duncan placenta
o Placenta slides along uterine wall and maternal side exposed during expulsion.
o "Dirty Duncan"
Involution of the uterus begins. Normal blood loss is approximately 500 mL.
The fourth stage or first hour postpartum is one of stabilization and transition in the immediate
postpartum period monitor maternal vital signs every 15 minutes for the first hour
Stage IV: First hour postpartum

Postpartum stage:
o Stabilization
o Transition
Physical assessment:
: Assess maternal vital signs, including blood pressure and pulse, q 15 min.
o Evaluate uterine fundus for tone and position.
 Bleeding from placental site increases with uterine atony.
o Reduce risk of uterine atony by fundal assessment and massage as necessary.
Evaluate the uterine fundus for tone and position should the uterus become flaccid or atonic postpartum
blood loss is increased due to bleeding from the placental site reduce risk of uterine atony by fundal
assessment and massage as necessary the postpartum assessment can be performed and documented
using the following pneumonia breast uterus bowel bladder Nokia and episiotomy
Postpartum stage:
o Stabilization
o Transition
Physical assessment:
 Assess maternal vital signs, including blood pressure and pulse, q 15 min.
o Evaluate uterine fundus for tone and position.
o Bleeding from placental site increases with uterine atony.
o Reduce risk of uterine atony by fundal assessment and massage as necessary.
BUBBLE
Breast
Uterus
Bowel
Bladder
Lochia
Episiotomy / Laceration / C-Section
Pain in the postpartum period may occur as a result of episiotomy lacerations perineal trauma incisions
uterine contractions so-called afterbirth pains hemorrhoids breast engorgement and ****** tenderness
nursing assessment should include type and severity of pain institution of comfort measures such as ice
packs or massage position change and analgesic medication as ordered
Stage IV Pain Management

Postpartum Pain:
o Episiotomy
o Lacerations
o Perineal trauma
o Incisions
o Uterine contractions - "afterbirth pains"
o Hemorrhoids
o Breast engorgement
o Nipple tenderness
Assessment of maternal psychosocial status should be ongoing with particular emphasis on the maternal
infant relationship and family dynamics walking
Stage IV Psychosocial Assessment

o Ongoing
o Maternal-infant relationship
o Family dynamics
Determining which outcomes nurses may be held accountable for require recognition of dependent
independent and interdependent nursing activities please review the independent nursing care
functions listed on screen
Nursing outcomes based on:

o Dependent function
o Interdependent functions
o Independent functions
Independent nursing functions:
o Supportive care during labor
o Patient knowledge of labor and birth
o Postpartum care
o Newborn care
o Pain management during the perinatal period
yursing bragnose
1. Aleration in body image related to pregnancy.
2. Anxiety related to labor and birth
3. Alleration in comfort due to labor.
4. Knowiedge deficit related to normal labor process.
Anxiety related to dispanty between expected and actual birth experience.
Since labor and birth typically occur over a relatively short period outcomes must usually be met within a
12 to 18 hour period ideally expected outcomes are consistent among the provider the consumer and
the third party payers most outcomes are due to multiple factors nurses recognition of normal labor
provides a foundation for maternal support anticipatory guidance of the family and recognition of events
that may require intervention to improve maternal fetal outcome
Quality of care is measured by:

o Patient outcomes
o Quality improvement
o Clinical indicators
Quality of service is measure by:
• Patient Satisfaction
Contractions are assessed in terms of frequency intensity and duration assess contractions by gently
applying the fingertips of one hand to the maternal fundus and palpating for change muscle tone some
practitioners describe the firmness of contractions in relation to body parts nose mild contraction chin
moderate contraction and forehead firm contraction resting tone is especially important to evaluate in
women who complain of greater than expected pain or who are experiencing pharmacologically
augmented labor missus Smith's contractions are every 3 minutes lasting 60 seconds and firm
Contraction frequency:
o Time from beginning of one contraction to the beginning of the next, or from
contraction peak to peak, so long as the method is consistent.
o Expressed in terms of minutes (ie "every 3 minutes").
Contraction intensity:
o Expressed as mild, moderate, or firm.
o Mild: The fundus can be easily indented during the contraction.
o Moderate: The fundus can be slightly indented during the contraction.
Contraction duration:
• Time from the beginning of a contraction to the end of the contraction.
• Expressed in terms of seconds.
Resting tone:
Tone of the uterus in the absence of contractions or between contractions.
Expressed in terms of soft or firm.
Intermittent auscultation of fetal heart tones using a handheld Doppler is the most commonly
used approach auscultation before during and after a convection is the most reliable means of
ensuring fetal well-beingthe normal fetal heart baseline rate is between 110 to 160 beats per
minuteit is normal for the rate to vary between 5 to 25 beats per minute fetal movement will
also cause the baseline rate to momentarily increase 1520 beats before returning to baseline
a reassuring signin the absence of risk factors auscultate fetal heart rate every 30 minutes
during active labor and every 15 minutes in the second stage of Labor if risk factors are
present assessment and the active phase should occur every 15 minutes and in second stage
every 5 minuteswhen asked cultivation is the primary method of fetal surveillance during labor
a one to one nurse patient ratio is required
Intermittent Auscultation of Fetal Heart Tones

o Hand-held Doppler is the most common.
o Auscultate before, during, and after a contraction for the most reliable means of
ensuring fetal well being.
o Normal fetal heart baseline rate is between 110 and 160 beats per minute.
o Normal for the rate to vary from 5 to 25 beats per minute.
 Fetal movement may increase rate between 15 and 20 beats before returning to
baseline (a reassuring sign).
In absence of risk factors assess fetal heart rate every 30 minutes during active labor
and every 15 minutes in the second stage of labor.
If risk factor are present assess every 15 minutes during active labor and every 5
minutes in the second stage.
o If primary method of fetal surveillance during labor requires 1:1 nurse-patient ratio.
Summary although there are common theories the true impetus for labor onset is yet unknown there
are four key factors that play a vital role in normal labor and birth passenger power passage and psyche
nurses play a key role in facilitating a normal birth and providing support to the mother and her family
during the process there are four stages of Labor and birth each with a specific milestone characteristic
duration contraction pattern maternal behavior and physical sensation a nurse's recognition of normal
labor provides a foundation for maternal support anticipatory guidance of the family and recognition of
the events that may require intervention to improve maternal fetal outcome
Key Points
o Although there are common theories, the true impetus for labor onset is yet unknown.
o There are four key factors that play a vital role in normal labor and birth: passenger,
power, passage, and psyche.
o Nurses play a key role in facilitating a normal birth and providing support to the mother
and her family during the process.
o There are four stages of labor and birth, each with a specific milestone, characteristic
duration, contraction pattern, maternal behavior, and physical sensation.
o A nurse's recognition of normal labor provides a foundation for maternal support,
anticipatory guidance of the family, and recognition of the events that may require
intervention to improve maternal-fetal outcome.
Description and Objectives

Description
This case focuses on perinatal care of a primigravid patient presenting to the maternity unit at
40 weeks gestation.
Objectives
At the completion of this case, the participant will know how to:
o Assess maternal, fetal, and family physiological and behavioral responses during labor,
delivery, and the immediate postpartum period.
o Prioritize nursing interventions as determined by assessment findings.
o Intervene appropriately to promote positive outcomes for the mother, baby, and family
unit.
Kim Adler is a nurse in the labor and delivery unit of a large maternity center in a City Hospitalat 5:30 she
receives a call from Susan Nashhello my name is Susan Nash I'm in my 40th week of pregnancy and I've
been having regular contractions since 2:00 AM they're getting more intense and they're coming closer
together this is the first time I've ever been pregnant
Time: 05:30
• Telephone call from Susan Nash,
• Been having regular contractions for 3.5 hours.
• Contractions getting more intense and closer together.
• She is 40 weeks pregnant.
• Primigravida
Hence contractions that I should call the hospital I I'm having another contraction now I think I'm
definitely in laborhave you experienced any problems during your pregnancy i've had a normal
pregnancy with minor backaches some nausea early in my pregnancy and some leg cramping i haven't
had any other problems
Time: 05:30
Susan Nash reports:
• Attended prenatal classes.
• Normal pregnancy.
• Minor backaches.
• Some nausea early in the pregnancy.
• Some leg cramping.
• No other problems.
At 7:00 AM Susan and Michael presented the admitting room with the labor delivery unit the nurse
meets them to gather essential baseline data to determine susan's progress she is 40 weeks pregnant
Time: 07:00
• Onset of labor and an evaluation is now indicated
• Susan and Michael present to the labor and delivery unit.
• Begin baseline assessment.
With high risk she is now settled comfortably in her room
Time: 07:20
Initial assessment:
• Temperature: 98.2° F
• Pulse: 80/min
• Respiration rate: 20/min
• Blood pressure: 100/76 mm Hg
• Fetal heart rate: 136/min, reactive
• No knownallergies.
• Susan is low risk.
• Resting comfortably.
kim susan's nurse completes the initial assessment please review the assessment findings listed on the
screen
Initial assessment (continued):

• Fetal movement present.
- LOP, vertex presentation, at the time ischial spines, or station 0.
- Cervix: 3 cm dilated, 100% effaced, soft.
- Contractions: mild, q 8-10 min, 30 sec duration.
• Membranes intact.
- No bleeding.
Latent phase of stage one labor with contractions 8 to 10 minutes apart the nurse helps Susan identify
ways to promote optimal progress
LATENT PHASE STAGE 1
 Contractions are 8 to 10 minutes apart.

 Cervix is 3 cm dilated.
• Nurse intervenes to promote optimal progress.
At 10:00 AM after a vaginal exam the physician orders a PRN lock to be placed
intravenously in case emergency access is neededSusan is allowed clear liquids by mouth
to ensure adequate hydration
Hospital Day: Admission

Time: 10:00
o Contractions: moderate, q 6 min,
45 sec duration.
o Physician's orders:
o PRN ockfor |Vaccess
o Clearliquids
Susan has progressed to the active phase of Labor her cervix is six to seven centimeters
dilated contractions are every 5 minutes lasting 40 seconds Susan becomes increasingly
uncomfortable and is unable to cope effectively with contractions
you're doing very well with your contractions Susan you're making good progress hang in
there
Active labor:
• Cervix 6-7 cm dilated.
• Contractions: q 5 min, 40 sec duration.
•Susan uncomfortable, less effective coping.
Susan begins to breathe rapidly in response to stronger contractions she begins to

experience tingling sensation in her fingers and toes

Time: 10:00
Active labor:
•Cervix 6-7 cm dilated
Contractions: 9 5 min, 40 sec duration.
o Susan uncomfortable, breathing rapidly in response to stronger contractions.
o Experiences 'tingling sensation in fingers and toes
susan's tingling dissipates in her labor progresses normally at 11:30 AM susan's

membranes rupture

Time: 11:30
Active labor:
• Tingling sensation dissipates
Labor progresses normally.
• Spontaneous rupture of membranes.
Shortly after susan's membranes rupture the physician performs an internal examination
the cervix is now 8cm dilated Dr. Isaac informs Susan of her progress

Time: 11:45
Active labor:
• Cervix 8 cm dilated.
Contractions: strong, q 2-3 minutes, 55 sec duration.
Summary although there are common theories the true impetus for labor onset is yet
unknownthere are four key factors that play a vital role in normal labor and birth
passenger power passage and psychicnurses play a key role in facilitating a normal birth
and providing support to the mother and her family during the processthere are four
stages of Labor and birth each with a specific milestone characteristic duration
contraction pattern maternal behavior and physical sensationa nurse's recognition of
normal labor provides a foundation for maternal support anticipatory guidance of the
family and recognition of the events that may require intervention to improve maternal
fetal outcome
Susan is experiencing intense lower back discomfort through a vaginal exam the
physician determined that the occiput is still in posterior position the incidence of a
posterior position in labor is between 15 and 30%but most go unrecognized because they
rotate to the anterior position during labor

Time: 11:45
o Stage I, transitional phase.
o Susan complains of lower back discomfort.
o Occiput posterior (OP)
presentation.
Incidence of a posterior position in labor is between 15% and 30%.
At 11:45 AM Michael voice is concerned to the nurse I think something is wrong with
Susan she won't use the relaxation techniques we practiced at home Kim reassures
Michael that Susan is acting appropriately for the transitional phase of Labor
Time 11:45
Stage I, transitional phase
Michael thinks something is wrong because Susan won't practice the relaxation techniques
they
practiced at home.
It is 12 noon and Susan strong contractions continue fetal heart rate drops to 100 beats
per minute at the beginning of the contraction and returns to normal at the conclusion of
the contraction beat to beat variability is good
Time: 12:00 noon
• Stage I, transitional phase
Susan's strong contractions continue
Fetal monitor
o Fetal heart rate (FHR) 100/min with contraction, then returns to 120-140/min.
o Good beat to beat variability.
At 12:30 the nurse assesses susan's progress
At 2:00 PM with Cabot visible Susan and Michael are ready for delivery the delivery
process involves stages 2 and threeSusan delivers a full term female neonate weighing 7
lbs seven oz over a midline episiotomythis is a girl I'm so happy oh everything we have is
pink
Time: 14:00
Caput visible
Stages ll and Ill of labor.
Susan delivers a full-term female neonate weighing 7 pounds, 7 ounces.
And local anesthesiathe nurse remains with her as she begins stage 4 recuperation
Time: 13:40
Midline episiotomy repaired
• Stage IV, recuperation/recovery period.
There's performs her initial assessment for PM two hours after delivery susan's vital signs
fundus episiotomy and lokia flow are all within normal limits
One hour later Beth continues to monitor Susanduring this assessment her fundus is
boggy two finger breadths above the umbilicus and displaced to the right
Beth helps Susan walked to the bathroom and she voiced 750 milliliters the nurse helps
Susan return to bed
Susan Susan's PRN lock was discontinued after she voided the nurse reminds her to drink
fluids regularly
Hospital Day: Admission/Day of Delivery

Time: 18:00
o Fundus firm after voiding and 3 fingerbreadths below the umbilicus.
o Susan's IV discontinued.
o Encourage fluids by mouth.
it is now 24 hours after delivery the nurse assesses susan for anticipated physiological changes
The nurse recognizes the importance of helping Michael adapt to his fathering role
I'm having trouble getting the baby to nurse she seems to have a little trouble getting the ****** into
her mouth
Hospital Day: 2
Time: 09:30
Susan is having some trouble with breastfeeding.
• Unable to get nipple into infant's mouth.
And Susan and Michael for discharge the nurse offers anticipatory guidance to assist in positive
adaptation to the early postpartum period often called the 4th trimester
Susan and Michael are bonding with their daughter the nurse continues to promote bonding and
reinforce parental teaching as needed
Summary
Key Points
Accurate initial assessment of the labor patient is important in determining if the woman or
fetus is at risk, and in determining the approximate phase of labor.
Labor results in progressive changes in the uterus to allow for delivery of the fetus.
Labor is divided into the following four stages:
o Stage I'
o Latent phase: Mild contractions every 5 to 20 minutes. Cervix is 0 to 3 cm di
Red
o Active phase: Moderate to strong contractions every 3 to 5 minutes. Cervix is 4 to 7 cm
dilated.
o Transition phase: Strong contractions every 1 to 3 minutes. Cervix is 8 to 10 cm
dilated.
Stage lI
o Expulsive stage: Complete dilation and delivery of the neonate.
o Stage Ill
o Placental separation and expulsion.
o Stage IV
o Recovery or recuperation period after delivery 1 to 4 hours.
The needs of each laboring woman and couple must be recognized and respected.
Nursing interventions include:
o Ensure privacy.
o Provide thorough explanations of all procedures.
o Promote the couple's knowledge and preparedness.
o Instill confidence.
Ongoing assessment of the labor process is important for the following reasons:
o Assure the mother's ability to cope with uterine contractions.
o Assure efficiency of the contractions.
o Monitor fetus well being by its fetal heart rate (FHR) pattern.
o Allow time to prepare for the impending birth.
Immediate assessment of the mother and newborn following delivery should focus on:
o Vital signs of the mother.
o Assessment of vaginal bleeding and fundal firmness.
o Assessment of the newborn using the Apgar score.
o Enhancing maternal and paternal attachment.
Postpartum care to enhance family bonding and a smooth transition to home should include:
o Continued monitoring of the mother's physiologic changes including uterine involution,
bleeding pattern, and breast changes.
Assessment of the newborn.
o Education and emotional support for the parents
Listed here are the average and upper limit time frames during the first and second stages of
Labornote that for prima gravitas in the active phase cervical dilation less than 1.2cm per hour
is abnormalin multiple areas cervical dilation less than 1.5cm per hour is abnormal during the
active phase
The primary causes of prolonged labor are fetal pelvic disproportion malpresentation and
malposition and ineffective uterine contractionsadditional factors include prima gravitic
pregnancy rupture of membranes before cervical ripening and excessive analgesia or
anesthesiaduring this program we will address each of these factors in the context of Labor
and birth
In most cases it is impossible to predict the ability of a woman to have a vaginal birth prior to
onset of Laborhormonally induced pelvic relaxation and soft tissue changes can have a
profound impact in preparing the birth canal to accommodate the transit of a term
newbornthere are however certain pre-existing conditions that lend themselves to facilitating
or impeding this process there are four primary maternal pelvic shapes
please review the types and their characteristics listed on screen
Passage or Birth Canal

Hormones and soft tissue changes influence the birth canal.
The Four Primary Maternal Pelvic Types
Android - "male" pelvis:
o Acute angle at arch
o Narrow outlet
Anthropoid - "apelike" pelvis:
• Narrow transverse diameter
Gynecoid - "normal" female pelvis:
o Rounded inlet
o Wide pubic arch
Platypelloid - "flattened" pelvis:
• Anterior-posterior diameter is short
to fit through the birth canal the vertex the most common presenting part must enter into the
pelvisThe diameter fits into the smaller pelvic opening and the widest fetal head diameter fits
into the widest area of the pelvis if this does not occur descent of the presenting part may
become obstructedadditionally the fetus may present in a non vertex manner such as breech
or transverse lie these male presentations introduce an entirely new set of mechanics and
challenges that must occur for birth to take place typically the laborand the presenting part
station from minus
Descent Through the Birth Canal

Vertex is the most common presenting part (first into the birth canal) in childbirth.
The smallest head diameter must fit into the smaller pelvic opening, and the widest fetal head
diameter fits into the widest area of the pelvis
Malposition: If not positioned properly, descent may be obstructed.
Malpresentation: If not vertex presentation (eg, breech or transverse), malpresentation
introduces
additional challenges to vaginal birth
• Typical labor graph: Cervical dilatation from 1 to 10 cm on the left and presenting part
station from -4 to -4 on the right.
The uterine musculature is the primary power source for labor the focal point of this power is
the uterine fundus each uterine contraction originates at the fundus and extends downward in
a wave like fashion causing the lower uterine segment to thinas the fundal area becomes
increasingly thickerin this graphic notice how the upper uterine segment is becoming thicker
and the lower uterine segment is thinninga disingenuous contraction pattern or weak
contractions may result in insufficient power for cervical dilation and fetal descent
Power Source for Labor

Uterine musculature
Uterine contraction originates at the fundus
Dyssynchronous contraction pattern or weak contractions may result in insufficient power for
cervical dilatation and fetal descent
The latent phase is primarily a time of preparationin prima Paris women this is the time when the cervix
will completely efface if it is not already done so and begin to dilate it is not unusual for multigravida
women to skip this phase altogetheror perhaps some simply overlook it or perceive this time as an
episode of Braxton Hicks contractionswhen the latent phase lasts longer than 20 hours in a primigravida
or 14 hours in a multi para the latent phase is considered prolonged
Prolonged Latent Phase of Stage I

o Effacement
o Typical duration
o Multipara: 5 h
o Prolonged latent phase
Primigravida: >20 h
Multipare: >14 h
Common causes of prolonged latent phase are listed on screenalthough a prolonged latent phase may
be worrisome or tiring it represents no acute danger to the mother or the fetus
Causes of prolonged latent phase:

o Unripe cervix
o Abnormal fetal position
o Fetopelvic disproportion
o Dysfunctional labor
o Excessive sedation
Prolonged latent phase presents no acute danger to mother or fetus.
During the active phase the principal work of dilating the cervix is accomplished for both prima paras
and multigravida women it is very clear that labor has arrivedthe active phase is sometimes called the
phase of maximum slope because cervical dilation proceeds at the most rapid pace during this
timeduring the phase of maximum slopethe cervix may dilate 3.5 centimeters per hour in prima gravitas
and up to 9 centimeters per hour in multiple paras
Prolonged Active Phase of Stage I: "Phase of Maximum Slope"

o Contractions:
o Moderate to strong
o Regular, q2 to 5 min
o Last 1 min
o Rate of cervical dilation:
o Primigravida: 3.5 cm/h
o Multipara: 9 cm/h
In prima gravida women an active phase lasting longer than 12 hours is abnormal cervical dilation at a
rate of less than 1.2cm per hour is an indication of some abnormality and assessment is
necessaryprolonged active phase may occur due to malposition of the fetus fetal pelvic
disproportionexcessive analgesia or premature rupture of membranesprolonged active phase may be
further divided into two main categories primary dysfunctional labor and secondary arrest of dilation
Prolonged Primigravida Active Phase(duration: >12 h)

Abnormal cervical dilation rate:
• Less than 1.2 cm/h
Causes of prolonged active phase:
o Malposition of the fetus
o Excessive or prematurely administered analgesia or sedation
o Premature rupture of membranes
Two categories of prolonged active phase:
o Primary dysfunctional labor
 Secondary arrest of dilatation
Primary dysfunctional labor is slow but with steady cervical dilation where the rate of dilation is less than
1.2cm per hour little can be done to speed up progress if contractions are adequate slow progression is
acceptable as long as the mother and fetus are healthy2/3 of these women will go on to deliver
normally20% require forcepsand 10% will likely have a cesarean sectionprimary dysfunctional labor is
best depicted on the Friedman curve shown here
Prolonged Active Phase of Stage II

Primary dysfunctional labor
o Slow, but steady cervical dilatation
o 70% vaginal birth
o 20% forceps
o 10% C-section
When progressive cervical dilation stops during active phase it is known as secondary arrest of dilation
on the Friedman curve this is visualized as a flat line two hours without cervical change as diagnostic
there are two potential causes of this condition insufficient uterine contractions and failure of the cervix
to dilate despite strong efficient contractions when secondary arrest is encountered care must be taken
to rule out mechanical factors such as malpresentation or position corrective action frequently includes
means of enhancing insufficient contraction strength or frequency
Prolonged Primigravida Active Phase

Secondary arrest of dilatation:
o Arrest of cervical dilatation
o Insufficient contractions
o Cervical stenosis
R/O mechanical factors:
o Malpresentation
o Malposition
Treatment:
• Enhance contraction strength or frequency.
Click and drag a check mark to the true statements
Prolonged active phase in multiparous women is recognized as lasting over six hours or a cervical dilation
rate of less than 1.5cm per hourwhen compared to primigravida women prolonged active phase and
multiple pairs is relatively uncommon and occurs in less than 1% of birthswhen prolonged active face
occurs in multiple areas it is often due to fetal macrosomia or malpresentation
it carries a higher risk of cord prolapse or postpartum hemorrhage C-section rate for multipliers is 25%
Prolonged Multipara Active Phase (duration: >6 h)

Abnormal cervical dilation rate:
- Less than 1.5 cm/h
Prolonged active phase in multipara:
o Relatively uncommon
o Likely due to fetal macrosomia or malpresentation
 Carries a higher risk of cord prolapse
o Carries a higher risk of postpartum hemorrhage
o Cesarean section rate is 25%
During active phase descent of the presenting part usually the vertex should advance progressively until
birth is imminent if the presenting part does not advance over a 2 hour.The provider should suspect fetal
pelvic disproportion or insufficient contractions
Descent of the presenting part, usually the vertex, should advance progressively until birth is
imminent.
If no progress over 2 hours, suspect:
o Insufficient contrections
once the cervix is fully dilated the primary goal of the second stage is passage of the fetus through the
birth canal failure of dissent may occur due to fetal pelvic disproportion malpresentation and
malposition and ineffective uterine contractions
Prolonged Stage Il
Primary causes:
o Fetopelvic disproportion (disproportion between the fetus and the pelvis)
o Malpresentation and malposition
Ineffective uterine power (contractions)
Some experts divide the second stage into two phases the first is from full cervical dilation to
spontaneous bearing down the second phase is from the onset of vigorous and spontaneous bearing
down efforts until birthsome women have actually been observed to take an hour long nap after full
cervical dilation prior to the onset of spontaneous bearing down efforts it's important to remember this
physiologic rest period and not rush the woman into the active pushing phase prematurely
The two phases of Stage Il:

o Full cervical dilatation to spontaneous bearing down.
 Onset of vigorous and spontaneous bearing down until birth.
Remember:
o "Physiologic rest period" may occur.
 Do not rush the woman into the active pushing phase prematurely.
the term dysfunctional labor may be used to describe any contraction pattern that is ineffective in
producing progress toward birthineffective uterine force can be a factor during any stage of Labor
uterine contractions are required to both dilate the cervix and move the fetus through the birth canal
inertia is a term used to describe sluggish or poor contraction stRength
Dysfunctional Labor
Contraction patterns, such as hypotonic contractions, that are ineffective in producing
progress
toward birth
Aterineinaria is termused to describe poor contraction strength.
Hypotonic uterine contractions are usually weak and infrequentthey are more likely to occur during the
active phase of Labor when analgesia or anesthesia is administered early in labor when bowel or bladder
distension prevent optimal engagementover distension of the uterus due to multiple gestation or
polyhydramnioshypotonic uterine contractions are usually not perceived as painful
Hypotonic Contractions
- Weak, infrequent
During active phase
- Untimely analgesia/anesthesia
: Ortrdtensore ters hute setaten
polyhydramnios
Hypertonic uterine contractions occur when the uterus does not relax completely between
contractionsthe uterine muscle tone remains elevated during the resting phase however the intensity of
the specific contractions is usually not affectedhypertonic contractions tend to occur frequently and are
most common during the latent phase of Laborthese contractions tend to be perceived as painfuluterine
muscle fibers known as the myometrium do not repolarize after a contraction probably because they're
stimulated by more than one pacemaker this constant muscle tension inhibits uterine artery filling which
may lead to decreased perfusion to the fetus
Hypertonic Contractions
o Uterine muscle tone elevated during resting phase
o Most often during latent phase
o Painful
o Over-stimulation of myometrium
o Fetal hypoxia due to decreased perfusion
o May respond to sedation
Women in prolonged latent phase may benefit from a medication induced respite to relieve a
dysfunctional early labor pattern in essence a low dose of medication such as nembutal may be
administered to produce a sedative hypnotic effectthe purpose of this respite is to rest the myometrium
essentially eliminate contractions and allow the woman to rest or even sleepsedation during latent
phase is an effective means of wiping out the stimulation of multiple pacemakers much like
cardioversion works to resynchronize the heart during fibrillationwhen the medication effects subside
the myometrial irritability will either be gone as with false labor or the woman will awake refreshed and
in a more synchronous contraction pattern
Strategies to Treat Dysfunctional Labor

Medication-induced respite during latent phase:
o Low dose sedative hypnotic (such as Nembutal)
o Rest the myometrium
o Allow rest or sleep
When effects subside:
o Woman refreshed
o More synchronous contraction pattern
Please review the electronic fetal monitor tracings on screen that demonstrate uterine force
Timing of vital signs depends on the maternal and fetal status and stage of Labor it is important to note
that the time frames mentioned are the minimal guidelines and the maternal fetal status may dictate
more frequent evaluationcollectively this information helps identify risks for pregnancy complications
and any underlying disease processesin women who have prolonged labor vital signs are especially
important to identify maternal or fetal compromise
Assessment of Prolonged Labor

Vital signs help identify maternal or fetal compromise.
Maternal vital signs:
• Blood pressure, pulse, respiration, and temperature
• Uterine contraction pattern
• Fetal heart rate
• Obtain and document every 4 hours or less
Fetal heart rate (in absence of risk factors):
• During active phase of labor, every 30 minutes.
• During second stage, every 15 minutes.
Oral intake during labor remains controversial in the United states in cases of prolonged labor however it
is logical to consider supplementation of hydration status through the use of intravenous
fluidsadditionally the energy needs of laboring women have been compared to those of a marathon
runner supplemental oral or intravenous glucose may be beneficialthe volume may be less important
than the quality of the intakeinstitutional policy will likely govern oral and parenteral intake during labor
in active labor urinary output is especially important it gets important clues to hydration status and a
distended bladder can impede descent of the fetus down the birth canal

Hydration and energy needs:
• Consider supplementation with IV fluids.
Supplemental oral or IV glucose may be beneficial.
• Follow institutional policy regarding oral and parenteral intake during labor.

Urinary output:
• Helps evaluate hydration status.
• Distended bladder can impede descent of fetus down the birth canal.
electronic fetal monitoring is a commonly used means of evaluating labor progress and fetal well-being
during labor it can be used to monitor both uterine contractions and fetal heart rate either continuously
or intermittently monitoring can also be accomplished through external or internal meansusing an
external approach sensors are placed on the maternal abdomen to transmit tension from the uterine
muscle and to document the fetal heart rate

Electronic fetal monitoring:
• External
Internal
Evaluates labor progress by monitoring:
• Fetal well being
• Uterine contractions
• Fetal heart rate
In situations such as prolonged labor were a more exact measurement of fetal heart rate and contraction
as necessary internal electronic fetal monitoring may be usedin order to monitor in this manner the
amniotic membranes must be ruptured using this approach a fluid filled catheter is inserted into the
uterine cavity through the cervix in this manner the contraction tracing is accurate in terms of frequency
duration and intensity with emphasis on intensityintensity is expressed in terms of millimeters of
mercury much like a blood pressure internal uterine monitoring is also useful for accurately documenting
uterine resting tone between contractionsthe fetal heart rate can be documented internally by means of
a fetal electrodein this manner the beats per minute are documented and the tracing is reliable for
documentation of fetal heart rate variability fetal heart rate variability reflects variation in the beats per
minute over timenormally this variation is between 5 to 25 beats per minute and is considered a reliable
indicator of fetal well-being
in this tracing the fetal heart rate is between 120 and 160 beats per minute and shows excellent
variability the contractions are every 2 1/2 to 3 minutes lasting 60 seconds and are 60 millimetres of
mercury in intensity above 50 is considered moderate to strongthe uterine resting tone is 10 to 20mm of
mercury which is normal

Internal electronic fetal monitoring:
• Provides more exact measurement of fetal heart rate and contractions.
• Amniotic membranes must be ruptured.
• Reliable documentation of fetal heart rate variability
additional means of assessing fetal well-being are listed on screen
mechanisms to stimulate labor may be as simple as assisting with ambulation to sophisticated measures
such as administration of intravenous oxytocinvolumes of medical research support specific maternal
activities to enhance labor progress these findings are listed on screenin the past care providers would
attempt to stimulate labor through the use of enema preparations during early labor this practice is no
longer common largely due to patient discomfort and the unpredictable impact on labor******
stimulation may also be effective for some womenthis stimulation causes release of endogenous
oxytocin and may enhance contractions
manipulation of the amniotic membrane such as stripping or artificial rupture may sometimes be
employed to stimulate contractions stripping or sweeping the membranes requires the cervix be dilated
sufficientlyto allow a finger to be introduced into the cervical OSS and separate the membrane from the
internal surface of the cervix in a 360 degree fashionin this manner the membranes are not ruptured
merely separated it is theorized that this mechanism is effective because it stimulates the release of
prostaglandin and oxytocinrisks include the potential for infectionunplanned rupture of the membranes
hemorrhage due to undiagnosed placenta previa and precipitous labor and birthlittle research is
available on the effectiveness of this maneuver
artificial rupture of the membranes or amniotomy may also stimulate the release of prostaglandin and
oxytocin thereby increasing contractions amniotomy is accomplished by puncturing the membrane
during a vaginal examinationrisks include infection
cord prolapse fetal injury bleeding from an undiagnosed placenta previa compression of the umbilical
cord during labor and precipitous labor and birth some data does exist regarding the efficacy of
amniotomy
oxytocin is the most commonly used pharmacological means of augmenting laborsynthetic oxytocin is
identical to endogenous oxytocinreceptors within the myometrium respond to oxytocin in the
bloodstream causing contraction of the uterine muscleoxytocin must be judiciously administered
according to strict protocols that define fetal and uterine monitoring techniques and safety measures
aimed at minimizing the potential for overstimulationoxytocin is administered intravenously at specified
rates for specific intervals according to institutional protocolsnursing judgment at the bedside is
imperative when administering this medication to ensure that hyperstimulation is avoidedhypertonic
contractions from oxytocin overdose can lead to uterine rupture and fetal compromise or deathbecause
of these risks the care provider should ensure that the benefit of the administration clearly outweighs
the risks
in certain controlled situations cervical ripening agents such as misoprostol may be used for
augmentation of Labor during the latent phase use of these products for augmentation of Labor
constitutes an off label indicationthese products are inserted near the cervix and appear to act locally to
soften the cervix and cause uterine contractions
because of the risk of hyperstimulation and the limited means of controlling absorption these agents
should be employed only and carefully monitored situations where the benefit clearly outweighs the risk
and never in combination with other means of augmentation
augmentation of Labor is contraindicated when there is fetal pelvic disproportion or pelvic deformities
plus center or vasa previa or umbilical cord compression
Curative vaginal birth is a term that encompasses the use of forceps and vacuum devices to facilitate
descent during second stage approximately 15% of all births are assisted in this manner
the caesarean birth rate remains relatively constant at one in every four to five births the most common
indications for cesarean birth according to birth certificate documentationon maternal medical
complicationscomplications of Labordystociabreach or malpresentationcephalopelvic disproportion and
placenta previa
note that these complications of Labor indications for C-section are all related to protracted labor in
some waynursing care can have a considerable impact in this area in many instances
Maternal pain control can play a significant role in labor progress pain management options exist along a
continuum from noninvasive to invasive and non pharmacologic to pharmacologic options should be
calibrated to manage the woman's pain without interrupting laboror causing harm to the maternal fetal
unit
Normal Tracing
Characteristics:
• Fetal heart rate: 120 to 160/ min
• Excellent variability
• Contractions q 2.5 to 3 min
• Duration: 60 sec
• Intensity: 60 mm Hg (»50 mm Hg is considered moderate to strong)
• Uterine resting tone: 10 to 20 mm Hg (within normal limits)
physiological responses to pain have been shown to negatively impact labor progresscatecholamine
excess can also lengthen labor by decreasing contraction strength duration and coordinationby helping
to manage labor pain nurses can positively affect birth outcomes not only by improving patient
satisfaction but in terms of length of Labor as well as maternal fetal outcomes
Physiological responses to pain impedes labor progress.

By helping to manage labor pain, nurses can positively affect:
• Birth outcomes
Patient satisfaction
• Length of labor
Maternal-fetal outcomes
maternal psyche can have a huge impact on the progress of Labor women with a strong self esteem and
a good relationship with their support person have a distinct advantage in terms of Labor progress
conversely there are reports of women holding back or holding in during labor therebyunconsciously
prolonging the processwomen who have a history of abuse especially intimate partner or sexual abuse
are at highest risk for this complication
Maternal psyche influences progress of labor.

• Strong self-esteem and good relationship have advantage during labor.
• Women with a history of abuse are at highest risk for prolonged labor.
adverse effects of prolonged labor can occur in both the mother and newborn
Potential Adverse Effects of Prolonged Labor

Maternal:
• Uterine atony
• Lacerations
• Hemorrhage
• Infection
• Exhaustion
• Shock
• Increased risk of operative birth.
Neonatal:
• Asphyxia
• Cerebral hemorrhage
• Injury related to operative birth.
• Infection
Macrosomia
Fetus weighs >4500 grams
Predisposing factors include:
• Multiparity
• Maternal age: >35 yearsold
Tall women: >170 centimeters
• Prepregnant weight >70 kg
• Weight gain: >20kg during pregnancy
• Maternal diabetes
Macrosomia in previous pregnancy
• Delivery: 27 days post-term
• Two-thirds of macrosomic infants are male.
Too large for any pelvisbut the most important question is can this baby pass through this pelvisby
definition macrosomia is present when a fetus weighs 4500 grams or moreapproximately 1% of all births
involve macrosomic infants
Labor in the presence of fetal macrosomia:

• Usually cephalic presentation.
• Prolonged second stage.
Risk associated with fetal macrosomia:
• Risk for shoulder dystocia (obstetrical emergency)
Forceps-assisted birth.
• Neonatal birth trauma.
• Cesarean section birth.
• Lacerations of the genital tract.
• Postpartum hemorrhage.
• Separation of the symphysis pubis.
• Increased infant morbidity and mortality.
in most cases macrosomic infants have a cephalic presentationthe total length of Labor may not be
prolonged but the second stage usually is protractedonce the second stage nears an end birth of the
head may lead to an obstetrical emergency that of shoulder dystocia where the anterior fetal shoulder
becomes lodged behind the maternal synthesis pubisadditional risks are listed on screen
Suspected Macrosomia
Nursing actions:
Closely supervise labor; paying special attention to duration of second stage
• Monitor maternal and fetal well being, especially fetal heart rate
• Anticipate need for infant resuscitation.
• Evaluate for presence of caput succedaneum during vaginal exam, especially it it
occurs above 0 station.
• Anticipate nsed for intervention due to shoulder dystocia.
Stagethe potential for postpartum hemorrhage is present because the overly distended myometrium is
less able to contract and limit postpartum blood loss the perinatal mortality risk for larger infants is
substantially increased at 15% versus the typical risk of 4%even if macrosomia is suspected during the
antenatal. Most women will be allowed a trial of Laborplease review the nursing actions listed on screen
Shoulder Dystocia
Nursing actions:
• Call for additional help with the birth
• Work with the birth attendant quickly to perform maneuvers to assist birth.
• Perform duties in a calm, supportive manner.
• Anticipate, Anticipate, Anticipate: especially if gentle traction and adequate
episiotomy fail to achieve birth.
• AVOID fundal pressure.
Now let's return to the main program.
should shoulder dystocia occur the nurse will ensure the best possible outcomes by working in a
coordinated fashion with the birth care teamreview the nursing actions listed on screen Compaction of
the anterior shoulder into the synthesis pubisfundal pressure has been shown to increase the fetal injury
rate by 77% when it was the only maneuver used to relieve shoulder dystocia
fetal pelvic disproportion may result due to problems with pelvic size and shape and fetal size position
and presentation
Pelvic disproportion
Causes:
• Pelvicsize
• Pelvicshape
• Macrosomic fetal size
• Fetal attitude and position
• Moldability of the presenting part
• Fetal abnormality
ineffective uterine force can be a factor during any stage of Labor effective uterine contractions are
required to both dilate the cervix and move the fetus through the birth canalinertia is a term used to
describe sluggish or poor contraction strengthdysfunctional labor may be used to describe any
contraction pattern that is ineffective in producing progress toward birth
Dysfunctional Labor
• Contraction pattern that is ineffective in producing progress toward birth.
• May occur at any stage of labor.
Causes:
• Hypotonic contractions
Hypertonic contractions
• "Uterine inertia" is term used to describe poor contraction strength.
Peter Chamberlain invented obstetric forceps at the beginning of the 17th century the primary purpose
of forceps is to facilitate birth of the fetal head when a woman is unable to expel the fetus
independentlythe fetus is in danger or there is some urgency to accomplish the birthcertain
prerequisites must be met in order to use forceps safely
Conditions and prerequisites for forceps use:

• Adequate pelvis
• Fetal head engaged
• Cervix completely dilated
• Accurate diagnoses of position and station
• Membranes ruptured
• Bladder and rectum empty
•Good maternal positioning
• Anesthesia usually required
usually an episiotomy is performed nursing action should be targeted toward ensuring maternal and
fetal well-being during forceps birth by assisting the woman with positioning monitoring fetal heart rate
ensuring that the bladder is empty and assessing the newborn for trauma after birth
Nursing actions in the use of forceps:

• Quickly and calmly reinforce information by the birth attendant concerning the
use of forceps.
• Assist the woman with proper positioning.
• Monitor fetal heart rate.
• Ensure that the bladder is empty.
• Assess the neonate for birth trauma.
some physicians use vacuum extraction in place of forceps currently approximately 10% of births in the
United states are vacuum assistedin 1964 James young used a glass suction device to assist in the birth
of the fetal headtoday's vacuum extractor consists of a silastic cup that is placed on the fetal head within
the birth canal and gradually suction is applied until a seal is formedgentle traction is used to deliver the
fetal head indications conditions and prerequisites are same As for forcepsusually vacuum extraction
reduces need for anesthesia and reduces risk of maternal and neonatal injuries
Vacuum Extractor Devices

Indications, conditions and prerequisites for use are the same as for forceps.
Vacuum extractor use:
• Requires less anesthesia.
• Reduces maternal soft tissue injury.
• Reduces neonatal injuries.
Guidelines:
• 500 mg Hg pressure limit for suction.
Limit of 3 pop-offs or 20 minutes total application time Traction should be used
only when woman is pushing.
• Progress in descent should accompany each traction attempt.
Summary
Key Points
Nursing care can have a tremendous positive impact on labor outcomes in
situations where the nurse can:
• Recognize protracted first stage latent and active phases of labor, and initiate
appropriate nursing interventions for
• Recognize prolonged second stage of labor, and initiate appropriate nursing
interventions.
• Identify nursing actions to minimize the risk of prolonged labor.
• Identify nursing actions to facilitate labor.
• Identify steps to promote maternal and fetal well being in the presence of
prolonged labor.
• Nurses can play a key role in facilitating labor for most women.
• For each stage and phase of labor, there are well-established time parameters for
primigravid and multiparous women.
• Many factors that prolong labor can be prevented or corrected.
Excessive or insufficient pain management may result in prolonged labor.
• Nonpharmacological and pharmacological means may be employed to stimulate
labor.
• Operative interventions may be required to facilitate birth.
• Recognition of normal labor is vital to identification and assessment of prolonged
labor etiologies and the enactment of necessary intervention.

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MCN EL FINALS

Preparation for Labor

Preparation for Labor:

Click on the cards to match the corresponding pairs

Determining the "Due date"

Due date is based on gestational age:

Passage or Birth Canal

Power Source for Labor:

Maternal history of abuse presents special challenges to health care providers.

Stages of Labor and Birth

Assessments for risk/complications:

Stage I: Latent Phase

Stage I, Active Phase: "Phase of Maximum Slope"

Stage I Pharmacologic Pain Management

Stage I, Transition Phase

Stage | Assessment (continued)

Stage II: Full cervical dilatation to birth

Stage II: Full cervical dilatation to birth

Coaching during Stage II

Positioning during Stage Il

Positioning during Stage Il

Stage II: Birth

Stage II: Birth

Stage III: Birth until delivery of placenta

Stage III: Birth until delivery of placenta

Stage IV: First hour postpartum

Stage IV Pain Management

Stage IV Psychosocial Assessment

Nursing outcomes based on:

Quality of care is measured by:

Intermittent Auscultation of Fetal Heart Tones

Description and Objectives

With high risk she is now settled comfortably in her room

Initial assessment (continued):

LATENT PHASE STAGE 1

 Contractions are 8 to 10 minutes apart.

Hospital Day: Admission

Susan begins to breathe rapidly in response to stronger contractions she begins to

Hospital Day: Admission

susan's tingling dissipates in her labor progresses normally at 11:30 AM susan's

Hospital Day: Admission

Hospital Day: Admission

Hospital Day: Admission

At 12:30 the nurse assesses susan's progress

Hospital Day: Admission/Day of Delivery

please review the types and their characteristics listed on screen

Passage or Birth Canal

Descent Through the Birth Canal

Power Source for Labor

Prolonged Latent Phase of Stage I

Causes of prolonged latent phase:

Prolonged Active Phase of Stage I: "Phase of Maximum Slope"

Prolonged Primigravida Active Phase(duration: >12 h)

Prolonged Active Phase of Stage II

Prolonged Primigravida Active Phase

Click and drag a check mark to the true statements

Prolonged Multipara Active Phase (duration: >6 h)

The two phases of Stage Il:

Strategies to Treat Dysfunctional Labor

Assessment of Prolonged Labor

Assessment of Prolonged Labor

Assessment of Prolonged Labor

Assessment of Prolonged Labor