OB Assessment #2: Unit 4
Terms in this set (80)
Upper or lower uterus ACTIVELY CONTRACTS to push the baby down?
Upper or lower remains less or inactive to promote downward passage of the fetus?
"thinning and shortening of the cervix as it is drawn over the fetus and amniotic sac."
In the NULLIPARA woman, this is competed EARLIER than dilation.
Estimated as a % of the original cervical length.
*A fully thinned cervix is 100% effaced.
"Opening of the cervix."
In the PAROUS women, cervix is thicker than any nullipara during any labor stage.
This process occurs BEFORE effacement.
Caused by when the cervix is pulled upward and fetus pushed downward.
*Expressed in "cm"; a full reading is 10 cm to allow sufficient passage of average-sized-full-term fetus.
What is the characteristic of the cervix of a multigravida woman?
Thick (through dilation)
How the cardiovascular system is impacted during labor?
Relative increase in blood volume r/t shunting of blood (300-500mL) during uterine muscle contraction. *Resultantly: BP INCREASES & PULSE DECREASES.
*Best to assess mother's vital signs within the interval BETWEEN contractions.
What form of hypotension may occur during labor? How and what should be encouraged?
Supine hypotension is caused when the mother lies on her back, causing a compression of major blood vessels.
*Encourage the mother to lie in other positions other than on her back (left side-lying) to promote venous blood return to heart and thus enhance blood flow to placenta and promote fetal oxygenation.
How the respiratory system is impacted during labor?
INCREASE in depth and respiration (anxious or in pain).
Breathing deeply and heavily may lead to hyperventilation (respiratory alkalosis) r/t inhaling TOO MUCH CO2.
*May feel tingling of hands and feet, numbness, and dizziness.
*Encourage mother in breathing exercises: breathe slow and into a paper bag or cupped hands to restore normal blood levels of CO2 and symptom relief.
How the hematopoietic (blood) system is impacted during labor?
Accepted VAGINAL birth blood loss: 500 mL
Accepted C-SECTION birth blood loss: 800-1,000 mL
>1,000= HEMORRHAGE (uterus not clamping down)
Hgb: 10.5 g/dL
Leukocytes: 20,000-30,000 mm3
*An anemic mother at the beginning of labor has less reserve for normal blood loss and poor tolerance for excess bleeding.
*Elevated clotting factors (fibrinogen) during and after delivery. This provides protection from hemorrhage, BUT increases the risk for venous thrombosis during pregnancy and after birth.
*Encourage the wearing of SCDs (c-section) and TEDs to promote venous blood return!!!!
How the gastrointestinal system is impacted during labor?
Gastric motility is reduced, leading to N/V.
*Most women are THIRSTY and or have a dry mouth (not usually hungry). Thus, provide ice chips and small amounts of other clear liquids and juices, popsicles, and are non-sugar candy.
*Withhold solid foods to PREVENT aspiration and vomiting of undigested food in the event of general anesthesia; there is a decreased risk of aspiration with liquids.
How the urinary system is impacted during labor?
*Reduced sensation of a full bladder (r/t intense contractions and effects of general anesthesia).
A full bladder can INHIBIT fetal descent b/c it occupies the pelvic space.
*ENCOURAGE the mom to empty her bladder often.
Where does exchange of oxygen, nutrients, and waste products occur between mom and baby (that doesn't interfere with mom and baby blood mixing)?
When does this exchange occur?
In the intervillous spaces; this placental exchange occurs during the interval BETWEEN contractions because a strong labor contraction causes a decrease and then cessation in maternal blood supply as the spiral arteries are supplying the IV spaces are compressed by the uterine muscle.
*SIDE NOTE: Placental circulation has enough reserve to compared to fetal basal needs to tolerate the periodic interruption of blood flow.
Which conditions (with reduced placental function) may alter the fetus' tolerance with labor contractions?
Maternal diabetes & HTN
Fetal anemia (reduced fetal O2 carrying capacity)
Characteristics of the fetal heart rate during labor?
*A low BP is OKAY, but a higher BP indicates infection and or fetal stress.
*When mom's BP DROPS, the baby's PULSE DROPS.
Characteristics of the fetal pulmonary system during labor?
Fetal lungs produce fluid to allow normal development of the airways.
*Labor speeds up the absorption of lung fluid, so 35% of fluid remains in the airway at birth: it is important to clear this to facilitate normal air breathing!!
*The other remaining fluid is absorbed into the interstitial spaces of the newborn's lungs and into the circulatory system, and a small amount is cleared by the lymphatic system.
*Infants born via C-SECTION (not preceded by labor) are more likely to have transient breathing DIFFICULTY.
Which catecholamines respond to fetal stress during labor? What do they do?
Norepinephrine and epinephrine
Stimulate cardiac contraction and breathing; QUICKEN the clearance of remaining lung fluid and aid in fetal temperature regulation.
What are the 4 components of the birth process?
1. Powers (allows more maternal sense of control)
*They are all interrelated and are NORMAL during childbirth.
Powers: first stage of labor (ONSET of full cervical dilation)
uterine CONTRACTIONS are the primary force to move the fetus through the maternal pelvis.
*Includes: effacement, dilation, frequency, duration and intensity.
Powers: second stage of labor (full cervical DILATION to birth of the baby)
Uterine contractions CONTINUE to propel the baby through the pelvis.
*Woman feels the urge to "push and bear down" as the fetus distends her vagina and puts pressure on the rectum.
Consists of maternal pelvis and soft tissues.
*BONY PELVIS more important to outcome of labor than soft tissue b/c...bones & joints are not able to readily yield to the forces of labor.
Which increased hormone level (near end of term) causes softening of the cartilage that links pelvic bones together?
Which form of passage is MOST conducive to a vaginal birth?
GYNECOID; if there is no one present, this poses a big problem.
Which form of passage is LEAST conducive to a vaginal birth?
short and round
Which forms of passage are the HARDEST?
Anthropoid (hard and narrow)
Android (harder than anthropoid)
Which pelvis part is the MOST IMPORTANT in childbirth?
the true pelvis...made of the inlet (inward pelvis), mid-pelvis and outlet (lower pelvic opening). It functions like a curved cylinder with various dimensions.
What is the "passenger"?
the fetus, membranes, and placenta
*fetal head, fontanels, and fetal head DIAMETERS...
Passenger: fetal head
*enters the birth canal in the CEPHALIC presentation: the head is DOWN and you can feel the noggin'!
*SUTURES connect the following: 2 frontal bones on the forehead, 2 parietal bones at the crown of the head; occipital bone at the back of head.
What is a suture?
narrow areas of flexible tissue that connect skull bones, allowing slight movement during labor.
What is a fontanel? Location and shapes?
*wider spaces at the intersections of sutures connecting fetal or infant skull bones.
*ANTERIOR: DIAMOND SHAPED (formed by intersection of the 4 sutures)
*POSTERIOR: very small, looks like a slight indentation of the skull and is TRIANGULAR SHAPED.
What does the suture and fontanel together, allow for?
Slight bone movement, changing the shape of the fetal head to allow adaptation to size and shape of the pelvis by MOLDING (shaping of fetal head during movement through birth canal).
*They provide important landmarks to determine fetal position and head flexion during vaginal examination.
Fetal head diameters
the biggest concern!
*want the cephalic presentation
What is the most FAVORABLE position of the fetal head during labor?
Head FULLY FLEXED and the anteroposterior diameter is SUBOCCIPITOBREGMATIC, measuring "9.5 cm."
Variations in passenger: FETAL LIE
the orientation of the long axis of fetus to long axis of woman.
*mostly longitudinal (HEAD or the BUTTOCKS down first to enter pelvis) and parallel to long axis of woman.
*transverse/side lie: long axis of fetus at right angle woman's long axis. This position is deemed as "bad" because of increased risk of prolapse causing decreased O2 supply and a dead baby.
Variations in passenger: ATTITUDE
relationship of fetal parts to one another: FLEXION or EXTENSION
*Best: Chin to chest, arms and legs flexed over the thorax with C-curve of the spine.
*Flexion remains characteristic of a newborn.
Variations in passenger: PRESENTATION
the fetal part that first enters the pelvis.
*Has 4 categories:
-Vertex/occiput: fetal head FULLY FLEXED!; most desired position b/c smallest suboccipitobregmatic diameter is present.
-Military: head is in neutral position, not flexed nor extended; longer SOB diameter is presenting.
-Brow: fetal head partly extended; UNSTABLE, usually converts to vertex if face presentation extends; longest SOB diameter is presenting. *The forehead is out, thus BRUISING may occur r/t presence of contractions.
-Face: head extended, fetal occiput near the fetal spine; *subMENTObregmatic diameter present. BIGGEST concern is r/t BREATHING.
fetal buttocks enters the pelvis FIRST. More common in preterm births and when a fetal abnormality (i.e.: hydrocephalus and placenta previa).
-fetal head compression, thus increasing risk for cut-off breathing/circulation.
-Frank: most common; fetal legs extended ACROSS abdomen TOWARDS the shoulders.
-Full (complete): a reversal of cephalic presentation: head, knees, and hips flexed, but buttocks in present.
-Footling: 1 or both feet are presenting
Transverse/side lie position: occurs mostly in preterm, high parity, hydramnios, placenta previa, and prematurely ruptured membranes.
*C-section may be necessary when fetus is VIABLE.
FYI! (r/t breech)
breeches can be delivered vaginally;
*Biggest concern is entrapment of the head once body is out of the cervix.
*with a full and frank breech, the WORRY is of a "cord prolapse."
Variations in passenger: POSITION
location of a fixed reference point on the presenting part in relation to the 4 quadrants of the maternal pelvis.
1. Right or Left?
2. Occiput (O): vertex position
Mentum (M): face presentation
Sacrum (S): breech presentation
3. Anterior (A)
Transverse (T): neither A nor P
Which fetal position causes the mother to have back pain? Why?
right or left posterior occipital
*the back of the baby's head is sitting on the back of mom's pelvis.
Psyche: 4 component of the birth process
a woman's psychological response to labor and birth that are influenced by anxiety, culture, expectations, life experiences, and support.
anxiety, culture & expectations, birth as an experience (not a spectator sport), support, and impact of technology.
For twins, the BEST presentation is???
Transverse breech, then cephalic
Dysfunctional labor: Problems of the POWERS
-ineffective maternal pushing
Dysfunctional labor: Problems with the PASSENGER
-abnormal fetal presentation or position
-fetal anomalies (anencephaly)
Dysfunctional labor: Problems of the PASSAGE
-Soft tissue obstructions
Dysfunctional labor: Problems of the psyche
need for meds
Dysfunctional labor: Abnormal labor duration
Prolonged: >3 hours, no curve of dilation
Precipitate: <3 hours, the baby is out
Theories of onset: how a normal labor is started
-placenta stops making progesterone, causing a withdrawal
-increased release of prostaglandins
-increased secretion of natural oxytocin
-increased oxytocin receptors in uterus
-increased stretching and pressure of uterus and cervix (amniotic sac pushes downward)
Premonitory signs of labor
-Braxton hick's contractions
-lightening (of uterus)
-increased vaginal mucus secretion
-cervical changes: softening (Goodell), possible dilation, bloody show (mucus plug out; less bloody show in multiparas)
-Energy spurt ("nesting") and weight loss (1-3 lbs.)
*there is a cervical change!
-increased contractions and discomfort such as back pain cause...(below)
-cervical change involves *progressive effacement and dilation.
NO cervical change
-annoying discomfort (very painful) in abdomen & groin
-cervix DOES NOT change
Mechanism of Labor: 7 cardinal movements
4. Internal rotation
6. External rotation
*all effectively use the available space in the maternal pelvis.
fetal presenting part through true pelvis
of fetal presenting part as its WIDEST diameter reaches the level of the ischial spines of mother's pelvis ("0" station).
*head enters the pelvic cavity
*want occiput anterior kids
of the fetal head, allows smallest head diameters to align with smaller diameters of the midpelvis as fetus descends.
*chin to chest
Allows largest fetal head diameters to align with the largest maternal pelvic diameters
of the fetal head, as neck pivots on the inner margin of the symphysis pubis, allowing head to align with the curves of the pelvic outlet
of the fetal head, aligning the head with the shoulders during expulsion.
*the head is rotated to fit through the pelvis
of fetal shoulders and fetal body
*if shoulders are not pulled out, there is an increased risk for shoulder distocia
Stages of Labor: 1st! (latent phase)
period of most cervical change: EFFACEMENT BEGINS
fetal positional change
onset of TRUE labor
7.3-8.6 hours in nulliparas and 4.1-5.3 hours in multiparas
Woman may notice discomfort in back with each contraction (similar to menstrual cramps)
Woman is sociable, excited, and cooperative
Anxious that contractions are NOT Braxton Hicks but the "real thing"
Stages of Labor: 1st! (active phase)
effacement of cervix is completed
fetus descends into pelvis
internal rotation BEGINS!
contractions quickly reach peak intensity and stay at peak longer.
mom has serious, inward focus
Stages of Labor: 1st! (Transition phase)
cervix dilates 8-10cm
fetus descends further into pelvis
Bloody show often increases with COMPLETION OF CERVICAL DILATON & EFFACEMENT.
Strong contractions w/fetal descent causes woman to "bear down" during contractions.(if this is an issue, nurses can help woman blow OUTWARD with each breath until urge passes).
May feel leg tremors, nausea, and vomiting
Often the most difficult if no epidural analgesia.
First stage of labor: labs
-blood tests: CBC, HIV, blood type & screen
-Amniotic membranes and fluid
-rapid test for GBS
Precautions for a step B + mother
antibiotics given during labor b/c birth area has bacteria
-baby stays in hospital for 48 hours after this is given.
Stages of labor: 2nd (expulsion)
ends in DELIVERY OF THE BABY!
-begins w/ full cervical dilation (10 cm)
-the "pushing" stage
-mom regains feeling of control
Stages of labor: 2nd (latent)
passive descent of baby through birth canal
Stages of labor: 2nd (active)
-pushing and urge to bear down: Valsalva maneuver
-Ferguson reflex (urge to bear down)
*encourage position changes whenever possible
-mom oblivious to surroundings, may appear asleep.
-observing FHR and pattern; support father or partner
Stages of labor: 3rd
-begins with baby's birth
-ends in expulsion of the placenta
-shortest stage of labor (6 minutes)
*if placenta is NOT expelled within 30 minutes= PROBLEM (should be between 10-15 minutes)
-UC lengthens r/t gravity pull
4 signs suggesting placental separation:
1) uterus has a spherical shape
2) uterus rises UPWARD in the abdomen as placenta descends into vagina and pushes vagina up.
3) The cord descends further from vagina
4) a "gush of blood" appears as blood trapped behind placenta is released.
Why does a mom feel "full" during the 3rd labor stage?
placenta pushing down/located on the pelvis
Stages of labor: 4th
physical recovery stage
-delivery of placenta- first 1-2 hours AFTER birth
-uterus palpated as a firm, round mass above or below the umbilicus
-*IMPORTANT TIME FOR BONDING BETWEEN MOM AND BABY!
How can the placenta be expelled?
Schultze mechanism & Duncan mechanism
What happens if uterus does not contract after birth?
What happens when the bladder is full or there is a blood clot in the uterus? (4th labor stage)
interference with uterine contraction and postpartum hemorrhage r/t non-compressed large blood vessels at placental site.
vaginal drainage after birth
3 stages of lochia: Which one is present during the 4th stage of labor?
-lochia rubia* (mostly blood)
What should be done to the uterus 90 minutes after birth? Why?
Pound on uterus every 15 minutes for 60-90 minutes to prevent clots and keep the uterus firm.
A woman may feel chilled after birth: what can you as the nurse do?
-lasts about 20 minutes
-give a warm blanket, hot cup of soup or drink
A woman may have localized discomfort from birth trauma (i.e.: lacerations, episiotomy, edema or a hematoma) w/diminished anesthetic effect. What can you do and why?
Place an ice pack on the perineum to limit edema and hematoma formation.
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