Labor-and-Delivery-Maternal Lab and Lecppt.pptx

maternal

1. Labor and Delivery

2. Labor is the series of events by which the products of conception are expelled from the woman’s body. The terms childbirth, encouchment , confinement, parturition, and travail are all synonyms for labor. Labor is an apt term because a great deal of work is involved in the process of birth. For the woman and the fetus alike it is a time of change, both a time of ending and a time for beginning.

3. A. THE FETAL SKULL Importance: From an obstetrical point of view the fetal skull is the most important part of the fetus because it is the : Largest part of the body Most frequent presenting part Least compressible of all parts Once the head has been born, the birth of the rest of the body is rarely delayed.

4. Three major parts of the fetal skull : The face The base of the skull (cranium) Vault of the cranium (roof)

5. Cranial bones: the first 3 are not important because they lie at the base of the cranium and, therefore, are never the presenting parts. 1. sphenoid - 1 4. frontal - 2 2. ethmoid - 1 5. occipital - 1 3. temporal - 2 6. parietal - 2

6. These bones are not fused, allowing this portion of the head to adjust in shape as the presenting parts passes through the narrow portions of the pelvis. The cranial bones overlap under pressure of the powers of labor and the demands of the underlying pelvis. The overlapping is called molding.

7. Membrane spaces: Suture lines are important because they allow the bones to move and overlap, changing the shape of the fetal head in order to fit through the birth canal, a process called molding . 1. Sagittal suture line – the membranous interspace which joins the parietal bones. 2. Coronal suture line – the membranous interspace which joins the frontal bone and the parietal bones. 3. Lamboid suture line – the membranous interspace which joins the occiput and parietals

8. Fontanels: membrane covered spaces at the junction of the main suture lines. 1. Anterior fontanel – the larger, diamond- shaped fontanel which closes between 12-18 months in an infant. 2. Posterior fontanel – the smaller, triangular shaped fontanel which closes between 2-3 months in the infant.

9. Measurements: the shape of the fetal skull causes it to be wider in its anteroposterior (AP) diameter than in its transverse diameter. 1. Transverse diameters of the fetal skull - biparietal = 9.25 cm. - bitemporal = 8 cm. - bimastoid =7cm

10. 2. Anteroposterior diameters - suboccipitobregmatic (A) – from below the occiput to the anterior fontanel = 9.5 cm. (the narrowest AP diameter) - occipitofrontal (B) – from the occiput to the mid-frontal bone = 12 cm. - occipitomental © - from the occiput to the chin = 13.5 (the widest AP diameter.)

11.  B. THEORIES OF LABOR ONSET Labor normally begins when the fetus is sufficiently mature to cope with extra-uterine life yet not to large to cause mechanical difficulties in delivery. However, the trigger that converts the random painless contractions into strong, coordinated, productive labor contractions is unknown. A number of theories have been proposed to explain why labor begins. These includes:

12. 1. Uterine stretch theory – any hollow body organ when stretched to capacity will necessary contract and empty. 2. Oxytocin theory – labor, being considered a stressful event, stimulates the hypophysis to produce oxytocin from to posterior pituitary gland. Oxytocin causes transaction of the smooth muscles of the body. E.g., uterine muscles. 3. Progesterone deprivation theory – progesterone, being the hormone designed to promote pregnancy, is believed to inhibit uterine motility. Thus, if its amount decreases, labor pains occur.

13. 4. Prostaglandin theory – initiation of labor is said to result from the release of Arachidonic acid produced by steroid action on lipid precursors. Arachidonic acid is said to increase prostaglandin synthesis which , in turn causes uterine contractions. 5. Theory of aging placenta – because of the decrease in blood supply, the uterus contracts.

14. Components of Labor A successful labor depends on these integrated concepts: 1. Passageway – this refers to the route the fetus must travel from the uterus through the cervix and vagina to the perineum; because these organs are contained inside the pelvis, the fetus must also pass between the pelvic ring.

15. 2. Passenger – Several aspects of the fetus body and position are critical to the outcome of labor. Primary among these are the size and the orientation of the fetal head. The fetus is of appropriate size and in advantageous position and presentation. 3. Power – this is supplied by the fundus of the uterus and implemented by uterine contractions, a process that causes cervical dilatation and the expulsion of the fetus from the uterus.

16. 4. Psyche – the woman’s psyche is preserved so afterwards labor can be viewed as a positive experience.

17. C. PRELIMINARY/PRODROMAL/PREMONITORY SIGNS OF LABOR 1.Lightening – the settling of the fetal head into the pelvic brim. In primis , it occurs 2 weeks before EDC; in multis , on or before labor onset. Lightening should not be confused with engagement. Engagement occurs when the presenting part has descended into the pelvic inlet.

18. Lightening results in: - Increase in urinary frequency - Relief of abdominal tightness and diaphragmatic pressure. - Shooting pains down the legs because of pressure on the sciatic nerve. - Increase in the amount of vaginal discharges.

19. - Increases lordosis as the fetus enters the pelvis and falls further forward - increased varicosities

20. 2. Increased in activity level – due to increased epinephrine secreted to prepare the body for the coming “work” ahead. Advise the pregnant woman not to use this increased energy for doing household chores. 3. Loss of weight – about 2-3 lbs. 1- 2 days before labor onset, probably due to decrease in progesterone production, leading to decrease in fluid retention. 4. Braxton-Hicks contractions – painless, irregular practice contractions.

21. What is Braxton Hicks? Before experiencing true contractions, many women have what’s known as Braxton Hicks contractions, also referred to as practice contractions or false labor. They are described by the American Congress of Obstetricians and Gynecologists as “irregular and they do not come closer together.” Therefore, the key to recognizing actual labor is understanding the pattern of the contractions.

22. These false labor contractions can begin in the second or third trimester and have been said to be the uterus practicing or toning up for real labor. They can range from a completely painless tightening to a jolt that can take your breath away. They can sometimes increase in frequency as the big day approaches.

23. False vs. True Labor The timing of the contractions is a big component for recognizing the differences between true and false labor. Other differences you might notice include the contractions changing when you change positions, like stopping with movement or rest. The strength of contractions is also different, and the pain is felt in different places.

24. It’s false labor if… Contractions don’t come regularly and they don’t get closer together They stop with walking or resting or with changes in position They are usually weak and don’t get stronger, or start strong and get weaker Usually the pain is only felt in the front

25. It’s true labor if… Contractions come and get closer together over time, lasting about 30-70 seconds each They continue regardless of movement or resting They progressively get stronger Usually they start in the back and move to the front

26. Other ways to recognize labor: The 5-1-1 Rule: The contractions come every 5 minutes, lasting 1 minute each, for at least 1 hour Fluids and other signs: You might notice amniotic fluid from the sac that holds the baby. This doesn’t always mean you’re in labor, but could mean it’s coming A bloody show or a “mucus plug” could mean a cervical change, which means labor is close

27. Nausea and/or vomiting might happen due to the contractions becoming very intense and the change in hormones in the blood Sometimes vaginal tears can indicate the discomfort is more intense and things are progressing One definite sign: The only way to know for sure if you’re in true labor is to be evaluated by a professional, as true labor is when contractions cause cervical change

28. When to Call Your Provider If you’re leaking fluid or think you might be If you notice decreased fetal movement If you’re bleeding If you have painful contractions of six or more in an hour — before 37 weeks of pregnancy

29. 5. Ripening of the cervix – from Goodell’s sign, the cervix becomes the “ butter-soft”

30. SIGNS OF TRUE LABOR 1. Uterine Contractions – the surest sign that labor has begun is the initiation of effective, productive, involuntary, uterine contractions. Pain in uterine contractions result from: - Contraction of uterine muscles when in an ischemic state. - Pressure on nerve ganglia in the cervix and lower uterine segment.

31. - Stretching of ligaments adjacent to the uterus and in the pelvic joints. - Stretching and in displacement of the tissues of the vulva and perineum.

32. Phases of uterine contractions: - Increment – first phases during which the intensity of contraction increases; also known as crescendo. - Acme – the height of the uterine contraction; also known as apex. -Decrement – last phase during which intensity of contraction decreases; also known as decrescendo.  

33. Characteristics of Contractions Frequency – this is the time from the beginning of one contraction to the beginning of the next. Duration – this is the time from the moment the uterus begins to tighten until it relaxes again. Intensity – it may be mild, moderate or strong at its acme.

34. a. mild – the uterine muscle becomes somewhat tense, but can be indented with gentle pressure. b. moderate – the uterus becomes moderately firm and a firmer pressure is needed to indent it. c. strong – the uterus becomes so firm that it has the fee of the wood like hardness, and at the height of the contraction, the uterus cannot be indented when pressure is applied by the examiner’s finger.

35. 2. Uterine Changes As labor contraction progresses, the uterus is gradually differentiated into two distinct portions. These are distinguished by a ridge formed in the inner uterine surface, the physiologic ring .

36. Physiological retraction ring is formed at the boundary of the upper and lower uterine segments. In difficult labor when the fetus is larger than the birth canal, the round ligaments of the uterus becomes tense during dilatation and expulsion, causing an abdominal indentation called Bandl’s pathological retraction ring, a danger sign of labor signifying impending rupture of the uterus if the obstruction is not relieved

37. Two distinct portion of the uterus: Upper uterine segment – this portion becomes thicker and active, preparing it to exert the strength necessary to expel the fetus during the expulsion phase. b. Lower uterine segment – this portion becomes thin walled, supple, and passive so that the fetus can pushed out of the uterus easily

38. Contour of the uterus changes – from a round ovoid to a structure markedly elongated in a vertical diameter than horizontally. This serves to straighten the body of the fetus and place it in better alignment to the cervix and pelvis.

39. 3. Cervical Changes a. Effacement – shortening and thinning of the cervical canal to paper-thin edges as distinct from the uterus. In primiparas , effacement is accomplished before dilatation begins while with multiparas , dilatation may proceed before effacement is completes. It is expressed in percentage.

40. b. Dilatation – enlargement of the external cervical is up to 10 cm primarily as a result of uterine contractions and secondarily as a result of pressure of the presenting part and the BOW. Dilatation occurs for two reasons : Uterine contractions gradually increase the diameter of the cervical canal lumen by pulling the cervix up over the presenting part of the fetus.

41. 2. The fluid-filled membranes press against the cervix.

42. 4. Show - due to pressure of the descending presenting part of the fetus which causes rupture of minute capillaries in the mucus membrane of the cervix. Blood mixes with mucus when the operculum is released. Show, therefore, is only a pinkish vaginal discharge.

43. Stage of Labor Primi Multi First stage 12 ½ hours 7 hours and 20 minutes Second stage Minutes 30 minutes Third stage 10 minutes 10 minutes Total 14 hours 8 hours

44. 5. Rupture of the membranes – this is the sudden gush or a scanty slow seeping of amniotic fluid from the vagina. It is important to remember that once membranes (BOW) have ruptured: Labor is inevitable. It will occur within 24 hours. The integrity of the uterus has been destroyed. Infection, therefore, can easily set in. That is why once membranes have ruptured: - Aseptic techniques should be observed in all procedures.

45. - Doctors do less obstetric manipulation (e.g., IE). - Enema is no longer ordered. - Temperature should be taken regularly so that fever, a sign of infection, can be detected. Umbilical cord compression and/or cord prolapsed can occur (especially in breech presentation.) nursing action depends on the specific situation

46. - A woman in labor seeking admission to the hospital and saying that her BOW has ruptured should be put to bed immediately, and the fetal heart tones taken consequently. - If a woman in the Labor Room says that her membranes have ruptured, the initial nursing action is to take the fetal heart tones.

47. - If a woman in labor says that’s he feels a loop of the cord coming out of the vagina (umbilical cord prolapse ), the first nursing action is to put her on Trendelenburg position (lower the head of the client) in order to reduce pressure on the cord. (Remember: only 5 minutes of cord compression can already lead to irreversible brain damage or even death.) In addition, apply a warm saline saturated OS on the prolapsed cord to prevent drying of the cord

48. The color of the amniotic fluid should always be noted. at term, this is clear, almost colorless and contains specks of vernix caseosa Freen staining means it has been contaminated with meconium , a sign of fetal distress Yellow staining may mean blood incompatibility

49. Pink staining may indicate bleeding If labor does not occur spontaneously at the end of 24 hrs after membrane ruptures, labor will be induced, provided the woman is estimated to be term.

50. Stage of Labor Primi Multi First stage 12 ½ hours 7 hours and 20 minutes Second stage Minutes 30 minutes Third stage 10 minutes 10 minutes Total 14 hours 8 hours

51. STAGES OF LABOR First stage (stage of dilatation) – begins with true labor pains and ends with complete dilatation of the cervix. Phases: Latent – early time in labor Cervical dilatation is minimal because effacement is occurring. Cervix dilates only 3-4 cm.

52. Contractions are of short duration and occur regularly 5-10 minutes apart (the best time for the pregnant woman to seek admission to the hospital.) Mother is excited but has some degree of apprehension and still has the ability to communicate. Active/accelerated

53. Cervical dilatation reaches 4-8 cm. Rapid increase in duration, frequency and intensity of contractions. Mother fears of losing control of herself.

54. Nursing care Hospital admission – provide privacy and reassurance from the very start. Personal; data – name, age, address, civil status Obstetrical data – determine the EDC; obstetrical score ( gravida , para , TPAL); amount and character of show; and whether or not membrane have ruptured. General physical examination, internal exam and Leopold’s maneuvers are done to determine: Effacement and dilatation

55. Station - relationship of the fetal presenting part to the level of the ischial spines. Station 0: at the level of the ischial spines; synonymous to engagement Station -1: presenting part above the level of the ischial spines Station +1: presenting part below the level of the ischial spines. Station +3 or +4: synonymous to crowning (encircling of the largest diameter of the fetal head by the vulvar ring.)

56. Presentation – relationship of the long axis of the mother to the long axis of the fetus; also known as lie. Presenting part is the fetal part which enters the pelvis first and covers the internal cervical os

57. 1. Vertical a. Cephalic Vertex: head is sharply flexed, making the parietal bones the presenting parts. In poor flexion: Face Brow Chin

58. Breech: buttocks are the presenting parts - complete: thighs is flexed on the abdomen and legs are on the thighs. - Frank: thighs are flexed and legs are extended, resting on the anterior surface of the body. c. Footing - Single: one leg unflexed and extended;one foot presenting - Double: legs unflexed and extended; both feet are presenting

59. Horizontal a. Transverse lie b. Shoulder presentation

60. 3. Important Considerations: a. in vertex and breech presentations, fetal heart sounds (FHS) are best heard at the area of the fetal back; in face presentations FHS are at the area of the fetal chest. b. in vertex presentations, FHS are usually located in either the left or right lower quadrant (LLQ or RLQ); in breech presentation, at or above the level of the umbilicus, either left or right upper quadrant (LUQ or RUQ).

61. . hazards of breech deliver: - cord compression - Abruption placenta - Erb-duchenne paralysis

62. Erb's palsy  or  Erb – Duchenne palsy  is a  paralysis  of the arm caused by injury to the upper trunk C5–C6  nerves . They form part of the brachial plexus, comprising the ventral rami of spinal nerves  C5–C8 and thoracic  nerve  T1. These injuries arise most commonly from shoulder dystocia during a difficult birth.

63. horizontal lie is very rare (1%) and maybe due to a relaxed abdominal wall because of multiparity , pelvic contraction or placenta previa .

64. Position – relationship of the fetal presenting part to a specific quadrant I the mother’s pelvis 1. The pelvis is divided into four quadrants: a. Right anterior b. Left anterior c. Right posterior d. Left posterior

65. Position – relationship of the fetal presenting part to a specific quadrant I the mother’s pelvis 1. The pelvis is divided into four quadrants a. Right anterior b. Left anterior c. Right posterior d. Left posterior

66. Posterior positions result in more backaches because of pressure of the fetal presenting part on the maternal sacrum

67. 2. Points of direction in the fetus: a. occiput – in vertex presentation b. chin ( mentum ) – in face presentations c. sacrum – in breech presentations d. scapula ( acromio ) – in horizontal presentations.

68. 3. Possible fetal positions a. Vertex - LOA (left occipitoanterior (most common and favorable position at birth) - LOP (left occipitoposterior ) - LOT (left occipitotransverse ) - ROA (right occipitoanterior ) - ROP (right occipitoposterior - ROT (right occipitotransverse )

69. b. Breech - LSA (left sacroanterior ) - LSP (left sacroposterior ) - LST (left sactrotransverse ) - RSA (right sacroanterior ) - RSP (right sacroposterior ) - RST (right sacrotransverse )

70. c. Face - LMA (left mentoanterior ) - LMP (left mentoposterior ) - LMT (left metrotransverse ) - RMA (right mentoanterior ) - RMP (right monteposterior ) - RMT (right mentotransverse )

71. d. Shoulder - LADA (left acromiodorsoanterior ) - LADP (left acromiodorsoposterior ) - RADA (right acromiodorsoanterior ) - RADP (right acromiodorsoposterior )

72. Monitoring and evaluating important aspects In assessing uterine contractions, fingers should be spared lightly over the fundus Duration – from the beginning of one contraction to the end of the same contraction (A an B) Duration during early labor : 20-30 seconds Duration late in labor : 60 to 70 seconds (should never be longer)

73. 2. Interval – from the end of one contraction to the beginning of the next contraction ( B to C) Interval early in labor : 40 – 45 minutes Interval late in labor : 2- 3 minutes 3. Frequency – from the beginning of one contraction to the beginning of the next contraction (A to C). Observe 3-4 contractions to have a good picture of the frequency of contractions

74. 4. Intensity – the strength of a contraction; maybe mild, moderate or strong. Intensity is measured by the consistency of the fundus at the acme of the contraction. When estimating the intensity, check fundus at the end of contraction to determine whether it relaxes. ______________ ______________ A B C D

75. Blood pressure – should not be taken during a contraction as it tends to increase. Because no blood supply goes to the placenta during a contraction, all of the blood is in the periphery that is why there is increased BP during uterine contractions. 1. BP reading should be taken at least every half hour during active labor. 2. When a woman in labor complains of a headache, the first nursing action is to take the BP. If it is normal, it is only stress headache; if the BP is increased, refer immediately to the doctor (it could be a sign of toxemia)

76. Blood pressure – should not be taken during a contraction as it tends to increase. Because no blood supply goes to the placenta during a contraction, all of the blood is in the periphery that is why there is increased BP during uterine contractions. 1. BP reading should be taken at least every half hour during active labor. 2. When a woman in labor complains of a headache, the first nursing action is to take the BP. If it is normal, it is only stress headache; if the BP is increased, refer immediately to the doctor (it could be a sign of toxemia)

77.  Fetal heart rate (FHR) – should not be mistaken for uterine soufflé (synchronizes with maternal pulse rate) 1. Normally 120 to 160 per minute. 2. Should not be taken during uterine contraction because it tends to decrease the FHB. Compression of the fetal head when the uterus contracts stimulates the vagal reflex which in turn, causes bradycardia .

78. 3. Should be taken every hour during the latent phase of labor, every half hour during the active phase and every 15 minutes during the transition period. 4. For any abnormality in FHR, the initial nursing action is to change the mother’s position.

79. 5. Signs of fetal distress: - Bradycardia (FHR less than 100/minute) or tachycardia (FHR more than 180/minute) - Meconium - stained amniotic fluid in non-breech presentation - fetal thrashing (hyperactivity of the fetus as it struggles for more oxygen)

80. e. Emotional support is provided for the woman in labor by keeping her constantly informed of the progress of labor. f. Health teachings Bath – advisable if contractions are tolerable or not too close to one another. Will make the mother feel more comfortable.

81. Ambulation – during the latent phase of labor helps shorten the first stage of labor. But definitely not allowed anymore if membranes have ruptured. Solid or liquid foods are to be avoided because digestion is delayed during labor. A full stomach interferes with proper bearing down. May vomit and cause aspiration.

82. g. Enema – not a routine procedure   Purposes: - A full bowel hinders the progress of labor – effectiveness of enema in labor can be determined by evaluating change in uterine tone and the amount of show - Expulsion of feces during second stage of labor predisposes mother and baby to infection - Full bowel predisposes to postpartum discomfort  

83. Procedure of enema administration - enema solution may either be soap suds or Fleet enema (contraindicated in patients with toxemia because of its sodium content.) - optimum temperature of the solution – 105 degrees Fahrenheit to 115 degrees Fahrenheit (40.5 degrees Celsius – 46.1 degrees Celsius) - patient on side- lying position

84. -when there is resistance while inserting rectal catheter, withdraw the tube slightly while letting a small amount of solution enter - clamp rectal tube during a contraction - important nursing action : check FHR after enema administration to determine after fetal distress.

85. Contraindications to enema in labor - Vaginal bleeding - Premature labor - Abnormal fetal presentation or position - Ruptured membranes - Crowning  

86. h. Encourage the mother to void every 2-3 hours by offering the bedpan because - A full bladder retards fetal descent - Urinary stasis can lead to urinary tract infection - A full bladder can be traumatized during the delivery

87.   i . Perineal prep – done aseptically. - Use “no.7” method, always from front to back j. Perineal shave – not a routine procedure; - maybe done to provide a clean area for delivery. - muscles at the symphysis pubis area should be kept taut and razor moved along the direction of hair growth.

88. k. Encourage Sim’s position because it: - Favors anterior rotation of the fetal head - Promotes relaxation between contractions - Prevents continual pressure of the gravid uterus on the inferior vena cava (the blood vessel which brings unoxygenated blood back to the heart.

89. - pressure results in supine hypotensive syndrome, also called vena cava syndrome. Hypotension is due to the reduced venous return resulting in decreased cardiac output and therefore, a fall in arterial BP.

90. l. Woman in labor should not be allowed to - push or bear down unnecessarily during contractions of the first stage because It leads to unnecessary exhaustion. Repeated strong pounding of the fetus against the pelvic floor will lead to cervical edema, thus interfering with dilatation and prolonging length of labor.

91. m. Abdominal breathing is advised for contractions during the first stage in order to reduce tension and prevent hyperventilation.

92. n. Administer analgesics as ordered. The dosage is based on the patient’s weight, status of labor and age of gestation. - Narcotics are the most commonly used, specifically, Demerol. - Pharmacologic effect: depresses the sensory portion of the cerebral cortex. It is not only a potent analgesics, it is also a sedative and an antispasmodic. - It is not given early in labor because it can retard progress (is an antispasmodic), but cannot also be given if deliver is only one hour away because it

93. - It is not given early in labor because it can retard progress (is an antispasmodic), but cannot also be given if deliver is only one hour away because it causes respiratory depression in the new born (that is why it can be given only if cervical dilatation is 6-8 cm.) - Given 25-100 mg., depending on body weight. - Takes effect in 20 minutes – patient experiences a sense of well – being and euphoria.

94. -Narcotic antagonists (e.g., Narcan , Nalline ) are given to counteract any toxic effects of Demerol. - Assist in administration of regional anesthesia – preferred over any other form of anesthesia because : it does not enter maternal circulation and so does not affect the fetus. Patient is completely awake and aware of what is happening. Does not depress uterine tone, thus optimal uterine contraction is achieved.

95. - Xylocaine is the anesthetic of choice - Patient on NPO with IV to prevent dehydration, exhaustion and aspiration because glucose aids in proper functioning of the fetus.

96. Types of Anesthesia a. Paracervical – transvaginal injection into either side of the cervix. Patient on lithotomy position. Coupled with a local anesthetic results in “painless childbirth” (uterine contractions are not felt by mother.)

97. b. Pudendal – through the sacrospinous ligament into the posterior areolar tissues to reduce perception of pain during second stage and make patient comfortable. Patient on lithotomy . Side effect: an ecchymotic (purplish discoloration of the skin due to blood in subcutaneous tissues) area of hematoma in the perineum may be an aftermath. No special treatment is needed: ice bag applied to the area on the first day may reduce the swelling.

98. c. Low spinal  - Epidural – injection of local anesthetic at the lumbar level outside the dura mater. - Saddle block – injection into the 5 th lumbar space, causing anesthesia in the parts of the body that come in contact with a saddle (perineum, upper thighs and lower pelvis.) blocks nerves that transmit pain of first stage of labor. In sitting or side- lying position, with back flexed.

99. - Forceps are generally needed in delivery of patient under anesthesia because of loss of coordination in second –stage pushing. - Post spinal headaches may be due to leakage of anesthetic into the CSF or injection of air at time of needle insertion. Management: flat on bed for 12 hours and increase fluid intake.

100. Common Side Effects: Hypotension – because Xylocaine is a vasodilator. Management: turning side; prompt elevation of leg; administration of vasopressor and oxygen, as ordered.) - Fetal bradycardia - Decreased maternal respirations

101. o. A sure sign that the baby is about to be born is the bulging of the perineum. In general, Primigravidas are transported from the labor Room to the Delivery Room when the cervix is fully dilated or when there is bulging of the perineum. Multiparas , on the other hand, are transported when cervical dilatations are 7-9 cm.

102. Transition Period – when the mood of the woman suddenly changes and the nature of the contractions intensify.

103. a. Characteristics   If membranes are still intact, this period is marked by a sudden gush of amniotic fluid as fetus is pushed into the birth canal. If spontaneous rupture does not occur, amniotomy (snipping of BOW with a sterile pointed instrument, e.g , Kelly or Allis forceps or amniohook to allow amniotic fluid to drain) is done to prevent fetus from aspirating the amniotic fluid as it makes its different fetal position changes.

104. Amniotomy , however, cannot be done if station is still “minus” , as this can lead to cord compression. There is an uncontrollable urge to push with contractions, a sign of impending second stage of labor. Profuse perspiration and distention of neck veins are seen. Nausea and vomiting is a reflex reaction due to a decreased gastric motility and absorption. In primis , baby is delivered within 20 contractions (40 minutes); in multis , after 10 contractions (20 minutes)

105. b. Nursing actions are primarily comfort measures:   Sacral pressure (applying pressure with the heel of the hand on the sacrum) – relieves discomfort from contractions. Proper bearing down techniques m- push with contractions. Controlled chest (costal) breathing during contractions. Emotional support

106. 3. Second Stage (stage expulsion) – begins with complete dilatation of the cervix and ends with the delivery of the baby.   a. Powers/Forces: involuntary uterine contractions and contractions of the diaphragmatic and abdominal muscles

107. b. Mechanism of labor/Fetal position Changes (D FIRE ERE) D escent – may be preceded by engagement. F lexion – as decent occurs, pressure from the pelvic floor causes chin to bend forward onto the chest. I nternal R otation – from AP to transverse, then AP to AP. E xtension – as the head comes out, the back of the neck stops beneath the public arch. The head extends and the forehead, nose, mouth and chin appear. E xternal R otation (also called restitution) – Anterior shoulder rotates externally to the AP position. E xpulsion – delivery of the rest of the body.

108. c. Nursing Care: When positioning legs on lithotomy , put them up at the same time to prevent injury to the uterine ligaments. As soon as the fetal head crowns, instruct the mother not to push, but to pant (rapid and shallow breathing to prevent rapid expulsion of the baby). If panting is deep and rapid, called hyperventilation, the patient will experience lightheadedness and tingling sensation of the fingers leading to carpopedal spasms because of respiratory alkalosis. Management: let the patient breathe into a brown paper bag to recover lost carbon dioxide; a cupped hand over the mouth and nose will serve the same purpose.

109. Assist in episiotomy (incision made in the perineum primarily to prevent lacerations) Other Purposes: a. prevent prolonged and severe stretching of muscles supporting the bladder or rectum. b. reduce duration of second stage when there is hypertension or fetal distress. c. enlarge outlet, as in breech presentation or forceps delivery.

110. Types of episiotomy: a. Median – from middle portion of the lower vaginal border directed towards the anus. b. Mediolateral – begun in the midline but directed laterally away from the anus. Often done because it prevents 4 th degree laceration should it occur despite episiotomy. Natural anesthesia is used in episiotomy, i.e.; no anesthetic is injected because pressure of fetal presenting part against the perenium is so intense that nerve endings for pain are momentarily deadened.

111. d. Apply the modified Ritgen’s maneuver .   1. Cover the anus with a sterile towel and exert upward and forward pressure on the fetal chin, while exerting gentle pressure with two fingers on the head to control emerging head. This will not only support the perineum, thus preventing lacerations, but will also favor flexion so that the smallest suboccipitobregmatic diameter of the fetal head is presented.

112. 2. Ease the head out and immediately wipe the nose and mouth of secretions to establish a patent airway (remember: the first and most important principle in the care of the newborn is established and maintains a patent airway.) The head should be delivered in between contractions.

113. 3. Insert 2 fingers into the vagina so as to feel for the presence of a cord looped around the neck ( nuchal cord). If so, but loose, slip it down the shoulders or up over the head; but if tight, clamp the cord twice, an inch apart, and then cut I between.   4. As the head rotates, deliver the anterior shoulder by exerting a gentle downward push and the slowly give an upward lift to deliver the posterior shoulder.  5. While supporting the head and the neck, deliver the rest of the body. Take note of the time of the delivery of the baby.

114. e. Immediately after the delivery, the newborn should be held below the level of the mother’s vulva for a few minutes to encourage flow of the blood from the placenta to the baby. f. The infant is held with his head in a dependent position (head lower than the rest of the body) to allow for drainage of secretions. (Remember: Never stimulate a baby to cry unless you have drained him out of his secretions.) g. Wrap the baby in a sterile towel to keep him warm. (Remember: Chilling increases the body’s need for oxygen.)

115. h. Put the baby on the mother’s abdomen. The weight of the baby will help contract the uterus. i . Cutting of the cord is postponed until the pulsations have stopped because it is believed that 50-100 ml of blood is flowing from the placenta to the baby at this time. After cord pulsations have stopped, clamp it twice, an inch apart and then cut in between.  

116. j. Show the baby to the mother, inform her of the sex and time of the delivery then give the baby to the circulating nurse.

117. 4. Third stage (placental stage) – begins with the delivery of the baby and ends with the delivery of the placenta.   a. Signs of Placental separation: Uterus becoming round and firming again, rising high to the level of the umbilicus ( Calkin’s sign) – in the earliest sign of placental separation Sudden gush of blood from the vagina Lengthening of the cord

118. b. types of placental delivery: Schultz – if placenta separates first at its center and then at its edges, it tends to fold on itself like an umbrella and presents the fetal surface which is shiny (“Shiny” for Schultz); 80% of placentas separate in this manner. Duncan – if placenta separates firsts at its edges, it slides along the uterine surface and presents with the maternal surface which is raw, red, beefy, irregular and “dirty” (“Dirty” for Duncan). Only about 210% of placentas separate this way.  

119. c. Nursing Care 1. Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous fundal push as this can cause uterine inversion. Just watch for the signs of placental separation. 2. Tract the cord slowly, winding it around the clamp until the placenta spontaneously comes out, slowly rotating it so that no membranes are left inside the uterus, a method called Brandt-Andrews maneuver . 3. Take note of the time of placental delivery. It should be delivered within 20 minutes after the delivery of the baby. Otherwise, refer immediately to the doctor as this can cause severe bleeding in the mother.

120. 4. Take note of the time of placental delivery. It should be delivered within 20 minutes after the delivery of the baby. Otherwise, refer immediately to the doctor as this can cause severe bleeding in the mother. 5. Inspect for completeness of cotyledons; any placental fragment retained can also cause severe bleeding and possible death. 6. Palpate the uterus to determine degree of contraction. If relaxed boggy or non-contracted, first nursing action is to massage gently and properly. An ice cap over the abdomen will also help contract the uterus since cold causes vasoconstriction.

121. 7. Inject oxytocin ( Methergin = 0.2mg/ml or Syntocinon = 100/ml) IM to maintain uterine contractions, thus prevent hemorrhage. Note: oxytocins are not given before placental delivery. 8. Inspect the perineum for lacerations. Any time the uterus is firm following placental delivery, yet bright red vaginal bleeding is gushing forth from the vaginal opening, suspect lacerations (tend to heal more slowly because of ragged edges)

122. Categories of Lacerations: First degree – involves the vaginal mucous membranes and perineal skin. Second degree – involves not only the muscles, vaginal mucous membranes and skin, but also the muscles. 3. Third degree – involves not only the vaginal mucous membranes and skin, but also the extern al sphincter of the rectum.

123. 4. Fourth Degree – involves not only the external sphincter of the rectum, the muscles, vaginal mucous membranes and skin, but also the mucous membranes of the rectum.  a. Assist the doctor in doing episiorrhaphy (repair of episiotomy or lacerations). In vaginal episiorrhaphy , packing is done to maintain pressure on the suture line, thus prevent further bleeding. Note: vaginal packs have to be removed after 24-48 hours .  b. Make mother comfortable by perineal care and applying clean sanitary napkin snugly to prevent its moving forward from the anus to the vaginal opening. Soiled napkins should be removed from front to back.

124. c. Position the newly-delivered mother flat on bed without pillows to prevent dizziness due to decrease in intra-abdominal pressure. d. The newly-delivered mother may suddenly complain of chills due to decreased blood pressure, fatigue or cold temperature in the delivery room. Management: a. Provide additional blankets to keep her warm. b. May give initial nourishment, e.g., milk, coffee, or tea. c. Allow patient to sleep in order to regain lost energy.

125. 5. Fourth Stage – first 1-2 hours after delivery which is said to be the most critical stage for the mother because of unstable vital signs. a. Assessment Fundus – should be checked every 15 minutes for 1 hour then every 30 minutes for the next 4 hours. Fundus should be firm, in the midline , and during the first 12 hours postpartum, is a little above the umbilicus . First nursing action for a non-contracted uterus: massage.

126. Lochia - should be moderate in amount. Immediately after delivery, a perineal pad can be fully saturated in 15 minutes or earlier, may mean hemorrhage.

127. Bladder – a full bladder is evidenced by a fundus which is to the right of the midline and dark-red bleeding with some clots. Will prevent adequate uterine contraction. Perineum – is normally tender, discolored and edematous. It should be clean, with intact sutures. Blood pressure and pulse rate may be slightly increased from excitement and effort of delivery, but normalize within one hour.

128. b. Lactation – suppressing the agents – estrogen – androgen preparations given within the first hours postpartum to prevent breast milk production in mothers who will not (or cannot) breastfeed, e.g., diethylstilbestrol, TACE#, Parlodel or deladumone . These drugs tend to increase uterine bleeding and retard menstrual return.

129. c. Rooming-in concept – mother and baby are together while in the hospital. The concept of a family, therefore, is felt from the very beginning because parents have the baby with them, thus providing opportunities for developing a positive relationship between parents and newborn (maternal-infant bonding). Eye-to- eye contact is immediately established, releasing the maternal caretaking responses