1

Labor Review

Petrenko N MDPhD

2

Critical Factors in Labor

bull 5 critical factorsndash Birth passagendash Fetusndash Relationship of Maternal Pelvis and

Presenting Partndash Physiologic forces of laborndash Psychosocial considerations

3

4

1 Birth Passage

bull Four different types of pelvises but frequently mixed types

gynaecoidanthrapoid android

platypelloid

5

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

6

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

7

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

8

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

9

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

10

Fetus Fetal lie

Longitudinal

Transverse

11

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

12

Fetus Fetal lie

Cephalic

Shoulder

Breech

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

2

Critical Factors in Labor

bull 5 critical factorsndash Birth passagendash Fetusndash Relationship of Maternal Pelvis and

Presenting Partndash Physiologic forces of laborndash Psychosocial considerations

3

4

1 Birth Passage

bull Four different types of pelvises but frequently mixed types

gynaecoidanthrapoid android

platypelloid

5

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

6

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

7

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

8

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

9

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

10

Fetus Fetal lie

Longitudinal

Transverse

11

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

12

Fetus Fetal lie

Cephalic

Shoulder

Breech

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

3

4

1 Birth Passage

bull Four different types of pelvises but frequently mixed types

gynaecoidanthrapoid android

platypelloid

5

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

6

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

7

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

8

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

9

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

10

Fetus Fetal lie

Longitudinal

Transverse

11

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

12

Fetus Fetal lie

Cephalic

Shoulder

Breech

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

4

1 Birth Passage

bull Four different types of pelvises but frequently mixed types

gynaecoidanthrapoid android

platypelloid

5

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

6

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

7

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

8

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

9

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

10

Fetus Fetal lie

Longitudinal

Transverse

11

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

12

Fetus Fetal lie

Cephalic

Shoulder

Breech

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

5

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

6

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

7

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

8

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

9

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

10

Fetus Fetal lie

Longitudinal

Transverse

11

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

12

Fetus Fetal lie

Cephalic

Shoulder

Breech

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

6

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

7

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

8

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

9

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

10

Fetus Fetal lie

Longitudinal

Transverse

11

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

12

Fetus Fetal lie

Cephalic

Shoulder

Breech

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

7

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

8

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

9

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

10

Fetus Fetal lie

Longitudinal

Transverse

11

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

12

Fetus Fetal lie

Cephalic

Shoulder

Breech

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

8

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

9

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

10

Fetus Fetal lie

Longitudinal

Transverse

11

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

12

Fetus Fetal lie

Cephalic

Shoulder

Breech

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

9

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

10

Fetus Fetal lie

Longitudinal

Transverse

11

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

12

Fetus Fetal lie

Cephalic

Shoulder

Breech

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

10

Fetus Fetal lie

Longitudinal

Transverse

11

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

12

Fetus Fetal lie

Cephalic

Shoulder

Breech

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

11

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

12

Fetus Fetal lie

Cephalic

Shoulder

Breech

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

12

Fetus Fetal lie

Cephalic

Shoulder

Breech

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

13

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

14

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

15

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

16

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

17

Fetal presentations

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

18

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

19

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

20

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

21

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

22

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

23

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

24

Relationship of maternal pelvis and presenting part

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

25

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

26

2 Fetusbull Sutures

ndash Frontalndash Sagittalndash Coronalndash Lambdoidal

Frontal suture

Sagittal suture

Coronal suture

Lambdoidal suture

Note sutures are actually membranous spaces that meet at fontanels

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

27

Fetus

bull Fontanelles intersection of sutures allows for molding helps identify position of headndash Anterior (bregma)

bull Diamond shapedbull Approx 2-3 cmbull Ossifies in ~12-18 months

ndash Posteriorbull Triangle shapedbull Smallerbull Closes in 8-12 weeks

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

28

Fetus

bull Other landmarks on the fetal headndash Mentumndash Sinciputndash Vertexndash occiput

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

29

Fetus

bull Fetal attitudendash Relation of fetal parts to one anotherndash Normal mod flexion of head flexion of arms

onto chest flexion of legs onto abdomen

bull Changes in attitude can contribute to longer more difficult labor or Cesarean Section

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

30

Fetus

bull Fetal liendash Relationship of the spine

(cephalocaudal axis) of the fetus to the spine of the mom

ndash Longitudinal parallelndash Transverse right anglendash Oblique acute abgle

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

31

Fetus Fetal lie

Longitudinal

Transverse

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

32

Fetus

bull Fetal presentationndash Body part entering the pelvis (presenting

part)bull Cephalicbull Breechbull Shoulder

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

33

Fetus Fetal lie

Cephalic

Shoulder

Breech

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

34

Fetus

bull Fetal presentation Cephalicndash Vertex presentation

bull Most commonbull Head completely flexed on chestbull Suboccipitobregmatic (Smallest

diameter)bull Occiput in presenting part

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

35

Fetus

bull Fetal presentation Cephalicndash Military presentation

bull Fetal head neither flexed nor extendedbull Occipitofrontal diameter presentsbull Top of the head is presenting part

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

36

Fetus

bull Fetal presentation Cephalicndash Brow presentation

bull Fetal head partially extended

bull Occipitomental diameter presents

bull Sinciput is presenting part

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

37

Fetus

bull Fetal presentation Cephalicndash Face presentation

bull Head hyperextendedbull Submentobregmatic diameter

presentsbull Face is presenting part

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

38

Fetal presentations

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

39

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

40

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Complete breech

bull Knees and hips are flexed thighs on abdomen (ldquofetal positionrdquo)

bull Buttocks and feet are presenting parts

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

41

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Frank breech

bull Hips flexed knees extended

bull Buttocks is presenting part

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

42

Fetusbull Fetal presentation

Breechndash Sacrum is the

landmarkndash Footling breech

bull Hips and legs extended

bull Feet are presenting parts (single vs double)

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

43

Fetusbull Fetal

presentation Shoulderndash Acromion

process of shoulder is presenting part

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

44

Station

Station of the head inrelation to ischial spines

1048713In Gynaecoid amp Android pelvis distance between ischial spine to brim is ~5 cm1048713In Anthropoid pelvis distance is ~7 cm1048713In Platypelloid pelvis distance is ~3 cm

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

45

Relationship of maternal pelvis and presenting part

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

46

Relationship of maternal pelvis and presenting part

bull OA most common easiest to deliver

bull Other positions are considered malpositions

bull Position influences labor and birth

bull Largest diameter in posterior position back pain longer 2nd stage

bull Can tell position by palpation of abdomen and Vaginal Examination

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

47

Physiologic forces of labor

bull Primary uterine muscles (causes dilation and effacement)

bull Secondary abdominal muscles (for 2nd stage)

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

48

Physiologic forces of labor

bull Phases of contractionsndash Incrementndash Acmendash Decrement

bull Relaxationndash Uterine muscle restndash Rest for momndash Restores oxygenation to baby

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

49

Physiologic forces of labor

Frequency

Duration

Intensity

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

50

Physiologic forces of labor

Intensity

indirect (subjective) palpation mild moderate strong

direct (objective) mmHg pressure with IUPC (intauterine)

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

51

Physiologic forces of labor

Early labor mild short duration irregular

As labor progresses stronger longer more regular closer together

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

52

Physiologic forces of labor

Bearing down (Pushing)

must be 10cm dilated (complete)

involuntary and voluntary muscles

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

53

Stages of Labor

bull Stage 1ndash Onset of regular contractions to complete

dilatation

bull Stage 2ndash Complete dilatation to birth

bull Stage 3ndash Birth of infant to birth of placenta

bull Stage 4ndash Birth of placenta to 1-4 hrs recovery

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

54

Stages of Labor bull Stage 1 divided into 3 phases

ndash 1 Latent phase 0-3 cmbull Primip 86 hrsbull Multip 53 hrsbull May have irregular contractions short mild ndash

moderatebull Excited talkative smiling

ndash 2 Active phase 4-7 cmbull Primip 46 hrs dilation at least 12 cmhrbull Multip 24 dilation at least 15 cmhrbull Uterus contraction through 2-5 min by 40-60 sec

mod ndash strongbull uarr anxiety sense of hopelessness fear of loss of

control

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

55

Stages of Labor bull Stage 1 divided into 3 phases conthellipbull 3 Transition phase 8-10 cm

bull Primip 36 hrsbull Multip variablebull Uterus contraction through 1 frac12 - 2 min 60-90 sec

mod ndash strongbull Acutely aware of intensity of uterus contraction

significant anxiety restless canrsquot get comfortable fears being alone yet may not want anyone to touch her hot-cold apprehensive

ndash As dilation progresses uarr bloody show ROM As gets to closer to complete uarr rectal pressure splitting feeling urge to push

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

56

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

57

Stages of Labor bull 2nd stage

ndash Usually lt2 hrs (less in multips)ndash Affected by epidural maternal pushing

position of presenting part size of pelvisndash As head approaches perineum labia

separate may see presenting part with pushing then recede Rectum bulges and flattens

ndash Crowning

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

58

Stages of

Labor

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

59

Stages of Labor bull 3rd stage

ndash Usually will induced 5 mins May be up to 30 mins Retained after 30 mins

ndash Signs of separationbull Globular shaped uterusbull Rise in fundusbull Sudden gush or heavy trickle of bloodbull Lengthening of cord from vagina

ndash Shiny schultzendash Dirty duncan

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

60

Stages of Labor bull 4th stage

ndash Blood loss normal up to 500mL (vag del)ndash Hemodynamic changes darr BP uarr

pulse pressure tachycardiandash Uterus contracted and midline ~12 way

between symphysis and umbilicus Within 1st hour about level with umbilicus

ndash Shaking hunger thirstndash Bladder is hypotonic

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

61

Post-term Pregnancybull gt 42 completed weeks bull Cause of true post-term is unknown often

incorrect datesbull Maternal Risks

ndash Large baby and associationsndash Psychologic ills

bull Fetal-Neonatal Risksndash Placental changes insufficienciesndash Oligohydramniosndash macrosomia birth trauma glucose maintenance problemsndash Meconmium stained fluid (aspiration)

bull As pregnancy approached term fetal well-being studies done

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

62

Fetal Malposition

bull OP positionndash Fetus must rotate 135deg or occasionally born in

OP positionndash If born OP increased risk of 3rd or 4th degree

laceration broken symphysisndash May use forceps or manual rotationndash Positioning knee chest pelvic rocking

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

63

Fetal Malpresentation

bull Brow ndash Usually CS recommendedndash Perinatal morbidity and mortality

bull Trauma cerebral and neck compression damage to trachea and larynx

ndash Tx pelvimetry oxytocin CS

bull Facendash Perinatal morbidity and mortality

bull Risk of prolonged labor fetal edema swelling of neck and internal structures petechiae ecchymosis

ndash Tx CS in no progress

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

64

Fetal Malpresentation

bull Breechndash Most common malpresentationndash Frank breech most commonndash Risk of cord prolapse fetal anomolies 3x

higherndash If vag del head trauma fetal entrapmentndash Tx external version (50-60 success) if vag

del epidural double set-up

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

65

Fetal Malpresentation

bull Shoulderndash Version may be attemptedndash CS

bull Compound presentation

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

66

Macrosomiabull gt4500 gbull Obese 3-4x more likely to have

macrosomic babybull uarrrisk of perineal lacerations infectionbull Most significant problem is shoulder dystocia

ndash OB emergency permanent injury of brachial plexus fx clavicle asphyxia neurologic damage

ndash Txbull Assessment of adequacy of pelvisbull Suprapubic pressurebull Intentional breaking of claviclebull CS

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

67

Prolapsed Cord

bull Umbilical cord precedes presenting part

bull May be visible or occult

bull More common withndash Abnormal liendash Low birth weightndash gt previous birthsndash Amniotomyndash Long cord

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

68

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

69

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

70

Prolapsed Cord

bull Key interventionsndash Relieve pressure on cord

bull Trendelberg or knee chest positionbull Oxygen to increase maternal oxygen saturationbull Pressure on the presenting part

ndash Call for help but do not leave motherndash Expedite delivery

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

71

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

72

Prolapsed Cord

bull Maternal Riskndash No direct risk

bull Fetal-Neonatal Riskndash Cord compression darrO2 possible death or

neurologic compromise

bull Txndash Preventionndash If palpated keep pressure off cordndash When ROM occurs listen to FHTs for full minute if

decel heard do vag exam to ro cord prolapse

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

73

Intrauterine Fetal Demise (IUFD)

bull May be found prior to coming to hosp or at time of admission

bull May be unexplained or rt materanal disease process or fetal insult

bull May be induced right away or wait for spontaneous labor CS not automatically done

bull Pain med give freely

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

74

Intrauterine Fetal Demise (IUFD)

bull Provide privacy for familiesbull Listenbull Avoid inappropriate consolationsbull Give accurate infobull Obtain mementosbull Allow opportunity to see and holdbull Provide information re burial optionsbull Provide support information

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

75

Premature Rupture of Membrane

(PROM)bull Spontaneous break in the amniotic sac before onset of

regular contractions

bull Mother at risk for chorioamnionitis especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours

bull Risk of fetal infection sepsis and perinatal mortality increase with prolonged ROM

bull Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

76

PROMSigns of Infection

bull Maternal fever

bull Fetal tachycardia

bull Foul-smelling vaginal discharge

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

77

PROM Detecting Amniotic Fluid

bull Nitrazine

bull Ferning Place a smear of fluid on a slide and allow to dry Check results If fluid takes on a fernlike pattern it is amniotic fluid

bull Speculum exam

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

78

fernlike pattern

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

79

PROM Treatment

bull Depends on fetal age and risk of infectionbull In a near-term pregnancy induction within

12-24 hours of membrane rupturebull In a preterm pregnancy (28 -34 weeks) the

woman is hospitalized and observed for signs of infection If an infection is detected labor is induced and an antibiotic is administered

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

80

PROMNursing Interventions

bull Explain all diagnostic testsbull Assist with examination and specimen

collectionbull Administer IV Fluidsbull Observe for initiation of labor bull Offer emotional supportbull Teach the patient with a history of PROM

how to recognize it and to report it immediately

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

81

Signs of Preterm Laborbull Rhythmic uterine contraction producing

cervical changes before fetal maturity

bull Onset of labor 20 ndash 37 weeks gestation

bull Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies

bull There is no known prevention except for treatment of conditions that might lead to preterm labor

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

82

Treatment of Preterm Labor

bull Used if tests show premature fetal lung development cervical dilation is less than 4 cm amp there are no that contraindications to continuation of pregnancy

bull Bed rest drug therapy (if indicated) with a tocolytic

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

83

Preterm Labor Pharmacotherapies

bull Terbutaline (Brethine) a beta-adrenergic blocker is the most commonly used tocolytic

bull Side effects maternal amp fetal tachycardia maternal pulmonary edema tremors hyperglycemia or chest pain and hypoglycemia in the infant after birth

bull Ritodrine (Yutopar) is less commonly used

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

84

Preterm Labor Pharmacotherapies

Magnesium Sulfate Acts as a smooth muscle relaxant and leads

to decreased blood pressure Many side effects including flushing nausea

vomiting and respiratory depression Should not be used in women with cardiac or

renal impairment Excreted by the kidneys

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

85

Perterm Labor Pharmacotherapies

bull Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before

delivery

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

86

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions and notify

the physician if they occur more than 4 times per hour

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

87

Nursing Interventions with Preterm Labor

Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay

potential for delivery of premature infant and possible need for neonatal intensive care

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

88

Nursing Interventions with Preterm Labor

Discharge teaching for home care Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor

and what to do

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

89

Birth Related Procedures

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

90

Procedures

bull Versionndash Externalndash Internal

bull Cervical Ripeningndash Cervidilndash Cytotec

bull Amnioinfusionndash ~250-500 mL warmed saline or LR is infused into

uterus via IUPC over 20-30 minndash Used to correct variables dilute mec stained fluid

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

91

Labor Induction

bull Stimulation of UC before spontaneous onset of labor

bull Prior to starting inductionndash Verification of gestation agendash Confirmation of fetal presentationndash Assessment of risk factorsndash Well-being assessment of mom and babyndash Cervical Assessment

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

92

Labor Induction

bull Cervical Assessment (Bishoprsquos Score)ndash Higher the score more successful the

induction will bendash Favorable cervix is most important criteria for

successful induction

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

93

Bishoprsquos Score)

Cervical dilatation

1-2 3-4 5-6

Cervical effacement

0-40 40-80 80+

Position of cervix

posterior medial Anterior

Consistency of cervix

Firm Medium soft

Station of presenting part

-2 -10 +1+2

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

94

Labor Inductionbull Methods

ndash Stripping membranesndash Oxytocin

bull Always given via IV pump (may be given IM after del)

bull Site closest to insertionbull Continuous EFMbull Risks

ndash Hyperstimulationndash Uterine rupturendash Water intoxicationndash Fetal risks associated with maternal problems

hyperbilirubinemia trauma from rapid birth

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

95

Episiotomy

bull Decline over the years

bull May make it more likely will have deep tears

bull Lacerations heal more quickly in absence of epis

bull 3rd or 4th degree lacerations more likely with epis

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

96

Episiotomybull Midline

ndash from vag orifice to fibers of rectal sphincterndash Less blood loss easier to repair heals with less

discomfort

bull Mediolateralndash From midline of posterier forchette to 45deg angle to right

or leftndash Provides more room but has gt blood loss longer

healing time and more discomfort

bull Txndash Pain relief measuresndash Icendash Inspect

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

97

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

98

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

99

Operative Assisted Deliveries

bull Forcepsndash Maternal complications

bull Traumabull Increased pain in pp periodbull Weakening of the pelvic floor

ndash Fetal-neonatal complicationsbull Caputbull Caphalohematomabull Transient facial paralysisbull trauma

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

100

Operative Assisted Deliveriesbull Vacuum Extractor

ndash Longer duration of suction more likely scalp injury

ndash Maternal complicationsbull Perineal traumabull Edemabull Genital tract and anal sphincter probs (lt than with forceps)

ndash Neonatal complicationsbull Scalp lacerationsbull Bruisingsubdural hematomabull Cephalohematomabull Jaundicebull Fx claviclebull Retinal hemorrhagebull death

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

101

Cesarean Birthbull 1970 - ~5bull 1988 ndash 247bull 2001 ndash 21bull 2005 - But higherbull Indications

ndash Failure to progressdescendndash Previaabruptionprolapse cordndash Non-reassuring fetal statusndash Malpresentationndash Previous CS

bull Maternal morbidity and mortality is gt than vag delivery

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

102

Cesarean Birthbull Technique

ndash NOTE Skin incision NOT indicative of uterine incision

ndash Transverse (Pfannenstiel)-lower uterine segment

bull Adv below pubic hair line less bleeding better healing

bull Disadv difficult to extend if needed requires more time if adipose fold difficult to keep clean and dry

ndash Vertical-between naval and symphysisbull Adv quicker more room

bull Disadv scar obvious longer

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

103

Cesarean Birth

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

104

Cesarean Birth

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

105

Cesarean Birthbull Technique

ndash Uterine incision (type depends on need for CS)

ndash Transverse-lower uterine segmentbull Adv thinnest less blood loss only mod

dissection of bladder easier to repair site less likely to rupture during subsequent pregnancies less chance of adherence of bowel or omentum to incision line

bull Disadv takes longer limited in size due to major blood vessels greater tendency to extend into uterine vessels

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

106

Cesarean Birthbull Technique

ndash Lower Uterine Segment Vertical Incisionbull Preferred for multiple gestation

abnormal presentation previa preterm macrosomia

bull Adv more roombull Disadv may extend into cx more extensive

dissection of the bladder is necessary if extends upward hemostasis and closure more difficult higher risk of rupture in subsequent pregnancies

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

107

Cesarean Birthbull Technique

ndash Classic incisionbull Upper uterine segmentbull Adv more room quicker to dobull Disadv more blood loss difficult to repair

higher risk of rupture in subsequent pregnancies

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

108

Cesarean Birth

bull Prep for CS (time dependent)ndash Permits NPOndash IV OralIV antacids H2 inhibitorsndash Foley Teachingndash Shave

bull Immediate PP carendash Freq vs (q 5-10 min) Lungsndash Check dressing IampOndash Lochia and uterus Anesthetic level

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

109

VBAC (vaginal birth after cesarean)

bull That was then this is now

bull Specific criteria

bull Must sign consent

bull Contraindicationsndash Classic incision or previous fundal uterine

surgery

bull Most common risk is hemorrhage and uterine rupture

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110

110

Placental accreta

bull occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle Placenta accreta is the most common accounting for approximately 75 of all cases

bull Approximately 1 in 2500 pregnancies experience placenta accreta increta or percreta

bull There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91
• Slide 92
• Slide 93
• Slide 94
• Slide 95
• Slide 96
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107
• Slide 108
• Slide 109
• Slide 110