OB Review 2

February 2009

True Labor

Contractions produce progressive dilatation and enfacement of the cervix.

Occur regularly and increase in frequency, duration, and intensity.

The discomfort of true labor contractions usually starts in the back and radiates around to the abdomen

Not relieved by walking.

FACTORS THAT MAY EXTEND OR INFLUENCE

THE DURATION OF LABOR - 4 Ps

Passage: Birth Passage: size and morphology of true pelvis, uterus, cervix, vagina, and perineum. Parity of woman.

The True Pelvis is a primary concern when a vaginal delivery is expected.

Passenger: Presentation of the fetus “part of the fetus that enters the pelvis first” (breech, transverse). Size of the fetus, moldability of the fetal skull.

Powers: Quality, force and frequency of uterine contractions

Psyche: mother’s attitude toward labor and her preparation for labor. Culture, Anxiety/Fear

Passenger Fetal Presentation – Referred to the fetal

presenting part. Part of the fetus that enters the pelvis first: Cephalic –presentation of any part of the fetus

head during labor - Vertex Breech Shoulder. 

Fetal attidude – Relationship of fetal parts to one another: all joints in flexion

Fetal lie – Relationship of cephalocaudal axis (spinal column) of fetus to the cephalocaudal axis of mother- transverse, parallel

The fetal head normally engages in the maternal pelvis in

an occiput transverse position, the vertex is formed

by four bones of the Skull: the frontal bone, the 2 parietal bones and the occipital bone.

In a vertex position when the occiput bone is the presenting part it refers to an occiput position.

Vertex Presentation is a normal presenting position

Left occiput anterior

Positioning During Labor

Assist the patient in turning from side to side. Side-lying promotes uteroplacental blood flow. Elevate the head of the bed 30 degrees; this

makes it easier for the patient to breathe. May result in pressure of the enlarged uterus on

the vena cava, reduces blood supply to the heart, decreases blood pressure, and reduces blood circulation to the uterus and across the placenta to the fetus.

The best position for the patient is on her left side since this increases fetal circulation.

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Characteristics of Contractions

Frequency: How often they occur? They are timed from the beginning of a

contraction to the beginning of the next contraction.

Regularity: Is the pattern rhythmic?Duration: From beginning to end - How

long does each contraction last?Intensity: By palpation mild, moderate, or

strong.

Average Length of Labor

. Latent Active Transition Second stage

Primigravida 8 – 10 hours

6 hours 2 hours 1 hour

Multigravida 5 hours 4 hours 1 hour 15 minutes

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Assessment of Contractions

Palpation: Use the fingertips to palpate the fundus of the uterus Mild: Uterus can be indented with gentle

pressure at peak of contraction – feels like tip of nose

Moderate: Uterus can be indented with firm pressure at peak of contraction - feels like chin

Strong: Uterus feels firm and cannot be indented during peak of contraction – feels like the forehead

Impending signs of Birth

Impending Signs of birth Bulging of the perineum. Crowning Dilatation of the anal

orifice. Complaints of severe

discomfort. Dilatation and effacement

– complete - patient is instructed to push with each contraction to bring the presenting part down into the pelvis

Amniotomy

Artificial rupture of membranes performed at or beyond 3 cm dilation.

May cause changes in the FHR ( accelerations or bradycardia).

Assess and monitor FHR for one full minute

Normal amniotic fluid is straw-colored and odorless.

Stage 1

Latent: ends 4 cm

Active: begins 4 cm ends 8 cm

Transition: begins 8 cm ends 10 cm

Stage 1 - Transition Phase

Begins when cervix is dilated 8 cm, ends when cervix is dilated 10 cm.

Contractions occur every 2 to 3 minutes

Duration of 60 to 90 seconds. The intensity of contractions

is strong. Completion of this phase

marks the end of the first stage of labor.

Urge to push or to have a BM

2nd Stage: Birth of the Baby

Begins when cervical dilatation is complete and ends with birth of the baby.

Dilatation and effacement – complete - Patient is instructed to push with each contraction to bring the presenting part down into the pelvis

Third Stage of Labor

The period from birth of the baby through delivery of the placenta.

Dangerous time because of the possibility of hemorrhaging.

Signs of the placental separation a. The uterus becomes globular in shape and

firmer. b. The uterus rises in the abdomen. c. The umbilical cord descends three inches or

more further out of the vagina. d. Sudden gush of blood.

4th stage

Period from the delivery of the placenta until the uterus remains firm on its own.

Uterus makes its initial readjustment to the non-pregnant state.

The primary goal is to prevent hemorrhage from the uterine atony and the cervical or vaginal lacerations.

Atony is the lack of normal muscle tone. Uterine atony is failure of the uterus to contract.

Fourth Stage of Labor

Referred as the Recovery StageFirst 4 hours after the birth.Blood loss is usually between 250 mL and

500 mL.Uterus should remain contracted to control

bleeding, positioned in the midline of the abdomen, level with the umbilicus.

Mother may experience shaking chills.

Intrathecal Block

Injected into the subarachnoid spaceRapid onsetLess sedationNo hypotension or motor block

Precipitated Birth Suddenly occurring and unexpectedly without a

physician or midwife to assist. Nursing intervention: Stay with mother Call for assistance Remain calm Open emergency birth pack Scrub if time permits As head crowns instruct mom to pant Suction newborn’s mouth and nose to

prevent aspiration

UMBILICAL PROLAPSE CORD1. Cord is protruding from the vagina. Goal is prevention of fetal anoxia. Management includes positioning

the mother on the left side in trendelenberg or in a knee-chest position and administering 100% oxygen.

If the cord is exposed, cover it with saline moistened sterile gauze. STAT C-section is performed.

Insert 2 fingers into the vagina with sterile gloves, and put pressure on the presenting part to relieve the compression of the cord.

Oxytocin Infusion SafetyDiscontinue infusion with oxytocin if the

following occur:Contractions are more frequent than every

2 minutes or duration is more than 90 seconds

Uterus resting tone is more than 20 mm hgFetal monitor shows: repeated late

decelerations, prolonged decelerations or no variability

CESAREAN BIRTH Birth of an infant through an incision in the abdomen and uterus.

Scheduled or unscheduled.

When C/Section is unscheduled: the nurse needs to review with the client events before the C/Section to ensure the client understands what happened

The Postpartum Period

Puerperium: Term 1st 6 weeks after the birth of an infant

Neonate–newborn from birth to 28 days.Family adaptation to neonate: Bonding–

rapid process of attachment during 1st 30 to 60 minutes after birth

Mother, father, siblings, grandparents

Uterine Involution Uterine Involution: return

of the uterus to its pre-pregnancy size and condition.

Normal postpartum uterus is firm and at midline

Uterine fundal descent: uterus size of grapefruit immediately after birth

Fundus rises to the umbilicus stays for 12 hours

Descends 1 cm (fingerbreadth) each day for about 10 days

Lochia Assessment Lochia–vaginal discharge after childbirth. It takes 6 weeks for the vagina to regain its pre-

pregnancy contour. Lochia: scant-moderate, rubra, serosa or alba Assessment of lochia includes noting color,

presence and size of clots and foul odor.

Day 1- 3 - lochia rubra (blood with small pieces of decidua and mucus)                               

Day 4-10 – lochia serosa (pink or pinkish brown serous exudate with cervical mucus, erythrocytes and leukocytes)

Day 11- 21 - lochia alba (yellowish white discharge)

Episiotomy Pain Relief

Instruct Mother:Tighten her buttocks and perineum before

sitting to prevent pulling on the episiotomy and perineal area and to release tightening after being seated.

Rest several times a day with feet elevated.

Practice Kegel exercise many times a day to increase circulation to the perineal area and to strengthen the perineal muscles.

Breast Assessment

Breasts: Soft, engorged, filling, swelling, redness, tenderness.

Nipples: Inverted, everted, cracked, bleeding, bruised, presence of colostrum or breastmilk.

Colostrum–yellowish fluid rich in antibodies and high in protein.

Engorgement occurs by day 3 or 4. Due to vasoconstriction as milk production begins

Lactation ceases within a week if breastfeeding is never begun or is stopped.

Postpartum Psychosis

A very serious type of PPD illness that can affect new mothers.

Begin 2-3 weeks post delivery Fatigue, restlessness,

insomnia, crying liable emotions, inability to move, irrationally statements incoherence confusion and obsessive concerns about the infant’s health

Psychiatric emergency

Nipple soreness is a portal of entry for bacteria - breast infection (Mastitis).

Maternal after pains: may be due to breastfeeding and multiparity (loss of uterine tone)

Always stay with the client when getting out of bed for the first time – hypotension effect and excess bleeding

When assessing fundal height, if you notice any discrepancies in fundal height have patient void and then reassess.

Postpartum Cesarean

Incision site…redness swelling, discharge. Intact? Abdomen soft, distended? Bowel sounds heard all

4 quadrants Flatus? Lochia is less amount than in normal

spontaneous vaginal delivery (NSVD) because uterus is wiped with sponges during c/section.

If lochia indicates excessive bleeding, combine palpation and pain management measures.

Auscultate breath sounds Fluid intake and output Pain?

Assessment of Edema & Homan’s Sign

Assess legs for presence and degree of edema; may have dependent edema in feet and legs.

Assess for Homan’s sign- thromboembolism Negative Homan’s Sign is with No PAIN If there is pain then it is positive (+) and the nurse

needs to report this finding immediately to the health care provider.

Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)

RhoGAM

It is given to an Rh- mother within 72 hours after delivery of an Rh+ infant or if the Rh is unknown.

Most people have Rh-positive blood. (Rh Factor)

An inherited protein found on the surface of RBCs.

A minority of individuals lack the Rh factor and are considered Rh-negative.

If the baby's Rh positive blood enters a mother who is Rh Negative, then her immune system sees the cells as 'foreign' and will produce anti-rhesus antibodies to try to destroy them for her own self-protection.

Thromboembolic Conditions

Thrombophlebitis–the formation of a clot in an inflamed vein.

Risk factors include maternal age over 35, cesarean birth, prolonged time in stirrups, obesity, smoking, and history of varicosities or venous thromboses.

Prevention: client needs to ambulate early after delivery.

Respiratory Distress

Respiratory Distress Syndrome (RDS)RDS: preterm infants/surfactant deficiencyHypoxia, respiratory acidosis and

metabolic acidosisSurfactant is produced by alveoli - lung

maturity L/S ratio (lecithin-to-sphingomyelin

ratio) is a test done before birth to determine fetal lung maturity.

These phospholipids stabilize alveoli so that they do not collapse on exhalation

Prophylactic Care

Vitamin K –to prevent hemorrhagic disorders – vit k (clotting process) is synthesized in the intestine requires food for this process.

Newborn’s stomach is sterile has no food. aquaMEPHYTON

Hepatitis B vaccination –within the first 12 hours

Eye prophylaxis –(Erythromycin Ointment) to prevent ophthalmia neonatorum – gonorrhea/chlamydia

The Head and Chest

The Head: Anterior fontanel diamond shaped 2-3 - 3-4 cms

Posterior fontanel triangular 0.5 - 1 cm

Fontanels soft, firm and flat head circumference is 33 –

35 cm The head is a few

centimeters larger than the chest!!!!

The Chest: circumference is 30.5 – 33 cm

Vital Signs normal

Temperature - range 36.5 to 37 axillary (97.7-98.6) Axillary vs Rectal about 0.2 to 0.5 difference

Common variations Crying may elevate temperature Stabilizes in 8 to 10 hours after delivery

Heart rate - range 120 to 160 beats per minute Apical pulse for one minute

Common variations Heart rate range to 100 when sleeping to 180 when crying Color pink with acrocyanosis Heart rate may be irregular with crying

Respiration - range 30 to 60 breaths per minute Blood pressure - not done routinely

Ranges between 60-80 mm systolic and 40-45 mm diastolic.

Common Normal Variations

Acrocyanosis - result of sluggish peripheral circulation.

Mongolian Spots: Patch of purple-black or blue-black color distributed over coccygeal and sacral regions of infants of African-American or Asian descent.

Milia: Tiny white bumps papules (plugged sebaceous glands) located over nose, cheek, and chin.

Erythema toxicum: Most common newborn rash. Variable, irregular macular patches. Lasts a few days.

Erythema toxicum, acrocyanosis, milia and mongolian spots

Caput succedaneum

Swelling of the soft tissue of the scalp caused by pressure of the fetal head on a cervix that is not fully dilated.

Swelling is generalized. may cross suture line and decreases rapidly in a few days after birth. Requires no treatment

2 – 3 days disappears

Cephalohematoma

Collection of blood between the periosteum and skull of newborn.

Does not cross suture lines

Caused by rupturing of the periosteal bridging veins due to friction and pressure during labor.

Lasts 3 – 6 weeks

Normal Reflexes

Babinski Reflex is (+) This is Normal Birth to after walking 12-18 months age

Tonic Neck Reflex (FENCING) EXTENDS arm & leg on the side

that the face points. Flexes opposite arm & leg 6-8 wks to 6 months

Gestational Age Relationship to Intrauterine Growth

Normal range of birth weight for each week of gestation.

Birth weight is classified as follows:Large for gestational age (LGA): weight falls

above the 90th percentile for gestational ageAppropriate for gestational age (AGA):

weight falls between the 90th and 10th percentile for gestational age

Small for gestational age (SGA): weight falls below the 10th percentile for gestational age

Newborn – Term vs Preterm The premature newborn has no flexion of

extremeties Full term newborn is fully flexed. Skin in a preterm is very transparent and thin Veins disappear as subcutaneous fat is

deposited. Lanugo is most abundant at 28 to 30 weeks

gestation a small amount may remain at full term Eyelids are fused until 26 to 28 weeks gestation Ears when folded remains folded at 32 weeks

and by 36 weeks there is enough cartilage for the ear to return to its original state when folded.

Bathing the Newborn

No tub bath until after the cord has fallen off and healing is complete.

Newborn’s first bath- the nurse needs to wear gloves to prevent infection.

What is wrong with this nursing action?

Circumcision

Circumcision is considered an elective procedure

Anesthesia should be provided. Parents must give written consent Full term health infants Aftercare: Check hourly for 12 hours Check for bleeding and voiding Before discharge: Newborn goes home within the first 12 hours

after procedure Bleeding should be minimal and infant must

void

Breastfeeding

Colostrum is rich in immunoglobulins to protect newborn GI tract from infection; laxative effect.

Breast milk in 2 weeks sufficient nutrients 20 kcal/oz (infant’s nutritional needs)

To support Breastfeeding: Mother needs to consume extra 500 calories per day.

Feeding length: should be long enough to remove all the foremilk (watery 1st milk from breast high in lactose - skim milk & effective in quenching thirst)

Hindmilk: higher in fat content leads to weight gain and more satisfying.

Breastfeeding time approximately 30 minutes

Infant Formula

Formula 7.5 ml to 15 ml at feeding gradually increase to 90 ml to 120 ml at each feeding in 2 weeks.

Formula preparation: mixing must be accurate to provide the 20 kcal/oz. (newborn nutritional need)

Burping: is needed to expel air swallowed when infant sucks.

Should be done about halfway through feeding for bottle feeders and when changing breasts for breast feeders.

Hyperbilirubinemia

Physiologic Jaundice =Appears 24 hours after birth peaks at 72 hrs.

Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days.

Due to Unconjugated bilirubin circulating in the blood stream that is deposited in the skin.

Immature liver unable to conjugate bilirubin released by destroyed RBC.

Pathologic Jaundice =Not appear until after 24 hrs leads to Kernicterus (deposits of bili in brain).

Bilirubin >20mg/dl The most common cause is Rh incompatibility.

Neural Tube Defects

3 types: Spina Bifida Occulta: failure of the vertebral arch

to close. Has dimple on the back with a tuft of hair. No treatment required.

Meningocele: saclike protrusion along the vertebral column filled with cerebrospinal fluid and meninges. Surgery required.

Myelomeningocele: saclike protrusion along the vertebral column filled with spinal fluid meninges, nerve roots, and spinal cord = paralysis. Surgical repair required.

Sterile saline dressing. hydrocepalus

Spina bifida occulta meningocele

Spina bifida Occulta myelomeningocele

Infants of DM mothers (IDM) Complications

Hypoglycemia: maternal glucose declines at birth. Infant has high level of insulin production= decreases infant’s blood glucose within hours after birth.

Respiratory Distress: less mature lungs due to insulin

Hyperbilirubinemia: hepatic immaturity, increased hematocrit, bruising due to difficult delivery.

Birth trauma: large size of infant Congenital birth defects: birth defects – Patent

Ductus Arteriosus, Ventricular Septal Defect and more.