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Common Discomforts

First Trimester
• Nausea & Vomiting
• Urinary Frequency
• Fatigue
• Breast Tenderness
• Increased Vaginal Discharge
• Nasal Stuffiness
• Epistaxia
• Ptyalism - excessive saliva

Common Discomforts

Second & Third Trimester
• Heartburn
• Ankle Edema
• Varicose Veins
• Hemorrhoids
• Constipation
• Backache
• Difficulty Sleeping
• Leg Cramps
• Faintness
• Dyspnea
• Flatulence
• Carpal Tunnels
• Round Ligament Pain

(Basic Teaching for the Pregnant Women) Fetal Activity Monitoring

• Recommended to begin at 28 weeks
• Lie down on left side and count fetal movements
• Should have at least 10 movements in 2 hours
• Decreased movement or no movement indicate possible fetal hypoxia
• Fetal activity affected by fetal sleep, sound, time of day, blood glucose level, cigarette smoking or drug use

(Basic Teaching for the Pregnant Women) Breast Preparation

• Advised not to use soap on nipples because of drying affect
• Braless - clothing rub against nipples and toughen them
• Expose nipples to sunlight and air
• Nipple rolling/stimulation
- Contraindicated in women with a history of pre-term labor
- Nipple stimulation triggers release of oxytocin
• Inverted nipples - can place "breast shells" in bra

(Basic Teaching for the Pregnant Women) Bathing

• No contraindications
• Caution related to safety factors in late pregnancy
• Avoid tub baths if membrane is ruptured - increased risk of infection

(Basic Teaching for the Pregnant Women) Travel

• No restrictions
• Avoid if history of bleeding, pre-eclamspia, multiple gestation
• Automobiles are particularly fatiguing and uncomfortable
- Recommend stopping every 2 hours to walk
- Should wear lap and shoulder belt
- Abruptio placenta major complication with MVA
• Long distance trips best by plane

(Basic Teaching for the Pregnant Women) Exercise

Normal participation can continue through uncomplicated pregnancy
• Contraindications - ROM, pre-eclampsia, incompetent cervix, persistent vaginal bleeding, pre-term labor, IUGR
• Is not a time to begin new activities
• Improves self image, promotes regular bowel function, controls weight gain, associated with improved postpartum recovery
• Avoid exercising in supine position

(Basic Teaching for the Pregnant Women) Exercise

• Walking, swimming and cycling best because of low risk for injury
• Avoid overheating - has a potential teratogenic effect on fetus
- Core body temperature should not be above 100.4
- Avoid sauna and hot tubs
- May soak in hot tub for 10 mins if temperature is maintained at LESS THAN 98 degrees

(Basic Teaching for the Pregnant Women) Sexual Activity

• No contraindications in a healthy pregnancy
• Refrain from intercourse if multiple pregnancy, threatened abortion, incompetent cervix, STDs
• Avoid intercourse if ROM or preterm labor
- Increased contractions with orgasm and/or ejaculation

(Basic Teaching for the Pregnant Women) Dental Care

• Link identified between periodontal disease and pre-term labor and low birth weight infants
• Avoid those with attenuated live viruses such as rubellla, chicken pox, mumps or smallpox vaccine
• Vaccines using "killed" viruses may be used
• Consult with health care provider about complementary & alternative therapies
- Some herbs are dangerous during pregnancy

Dangerous Signs in Pregnancy

• Premature ROM - sudden gush of fluid from vagina
• Vaginal Bleeding - Abruptio placenta, Placenta Previa, bloody show, miscarriage
• Abdominal Pain - premature labor, abruptio placenta
• Infection - temperature above 101
• Toxemia/Pre-Eclampsia (PIH) - dizziness, blurred vision, spots before eyes, severe headache, edema of hands, legs, face and feet

Dangerous Signs in Pregnancy

• Severe Toxemia/Pre-Eclampsia - epigastric pain
• Hyperemesis Gravidarum - persistant vomiting
• Oliguria - renal impairment, decreased fluid intake, PIH
• Dysuria - UTI
• Absence of fetal movement - maternal medication, obesity, fetal death

Teratogenic Substances

Any substance that adversely affects normal growth and development of fetus
• Greatest risk during first trimester
• Certain medications, psychotropic drugs, alcohol, tobacco
• Environmental factors such as pesticides, x-rays
• Need to weigh benefits of prescription medication
- Only Category A drugs considered safe
- Also caution with OTC drugs

Recommendation For Tobacco Use

• Stop or decrease number of cigarettes smoked per day
• Associated with low birth weight, preterm, placenta previa, placenta abruptio, ectopic pregnancy, premature ROM, increased risk of cleft lip/palate, SIDS, acute respiratory illness in infant, chronic respiratory problems
• Adverse effects related to carbon monoxide and nicotine

Recommendation For Alcohol Consuption

• No safe limit has been identified
• Recommened that pregnant woman abstain from ALL alcohol intake
• Heavy intake associated with Fetal Alcohol Syndrome

Recommendation For Caffiene Intake

• Increased risk of miscarriage in early pregnancy
• Advised to limit intake to no more than 3 cups of coffee or cola a day
• Decreases iron absorption

Recommendation For Illicit Drugs

• No identified teratogenic effects because of it being an illicit drug
• Thought to have adverse effects on CNS
• Risks for mom and fetus
• Associated with abruptio placenta, preterm, fetal distress, low birth weight, neonatal withdrawal, SIDS, spontaneous pneumothorax, congenital anomalies
• Urine screening only accurate for 1st 24-48 hours after drug use
• Can test meconium of baby for drug use during pregnancy

Historical Perspective of Childbirth Education

• 1933, Grantly Dick-Reed published book, Childbirth Without Fear. Talked about the fear-tension-pain syndrome
• 1951, Ferdinand Lamaze abserved the Psychorophylactic Method of Childbirht Preparation
- Method based on conditioned response to pain
• 1961, American Society of Psychoprophylaxis in Obstetrics (ASPO) founded
• Bradley Method - first to introduce husband as host
• Today's childbirth education - education, controlled relaxation, breathing patterns, exercises

Test That Assess Fetal Well Being

• Nonstress Test (NST)
• Biphysical Profile (BPP)
• Ultrasound
• Amniocentesis
• Chorionic Villus Sampling

Nonstress Test (NST)

Ordered to assess how well the placenta is functioning
• Indications: Post-dates, Maternal history of pregnancy complications, SGA, Decreased amniotic fluid
• Monitors externally, non-invasive
• Reactive test demonstrates 2 accelerations in 20 mins
• Statistically, a "reactive test" suggests that the placenta will provide adequate oxygen to the fetus for approximately the next 7 days
• Test will be ordered weekly

Biophysical Profile (BPP)

Utilizes ultrasound to evaluate fetal breathing movements, fetal movement of body and limbs, muscle tone, amniotic fluid volume and reactive NST
• A score 2 is assigned to each category for a total of 10
- Score of 8 is considered normal
• Also ordered to assess how well the placenta is functioning
- MORE definitive than NST


Assess fetus for genetic or congenital problems, abnormalities in size, shape or structure
• Gestational dating most accurate in 1st trimester
• Best done at 18-20 weeks


• Indications: Advanced maternal age, previous child born with chromosomal abnormality, parent carrying a chromosomal abnormality, family history of neural tube defects (anacephaly, spina bifida, omphalocele),
• Done at 16-18 weeks gestation

Chorionic Villus Sampling

Diagnostic capability similar to amniocentesis
• Done at 8-10 weeks gestation

Abortion (Miscarriage)

Expulsion of fetus prior to 20 weeks gestation
• A 1st/2nd trimester problem
• Major cause of bleeding during this time
• Types:
- Spontaneous (Miscarriage): occurs "naturally"
- Induced: result of artificial or mechanical interventions
- Missed: fetus dies in utero but is not expelled
- Threatened: unexplained bleeding, cramping, backache but cervix is closed

Abortion (Miscarriage)

Signs & Symptoms
• Spotting, bleeding
• Cramping & Backache
• Bedrest, IVs, blood transfusion, D&C
• Give Rhogam if RH negative
• Prepare woman for possible fetal loss
• Remember that ambivalence is common in 1st trimester. Might have guilt
• Encourage expression of feelings
• Give accurate information
• Support groups

Ectopic Pregnancy

Implantation of blastocyte in a site other than the endometrial lining of uterus
• Most common site: ampulla of tube
• Major symptom: pain
• Diagnosis: Ultrasound, serial serum hCG, serum progesterone levels
• Treatment: IVs, blood transfusion, surgery

Abruptio Placenta

Premature separation of a normally implanted placenta from the uterine wall
• Dark red bleeding associated with abdominal pain
• Uterus hard, firm and painful
• Cause Unknown
- Theory: caused by decreased blood flow to placenta, excessive uterine pressure, MVA, cocaine use, HTN, smoking, alcohol or drug ingestion, increased maternal age, increase parity, trauma
• Major concern is that circulation of fetus is affected when placenta separates

Placenta Previa

Placenta implanted in the lower uterine segment instead of in the upper portion of uterus
• Painless bright red bleeding
• Uterus is soft
• Major Concern is fetal hypoxia
- placenta circulation is affected when placenta detaches as cervix "opens up"
• When placenta detaches, bleeding occurs
- scant to profuse
- may hemorrhage rapidly

Incompetent Cervix (Cervical Insufficiency)

Premature dilation of cervix, 4-5 mons
• Associated with repeated 2nd trimester abortion
• Causes: cervical trauma, previous surgery on cervix, congenital defects
• Diagnosis: from history of multiple miscarriages, repeated pre-term delivery
• Treatment: Cerclage (Shirodkar-Barter)

Torch Infections

Group of infectious diseases that can cause serious harm to the embryo/fetus
• Toxoplasmosis
• Rubella
• Cytomegalovirus
• Herpes

Torch Infections

• Avoid poorly cooked or raw meats, wild game such as deer or rabbit, unwashed fruit/vegetables
• Avoid contact with the cat litter box
• Stress importance of wearing gloves while gardening
• Stress importance of receiving rubella vaccine AFTER delivery if non-immune

Torch Infections

• Can be transmitted through placenta to baby
• Causes birth defects and developmental disabilities (hearing loss, lower IQ, small head, cerebral palsy)
• Contracted by pregnant woman through exposure to child's saliva or urine
• Counsel pregnant woman to:
- wash hands after changing diaper or wiping runny nose
- avoid sharing food, drink or utensils with younger children
• C-Section will be method of delivery if herpes is active
• Valtrex given prophylactically to prevent outbreak

Premature Rupture of Membrane

Spontaneous rupture & leakage of fluid prior to onset of labor
• Pre-Term ROM - prior to 37 weeks gestation
• Associated with infection, previous history of ROM, polyhydraminos, multiple pregnancies, smoking, incompetent cervix, maternal reproductive tract abnormalities
• Assess: nitrizine paper, ferning, how long ROM, calculate gestational age to determine if baby is safe to deliver

Premature Rupture of Membrane

Risk To Mother
• Infection in uterus from ascending pathogens
• Stress related to condition of child
• Prolonged hospitalization
Risk to Fetus/Infant
• Fetal sepsis due to ascending pathogens
• Prolapse of umbilical cord
• Malpresentation
• Increased perinatal morbidity and mortality

Preterm Labor

Labor that occurs between 20-37 completed weeks
• Symptoms:
- Mild, menstrual like cramps in lower abdomen
- Uterine contractions every 10 mins or less
- Pelvic pressure: constant or intermittent
- Low backache
- Change in vaginal discharge: increased amount, more clear and watery, pinkish tinge
- Abdominal cramping with or without diarrhea

Preterm Labor

• Rest on left side
• Drink 2-3 quarts of fluid each day
• Avoid caffeine drinks
• Empty bladder every 2 hours
• Avoid lifting heavy object, nipple stimulation, sexual activity

Scope of Practice For LPN

• Assist with collection of data during labor process
• Assist the RN, APN, or MD during delivery
• Identify basic problems (actual & potential) and assist with developing the plan of care
• Provide basic teaching from established teaching plans

Scope of Practice For RN

• Comprehensive assessment of laboring woman
• Analyze assessment findings
• Care for patients with complex problems during L&D
• Establish nursing diagnosis and plan appropriate care
• Plan and carryout teaching based on individual needs

Five P's of Labor

• Passage
• Pasennger
• Powers
• Positionof Mother
• Psyc

The Passage

Pelvis & Birth Canal
• Type of Pelvis - gynecoid (open, roomy)
• Ability of cervix to change:
- efface: 0-100%
- dilate: 0-10cm
• Ability of vaginal canal and external opening of vagina (introitus) to distend
• More than 6 vaginal exams during labor increases risk for infection

The Passenger

Fetus & Placenta
• Fetal Head
• Fetal Attitude
• Fetal Lie
• Fetal Presentation
• Fetal Position
• Placenta Implantation Site

Position of Fetus

• Determines type of delivery
• Affects nursing care given to patient
• Abnormal positions may lead to difficult delivery
- breeched - buttock first
• Can change up until "engagement" occurs
• Ballotable - ability of baby head to be pushed from cervix
• Determined by Leopold's Maneuvers and Ultrasound


• Occurs when the largest diameter of fetus reaches or passes through the pelvic inlet
• In primigravida, usually occurs 2 weeks before term
• Multipara, may occur several weeks before labor or during labor
• Confirms the adequacy of the pelvic inlet (not midpelvis or outlet)
• Fetal presentation - occipital should be facing front. (baby looking back towards moms spine) pelvis is narrower in front


Relationship of presenting part to an imaginary line drawn between ischial spines of maternal pelvic
• Narrowest diameter
• Designated as "0" station
• Higher than ischial spines = -number
• Lower than ishcial spines = +number

The Powers

• Primary force is uterine muscular contractions
- begins in fundus where greatest concentration of muscle fibers are located
• Causes dilation and effacement of cervix
• Causes changes in station
• Secondary force is use of abdominal muscles to "PUSH"

Uterine Contractions

• Rhythmic but intermittent
- relaxation provides rest for uterine muscles, rest for laboring woman and restores uteroplacental circulation
• Three Phases:
- Increment: Building up
- Acme: Peak
- Decrement: Fading Away
• May monitor externally or internally with Intrauterine Pressure Catheter (IUPC)
• Essential to assess fetus' tolerance to contractions


How often contractions occur
• Determined from the beginning of one contraction to the beginning of the next contraction
- round to nearest half minute
• Normal frequency is 5 contractions or less in a 10 minute period
• Tachysystole - more than 5 contractions in a 10 minute period for over 30 minutes
- increases risk for fetal distress
- decrease Pitocin, side-lying position


How long a contraction lasts
• Determined from the beginning of a contraction to the end of that contraction
• Should NOT last longer than 90 seconds


How strong a contraction is
• Mild, moderate, strong
• When monitoring externally, palpate the fundal area
• MVU's - when monitoring internally

Resting Tone

Uterus should be relaxed between end of one contraction and beginning of next contraction
• Need to have 30 seconds or more of resting period between contractions
• Palpate fundal area

The Position of Laboring Woman

• Upright position recommended
- walking, sitting, kneeling, or squatting
• Lateral position when lying down

The Psyc

• Uncertain of what labor will be like
• Concern that she will live up to her own expectations of self
• Fear of injury
• Fear of lack of support
• Disruption of lifestyles, relationships and self image
• Concern about loss of control of bodily functions, emotional responses and reaction to pain

Pre-Labor Signs

• Lightening - baby moving down pelvis
• Braxton-Hicks Contractions
- irregular, intermittent, painless
- become more painful as term approaches
- described as "drawing" sensation
• Ripening of cervix
• Bloody Show - pink tinged secretions from cervical capillaries
• Burst of energy
• Diarrhea, nausea and vomiting (can be caused by Prostaglandins)
• Increased backache and sacroiliac pressure
- results from hormones
• 1-3 pound weight loss
- results from fluid loss and electrolyte shift

True Labor

• Contractions are regular
• Interval between contractions gradually shorten
• Increase in duration and intensity of contractions
• Discomfort begins in back and radiates to abdomen
• Intensity increases with walking
• PROGRESSIVE cervical dilation and effacement

False Labor

• Contractions irregular
• No change in duration and intensity of contractions
• Discomfort usually in abdomen
• Walking has no effect on contractions or lessens severity of contractions
• NO cervical change

Stages of Labor

• First: from beginning of labor to complete dilation and effacement of cervix
- Latent or early phase: 0-3 cm
- Active phase: 4-7 cm
- Transition phase: 8-10 cm
- Inducing labor increases risk for c section because it's doesnt allow cervix to naturally dilate
• Second: begins with complete dilation of cervix and ends with birth of baby. "PUSHING"
- Crowning
- Episiotomy: midline or mediolateral

Stages of Labor

• Third: begins with birth of baby and ends with delivery of placenta
• Fourth: first 1-2 hours after delivery of placenta; initial recovery time
- Expected amount of blood loss: 250-500ml for vaginal delivery
- Essential for uterus to remain contracted
- Priority Problems during this stage: Risk for hemorrhage, hypotonic bladder

Maternal Physiologic Response to Labor

• Increased CO and heart rate
• Increased BP, especially during contractions
• Supine Hypotensive Syndrome
• Stage 2: Valsalva maneuver

Fluid & Electrolytes
• Diaphoresis
• Hyperventilation


Maternal Physiologic Response to Labor

Body Temperature
• Slight elevation due to muscle activity
• Temperature over 100.4 is a sign of infection
- need to asses every 2 hours for rupture of membranes
• Increase fluid loss from sweating and evaporation of skin
• Increase respiratory rate
• Increased oxygen demand and consumption
• Hyperventilation and fall in PaCO2 results in RESPIRATORY ALKALOSIS
• No more than 30 breaths per min


A procedure in which a needle is inserted through the abdominal and uterine walls into the amniotic fluid; fluid is withdrawn; used for assessment of fetal health and maturity.
• Possible after 14 weeks
• Performed to obtain amniotic fluid (which contain fetal cells) for the purpose of a biochemical assessment/analysis of the amniotic fluid.
• Clinical significance: to evaluate for genetic disorders or congenital anomalies, assessment of pulmonary maturity, and diagnosis of fetal hemolytic disease

Maternal Physiologic Response to Labor

• Gastric motility decreased
• Gastric emptying prolonged
• Increased risk of aspiration with anesthesia
• Increased WBC - may be 15,000 or higher
• Increased fibrinogen
• Decreased blood glucose
• Slight proteinuria

Fetal Response to Labor

• Positive effects: decreased respiratory tract secretions
• Potential adverse effects: decreased placental perfusion, hypoxia

Pain Theories

• Gate-Control Theory - suggest a gating mechanism controlling transmission of painful stimuli
• Endogenous Pain Control Theory:
- Internally produced substances called endorphins that affect pain perception
- Endorphin levels higher just prior to labor
• Increased labor pain is correlated with decreased placenta perfusion

Pain Relief Options

Non-Pharmacological - • Relaxation techniques
- muscle tension causes fatigue and increased oxygen demand
- comfortable position
• Cutaneous stimulation
- Massage of large muscle groups stimulates gate-control theory
- Efflurage - massage of abdomen (flat hand stroking)
- Heating pad, warm shower, bath
- counter-pressure to low back
• Breathing techniques
- form of distraction
- enhances relaxation and provides good O2 exchange
- teach slow deep breathing if no prenatal education
• Patient hygiene and comfort measures

Pain Relief Options

Pharmacologic - • Nubain - systemic analgesia
- drug of choice
- recommended to wait until labor established
- IM, SubQ or IV
- should not be given within a few hours of birth because it may depress neonatal respirations
- antidote is Narcan
• Pudenal Block - provides perineal numbness
- used during stage 2

Pain Relief

Anesthesia - • Local - used during 2nd stage to provide perineal numbness
• Regional - Epidural (into dura, 75% numbness)
- Major side effect: hypotension
- Bolus of fluid prior to procedure, monitor BP ever 5 mins after procedure, side-lying down position, monitor for urinary retention
- Contraindications: low platelets, increases hemorrhage risk

Pain Relief

Anesthesia - • Regional - Spinal (L4,L5)
- Major side effect: hypotension
- Immediate effects
- Used during 2nd stage
- Tilt patient to side during C-section to lessen hypotensive effects
• General - only used for EMERGENCIES, high risk for fetal depression

Maternal Assessment

• Review prenatal history
• Identify risk factors
• Maternal VS, labor status, uterine activity, fetal status and alb values
- once patient in active phase must assess at least every 30 mins
• Don't forget assessment of pain and psychosocial status

Assessment of Fetus

• Fetal Heart Rate Pattern
- evaluate at least every 30mins
- external or internal
- membranes must be ruptured for internal monitoring (scalp electrode)
• Fetal movement
• Fetal response to scalp stimulation or sound
• Umbilical cord acid-base determination - done AFTER delivery
• Presence of meconium in amniotic fluid (yellow/green fluid)
- Suggest fetal stress (hypoxia)
- is sterile, but irritating to lungs
- Risk to infant's respiratory system once born

Fetal Heart Rate

Gives information about wellness of fetus
• Baseline 110-160
- recorded in increments of 5
• Look at 10 minute period of time EXCLUDING accelerations and decellerations
- prolonged decel over 10 mins indicates a baseline change
• Record average
• Monitor internally or externally
• Assess in relation to uterine contraction
• Reaction to scalp stimulation

Baseline Fetal Heart Rate Changes

• Bradycardia - baseline less than 110 bpm for 10 minutes or longer
- hypoxia, decreased BP, cord compression or prolapse
Tachycardia - baseline more than 160 bpm for 10 mins or longer
- prematurity, maternal fever, early hypoxia, medications, nicotine


Interplay of sympathetic and parasympathtetic nervous system causing fluctuations in FHR
• Can determine when monitoring externally
- Absent: no change in FHR (BAD)
- Minimal: change less than 5 bpm
- Moderate: change of 6-25 bpm (IDEAL)
- Marked: change greater than 25 bpm
• Important indicator of oxygen reserve
• Decreased variability could be due to fetal sleep, drugs, hypoxia, prematurity
• Increased could be due to early hypoxia, fetal activity or stimulation


• Abrupt increase if FHR of at least 15 beats lasting at least 15 seconds
• Indicate good oxygen reserve
• Scalp stimulation should cause accelerations
- if not, then baby might be hypoxic

Early Decelerations

• Results of head compression that results in a reflex vagal response
• Occurs at the same time as the contraction and is back to baseline by the end of contraction
• Gradual slowing of FHR (onset to lowest point of the deceleration, "nadir", is more than 30 seconds
• Usually a result of baby moving down the birth canal
• No intervention necessary

Variable Decelerations

• Result from decreased umbilical cord perfusion, usually caused by cord compression
• Abrupt decrease in FHR of at least 15 beats
• Onset of decel to lowest point occurs in LESS than 30 seconds
• Are sharp V shaped, or other odd shapes and can happen at any point during a contraction
• Interventions - change position, give O2, stop Pitocin, amnioinfusion

Late Decelerations

• Restult of uteroplacental insufficiency
• Gradual decrease of FHR associated with a contraction
• Lowest point of the decel (nadir) occurs after the peak of the contraction
• Takes 30 seconds or more from baseline to nadir
• Interventions: left side position (PRIORITY), O2, increase rate of IV (increases CO which increases placental perfusion), elevate legs, stop Pitocin

Prolonged Decelerations

• Decelerations of at least 15 beats lasting longer than 2 minutes but less than 10 minutes
• Could be result of hypotension, vagal stimulation, cord prolapse, uterine rupture, rapid fetal descent, oligohydraminos

Sinusoidal Fetal Heart Rate

• Smooth, wave-like, "undulating" pattern in FHR baseline
• Has a cycle frequency of 3-5 minutes lasting for more than 20 minutes

Veal Chop

Periodic Change Cause
V ariable decelerations = C ord compression
E arly Deceleration. = H ead compression
A ccelertion. = O ptimal oxygenation
L ate deceleration. = P oor perfusion/placental insufficiency

Goals for Treatment of Non-Reassuring FHR Patters

• Maximize Utero-Placental Blood Flow
- Position patient on side
- IV Hydration
- Ephedrine: restores normal blood pressure
- Reduce pain & anxiety
• Maximize Umbilical Circulation
- Position change
- Elevation of presenting part off cord (cord prolapse)
- Amnioinfusion

Goals for Treatment of Non-Reassuring FHR Patters

• Maximize Oxygenation
- Position change
- O2 at 10 L
- Guide breathing techniques
- Correct underlying maternal disease
• Reduce Uterine Activity
- Position change
- Reduce/Discontinue Pitocin
- Hydration
- Terbutaline: medication to relax uterus

Fetal Distress

Situation that if untreated may lead to serius injury or death of fetus
• Identified through FHR pattern, i.e. persistane late decels, persisiten severe variable decels or prolonged decels
- suggest compromised oxygen supply to fetus
- treat with O2, position change, IV fluids, pharmacologic relaxation of uterus

Fetal Heart Rate Classification System

Category I (Normal)
• Baseline rate 110-160 bpm
• Moderate variability
• No late or variable decelerations
• May have accelerations or early decelerations

Fetal Heart Rate Classification System

Category II (Indeterminate)
• Bradycardia not accompanied by absent variability
• Tacycardic FHR baseline
• Minimal variability or absent variability NOT accompanied by reccurent decels
• Marked baseline variability
• No accelerations in response to fetal scalp stimulation
• Recurrent variable deceleration, prolonged decelerations, reccurent late deceleration with moderate variability

Fetal Heart Rate Classification System

Category III (Abnormal)
• Absent baseline variability and recurrent late decels, recurrent variable decels or bradycardia
• Sinusoidal Pattern

Group B Strep

• Vaginal culture done at approximately 36 weeks
• If positive: mother will be given prophylactic antibiotics during labor
- optimal: receives treatment at least 4 hours before delivery
• Risk for baby developing infection from mother's GBS

First Stage of Labor: Interventions

• Admission assessment, H&P
• Ongoing assessment every hour
- VS, contraction pattern, FHR, urine output, pain
• Assessment of cervical status PRN
- limit vaginal exams especially if ROM
• Assess status of membranes
- ALWAYS assess FHT's immediately after ROM - risk of prolapsed cord
• Encourage ambulation unless ROM without "engagement"
- side lying position while in bed
• Shave prep and enema
- not routinely done today (done routinely to prevent contamination of vaginal area during delivery)

First Stage of Labor: Interventions

• NPO except ice chips
- may allow clear liquids
- assess for dehydration
• Comfort and hygiene measures
• Teach patient information to get though labor
- explain procedures, keep informed
- latent/early phase is best time
• Respect privacy
• As patient approaches the end of stage 1, she often complains of increased perineal pressure and urge to push
• She may complain of need to defecate
• Check cervical status
• Have patient breathe through contraction or pant

Second Stage of Labor: Interventions

• S&S: sudden increase in bloody show, uncontrolled bearing down efforts, bulging of perineum
• Teach pushing technique
- breath holding technique - causes valsalva
- exhalation pushing
• Continuous support
• Active participant
• Keep perineal area clean

Second Stage of Labor: Interventions

• Position: head elevated approximately 45 degrees, flexed on chest, shoulders rounded, legs bent and pulled towads head
• Change position: particularly if FHR complications
- side-lying, hands and knees, squatting
• Inform patient of progress
• Episotomy: mid-line or mediolateral
• Responsible for infant once born

Third/Fourth Stage of Labor: Interventions

Infant Responsibilities - • Suction immediately after birth
- if meconium present, extremely important to prevent meconium aspiration
- have support team/neonatologist present
• Maintain body temperature
- dry infant, radiant warmer, wrap in blanket
• Identify: bracelets, footprints
• Apgar: DOES NOT direct care
- done at one minute after birth and 5 minutes after birth
- heart rate, respiratory effort, muscle tone, reflex irritability, color

Fourth Stage of Labor: Interventions

• Care for Mom
- assess every 15 minutes: VS, fundus, lochia
- fundal massage if fundus is relaxed/boggy
- monitor IV
- may have PO fluids/food
• Care for Baby
- assess temp, HR, RR, color ever 30 minutes
- suction PRN
- encourage bonding
• Initial bonding extremely important
- encourage to hold, breastfeeding
- dim lights
- delay eye prophylaxis
• Support patient
• Oxytocin after delivery of placenta

Fetal Malposition

• Posterior position most common
- also: brow, face, breech, shoulder presentations
• Labor length icnreased
• Increased need for intervention
• External version may be attempted
- usually attempt to turn the fetus from breech to cephalic
- significant risk of cord compression &/or entanglement
- NEVER done with multiple gestation
- medicated with Terbutaline prior to procedure to relax uterus


Infusion of warmed, sterile fluid into the uterine cavity through intrauterine catheter
• Indications: Oligohydraminos, thick meconium stained fluid, variable decels
• Itnerventions: Monitoring, comfort measures, peri-care, bed rest

Induction of Labor

Artifical stimulation of labor
• Reasons:
- medical condition of mother or fetus
- post-dates
- decreased amniotic fluid
- non-reasuring antenatal testing
- large infant
• Assess: position, presentation of fetus, gestation
- the more favorable the cervix; the more likely the induction will be successful

Induction of Labor: Types

• Amniotomy: not color, odor, amount
• Pharmacological: Oxytocin & Cervical Ripening Agents
• Oxytocin: major complication - tachysystole (more than 5 contractions in 10 mins or less than 30 second rest period)
- causes contraction to become irregular
- risk of abruptio placenta or uterine rupture
- assess for signs of fetal distress
• Cervical Ripening Agents
- Prostaglandin Gel - Prepidil & Cervidil
- Misoprostal - Cytotec

Induction of Labor: Nursing Responsibilities

• Monitor VS of mother
• Monitor fetal response to contractions
- FHR baseline
- Variability
- Presence of decels
• Monitor contraction pattern
• Monitor I&O
• Major concern is tachysystole resulting in:
- fetal distress
- uterine rupture


Surgical incision of perineum
• Mid-line or Mediolateral
• Purpose: minimize stretching of perineum, decrease chance of infection , decrease trauma to fetal head, shorten length of second stage
• Disadvantages: may extend into longer incision or laceration, infection, increased pain
• Performed just before birth when presenting part is crowning
• Ice may be used during stage four


Can occur in conjunction with episiotomy
• 1st Degree: limited to superficial tissue
• 2nd Degree: involves skin, mucous membrane, and muscle of perineum
- similar to episiotomy
• 3rd Degree: extends to the anal sphincter but does not rip through the rectal mucosa
• 4th Degree: laceration extending through the rectal mucosa

Forceps Delivery

Use of an instrument to provide traction or assist in rotating fetus
• Indications:
- provide assistance during 2nd stage when client is exhausted or has decreased pushing efforts related to anesthesia
- speedy delivery with non-reassuring FHR
• Disadvantages:
- vaginal or perneal lacerations, postpartal hemorrhage
- trauma to fetus: ecchymosis/edema of face, facial paralysis

Vacuum Assisted Delivery

Use of suction to help deliver baby
• Soft silicon cup is attached by tubes to suction bottle or pump
• Traction applies with contraction
• Indications same as forceps
• Risks:
- cephalohematoma
- brachial plexus palsy
- elevated bilirubin
- retinal & intracranial hemorrhage

Cesarean Section

Surgical delivery of infant though abdominal tissue
• Indications: fetal distress, dystocia (difficult labor), malpresentation, CPD, cord prolapse, failure to progress, previous c-section, multiple gestation, preterm, active herpes, placenta previa or abruptio
• Risk:
- maternal: infection, hemorrhage, blood clots, injury to bladder
- infant: wet lungs

Cesarean Section

• Types:
- lower uterine segment: least blood loss and scar less likely to rupture
- classic: not done today except acute emergencies. Incision made up high in uterine body. Associated with complications with subsequent pregnancies and deliveries
• Prep: shave, foley, IV, medication to decrease gastric secretions/acidity, educate
• Major surgery
• Recovery during postpartum period will be longer

VBAC (Vaginal Birth After Cesarean)

• Need to asses why prior c-section was done
• never done if patient had classical incision
- increase risk of uterine rupture
• Assess frequently: contraction patter, signs of fetal distress, maternal VS
• May use Pitocin, but need to evaluate carefully during labor

Complications of Labor & Delivery

• Uterine Rupture
- may occur late in pregnancy or during labor
- extreme pain and cessation of uterine contractions
- increased risk with previous c-section
• Intrauterine Fetal Death
- prolonged retention of fetus may lead to DIC
- most women have spontaneous labor within 2 weeks
- may induce

Accelerations (Fetal)

Is defined as a visually abrupt (onset to peak less than 30 seconds) increase in FHR above the baseline rate
• The increase is 15 beats/min or greater and lasts 15 seconds or more, with the return to baseline less than 2 minutes from the beginning of the acceleration.
• An acceleration lasting > 10 minutes is considered a baseline change.


• Spontaneous fetal movement,
• Vaginal contractions,
• Electrode application,
• Fetal reation to external sounds,
• Breech presentation,
• Occiput posterior position,
• Uterine contractions,
• Fundal pressure,
• Abdominal palpation


Clinical Significance:
• Normal patter: Acceleration with fetal movement signifies fetal well being representing fetal alertness or arousal states.
- Nursing intervention: None required

Baseline Fetal Heartrate

Average FHR during a 10 minute period that excludes periodic and episodic changes and periods of marked variability,
• Recorded as a single number not a range.

Fetal Bradycardia

Baseline FHR < 110 BPM lasting More than 10 minutes
• Can Indicate: atrioventricular dissociation, structural defect, viral infections, medications, fetal heart failure, maternal hypoglycemia)

Fetal Tachycardia

Baseline FHR > 160 BPM lasting longer than 10 minutes
• Can Indicate: early fetal hypoxemia, fetal cardiac arrhythmias, maternal fever, infection, parasympathetic drugs

Normal Fetal Heartrate

110 - 1160 beats/min


The segment of uterine labor contractions during which muscle tension is greatest.
• Highest point; Peak.

Apgar Score

Permits a rapid assessment of the newborn's transition to extra-uterine life base on 5 signs: heart rate, respiratory effort, muscle tone, reflex irritability, color
• Scores of 0 - 3 indicate severe distress
• Scores of 4 - 6 indicate moderate difficulty
• Scores of 7 - 10 indicate infant is having no difficulty adjusting to extrauterine life
• Assigned at 1 min and 5 mins after birth.

Apgar Score

Heart Rate
• Absent = 0
• Slow (< 100 BPM) = 1
• > 100 BPM = 2

Apgar Score

Respiratory Effort
• Absent = 0
• Slow weak cry = 1
• Good Cry = 2

Apgar Score

Muscle Tone
• Flaccid = 0
• Some flexion of extremities = 1
• Well Flexed = 2

Apgar Score

Reflex irritability
• No Response = 0
• Grimace = 1
• Cry = 2

Apgar Score

• Blue - Pale = 0
• Body Pink, extremities blue = 1
• Completely pink = 2

Bloody Show

Vaginal discharge that originates in the cervix and consists of blood and mucus; increases as cervix dilates
• Labor usually results in next several weeks
• Pink-tinged secretions from cervical capillaries
- distinguished from bleeding by the fact that it is pink and feels sticky (related to mucoid nature).
• Very little bloody show in the beginning, the amount increases with effacement and dilation.

Braxton-Hicks Contractions

Contractions that facilitate uterine blood flow through the intervillous spaces of the placenta, promoting O2 delivery to the fetus.
• Pre-labor sign;
• Irregular, intermittent painless.
- Become painful as term approaches. Described as drawing (pulling up) sensation.
• After 4th months uterine contractions can be felt through abdominal wall.
• Usually ceases with walking or exercise

Cervical Dilation

Enlargement or widening of the cervical opening and canal that occurs once labor has begun.
• The diameter of the cervix increases from less than 1 cm to full dilation (approx. 10 cm) to allow birth of a term fetus.
• Cervix can not be palpated when fully dilated and completely retracted it
- Full dilation marks the end of the first stage of labor.
• Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by presenting part can promote cervical dilation.
• Scarring of the cervix (as a result of prior infection or surgery) may slow cervical dilation


Occurs when the widest part of the head (the biparietal diameter) distends the vulva just before birth.
• Stage of birth when the top of the fetal head can be seen at the vaginal orifice as the widest part of the head distends the vulva

Uterine Contractions

Each contraction exhibits a wave like patter:
• Increment - build up
• Acme - peak
• Decrement - fading away
• Interval of rest ends when next contraction begins

Uterine Contractions

• How often: Beginning of 1 contraction to beginning of next
• Normal frequency 5 or less in 10 minute period

Uterine Contractions

• How long: Beginning of contraction to end of contraction
• Should last no longer than 90 seconds

Uterine Contractions

• How Strong: Mild, moderate, strong
• Need to palpate fundal area when monitoring externally

Uterine Contractions

Resting Tone
• Uterus should be relaxed between end of 1 contraction and beginning of next
• Between contractions need 30 seconds or more resting period
• Palpate in fundal area


• 4 Types:
- Early,
- Late,
- Variable,
- Prolonged
• Defined according to their visual relation to the onset and end of a contraction and by their shape

Early deceleration

A visually apparent gradual (onset to lowest point 30 seconds or more) decrease in and return to baseline FHR associated with uterine contractions;
• Generally the onset, Nadir, and recovery of the deceleration correspond to the beginning, peak, and end of the contraction.
• Cause - Head compression resulting from the following:
- Uterine contractions
- Vaginal examination
- Fundus pressure
- Placement of internal mode of monitoring
• Nursing interventions - None

Late Deceleration

A visually apparent gradual (onset to lowest point 30 seconds or more) decrease in and return to baseline FHR associated with uterine contraction;
• Begins after the contraction has started, and the lowest point of the deceleration occurs after the peak of the contraction;
• The deceleration usually does not return to baseline until after the contraction is over

Late Deceleration

Cause - Uteroplacental insufficiency caused by the following:
- Uterine Tachysystole,
- Maternal Supine Hypotension
- Epidural or Spinal Anesthesia
- Placentaprevia
- Placental Abruption
- Hypertensive Disorders
- Post Maturity
- Diabetes Mellitus
- Intra-Amniotic Infection

Late Deceleration

Clinical Significance:
• Abnormal pattern associated with:
- Fetal hypoxemia, acidemia, and low Apgar scores.
• Ominous if persistent and uncorrected, especially when associated with fetal tachycardia and loss of variability
• Nursing Interventions:
- Change maternal position (lateral),
- Correct maternal hypotension by elevating legs,
- Increase rate of maintenance of IV solution,
- Palpate uterus to assess for tachysystole,
- Discontinue Oxytocin,
- Administer O2 at 8 -10 L/min by NRFM (non-rebreather face mask)
• May have vaginal assist or C-section if pattern cannot be corrected

Variable Decelerations

A visually abrupt (onset to lowest point < 30 seconds) decrease in FHR below the baseline;
- The decrease is 15 BPM or more, lasts at least 15 seconds and returns to baseline in less than 2 minutes from time of onset;
• Are not necessarily associated with uterine contractions, they have a U, V, or W shape.

Variable decelerations

• Cause - Umbilical cord compression caused by following:
- Maternal position with cord between fetus and maternal pelvis,
- Cord around fetal neck, arm, leg, or other body part, knot in cord, prolapsed cord
• Nursing interventions:
- Change maternal position (side to side, knee to chest),
- D/C oxytocin if infusing,
- Administer 02 8 - 10 L/min by non-rebreather facemask,
- Notify physician or nurse-midwife,
- Assist with vaginal or speculum examination to assess for cord prolapse

Prolonged Deceleration

A visually apparent decrease (may be either gradual or abrupt) in FHR of at least 15 BPM below the baseline and lasting more than 2 minutes but less than 10 minutes;
• Indicates a disruption in the fetal O2 supply.
• Causes: They may be caused by prolonged cord compression, profound uteroplacental insufficiency, or sustained head compression.
• A deceleration lasting more than 10 minutes is considered a baseline change.

Fetal Cardio Note

Sinysoidal FHR, smooth, wavelike undulating pattern in FHR baseline has a cycle frequency of 3 - 5 minutes lasting > 20 minutes

FHR variability

Normal irregularity of fetal cardio rhythms or fluctuations from the baseline FHR of 2 cycles or more; the 4 possible categories of variability are absent, minimal, moderate, marked.


Interplay of sympathetic and parasympathetic nervous system causing fluctuations in FHR
• Can determine when monitory externally:
- Absent - no change in FHR
- Minimal - change in FHR < 5 Bbpm
- Moderate - change in FHR 6 - 25 bpm
- Marked - change in FHR > 25 bpm
• Variability is important indicator of: O2 reserve; decreased variability could be due to fetal sleep state, drugs, hypoxia, prematurity.


Thinning and shortening or obliteration of the cervix that occurs during late pregnancy or labor or both;
• degree of is express in percentages from 0% to 100%


The entrance of the fetal presenting part into the superior pelvic strait and the beginning of the descent through the pelvic canal,
• Usually the lowest part of the presenting part is at or below the level of the iscial spines.
• Usually corresponds to station 0.
• Occurs in weeks just before labor with nulliparas,
• May occur before labor or during labor in multiparas.


Surgical incision of perineum, may be midline or media lateral. • The purpose is to minimize stretching of perineum, decrease chance of infection, decrease trauma to fetal head, shorten length of second stage.
• Performed just before birth when presenting part is crowning

Fetal Head

Flexibility of the cranial vault allows movement so the fetal head can adapt to the pelvis

Fetal Attitude

Relation of fetal body parts to each other in uterus
• Fetus assumes a characteristic posture in utero partly because the mode of fetal growth and partly because of the way fetus conforms to shape of uterine cavity.
• Normally back of fetus is rounded so chin is flexed on chest, thighs flexed on abdomen, legs flexed at knees. Arms are crossed over thorax and umbilical cord lies between arms and legs.
• Termed general flexion.

Fetal Lie

The relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. Two Types:
• Longitudinal (Vertical) - long axis of fetus is parallel to long axis of mother.
- Are either cephalic or breech
• Transverse (horizontal or oblique) - long axis of fetus is at right angle or diagonal to the long axis of the mother
- Vaginal deliveries cannot occur when fetus stays in transverse lie

Fetal Position

Relationship of a reference point on the presenting part of the fetus such as occipitant, sacrum, chin or scapula to its location in the front back or sides of the maternal pelvis

Fetal Position

Denoted by three part abbreviation;
• First letter denotes location of the presenting part in right or left side of mother pelvis
• Middle letter denotes the specific presenting part of the fetus
- O = occiput
- S = sacrum
- M = mentum [chin]
- Sc = scapula [shoulder]
• Third letter denotes location of presenting part in relation to portion of maternal pelvis
- A - anterior
- P - posterior
- T - transvers

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