Poweruterine contractionsmaternal pushing Passagebony boundaries of pelvissoftening of cartilage linking pelvic bones Passengerlie attitude presentation occiput brow, face shoulder sacrumposition – LOA,ROP Psych L&D- the P’s of Labor
POWER Uterine muscle layers. Muscle fiber placement.
PASSAGE Pelvic types: gynecoid, android, anthropoid, platypelloid
PASSENGER Typical anteroposterior diameters of the fetal skull.
LIE • The relationship of the long axis of the fetus to the long axis of the woman • 99% the lie is longitudinal and parallel • Transverse lie – fetus is at right angle to mother Transverse lie - uncommon
ATTITUDE Fetal attitude is the relationship of fetal body parts to itself. Flexion is normal flexed extension
PRESENTATION The fetal part that first enters the pelvis Cephalic Vertex presentation. Breech presentation.
Cephalic presentations Occiput/vertex Brow Face Military
Breech presentations Full Breech Frank Breech Footling Breech
Position • Fetal position describes the location of a fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvis • Abbreviations of presenting part is “cuddled” between maternal pelvis • LOA, LOP, ROA, ROP, RSA, LMP • Occiput, Sacrum, Mentum (chin), Anterior, Posterior
A B C D Quiz
PSYCHE • Preparation and information • Anxiety and fear decrease coping • Culture affects views • Both physical and emotional experience • Do not “nurse the machines”
HistoryAntepartal weight gain fetal gest & growth risk factors present status Obstetrical Medical surgical interval Assessmentmaternal vital signs uterine activity bladder status I&O bloody show response to labor maternal discomfortfetal heart rate Amniotic fluid L&D nursing responsibilities
L&D Leopold’s maneuvers • Palpate upper abdomen • Palpate opposite side in circular motion for fetal extremities • Palpate for engagement of presenting part • Palpate to identify cephalic prominence
Palpate position of head – determine descent & flexion
Electronic fetal monitoring by external technique. The tocodynamometer (“toco”) is placed over the uterine fundus. The ultrasound device is placed over the area of the fetal back.
Intrapartum Fetal Assessment • Fetal Heart Rate • Electronic Fetal Monitoringultrasound transducer • Response to contractionstocotransducer • Internal fetal monitoring – RBOW fetal scalp electrodeintrauterine pressure catheters (IUPC)
Fetal Heart Rate Patterns • Tachycardia – greater than 160 for 10 min • Bradycardia – less than 110 for 10 min • Absent or minimal beat-to-beat variability • Early decelerations – head compression • Late decelerations – uterine placenta insufficiency • Variable decelerations – cord compression
A B Comparison of labor patterns. A) Normal uterine contraction pattern. B) Hypotonic uterine contraction pattern..
Types and characteristics of early, late, and variable decelerations.
EarlyContinue to observe LateStop oxytocinReplace fluidsChange mother’s positionCheck B/P and PulseAdminister oxygenNotify physician VariableStop oxytocinReplace IV fluidsChange mothers positionCheck for prolapsed cordCheck B/P and PulseAdminister oxygenNotify the physicianPrepare to assist with fetal scalp blood sample Nursing Interventions for Decelerations
Conditions Associated with Fetal Compromise • FHR below 100 or above 160 • Amniotic fluid Meconium-stained (greenish) Cloudy, yellowish, or foul-smelling • Contractionslasting longer than 90 secondsoccurring less than 2 minutes apart • Maternal hypotension, hypertension, fever
Actions to increase oxygen to fetus • If receiving Pitocin stop or slow rate • Reposition mother • Increase non-additive IV fluids • Administer 100% oxygen thru snug face mask to mother at rate of 8-10 liters/min • Keep mothers bladder empty • Change under-pads regularly
True labor contractions: Start in back & move wavelike toward abdomen Become more intense with walking Result in ripening of cervix, dilation & effacement False labor contractions:Noticed primarily in abdomenBegin & remain consistentDisappear with walkingNo change in cervical dilation or effacement L & D true vs false labor
To gauge cervical dilatation, the nurse place the index and middle fingers against the cervix and determines the size of the opening.
Mechanism of Labor • Engagement / Decent • Flexion • Internal rotation • Extension • Restitution • External rotation • Expulsion
Stage Icervical dilation to 10 cm &effacement to 100%early/latentactivetransition Stage IIcrowning to birth of baby Stage IIIbirth of baby to delivery of placenta Stage IV1-4 hours after delivery of placentastabilizationrecovery Stages of Labor
Phases of Stage I of Labor • Early/latent - dilates - 0-3 cm contractions q 5 min X 30-40 sec • Active - dilates – 4 - 7 cm contractions q 2-5 min X 40-60 sec • Transition- dilates – 8-10 cm contractions q 2-3 min apart X 60-90 sec
Effacement of the cervix in the primigravida. Beginning of labor. There is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid.
Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head.
Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic fluid exerts hydrostatic pressure.
Complete effacement and dilatation. End of Stage 1
Friedman Curve Predicable progression of labor for Nulliparous and Multiparous
Responsibilities during First Stage of Labor • Promote Comfort positioning, lightingtemperature, cleanlinessbladder, mouth care • Relieve painbreathing techniquesnonpharmacologic massage, touch, pressure hydrotherapy imagery or focal point
Stage 2From 10cm 100% to birth of Baby • Assist mother with pushing • Preparation of sterile delivery table • Perineal cleansing • Sutures for episiotomy or laceration • Initial care and assessment of newborn • APGAR
Care of Infant • Maintaining cardiopulmonary function – APGAR • Supporting thermoregulation • Identifying infant • Examining for obvious anomalies and birth injuries • Medication administration