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Unit OB Perineum

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					Unit 2 OB Intrapartum

LABOR & DELIVERY
    Rev. 5/09
              REVIEW

•   Gravida
•   Para
•   Primigravide
•   Multigravida
•   Primipara
     5 Digit Classification Code

•   G = Gravida
•   T = Term
•   P = Premature
•   A = Abortions
•   L = # of living children
Signs of Impending Labor

1. Lightening
2. Bloody Show
3. Braxton Hicks Contractions
4. Energy Spurt
5. Weight Loss
    True vs. False Labor

• Regular pattern • Rarely follow a
                     pattern
• Inc. in duration
                   • Vary in duration,
  frequency &        frequency and
  intensity          intensity
• Inc w/           • Dec w/
  ambulating         ambulating
      True vs. False Labor

• Start in back & • Often noticed
  radiate to abd.   in abdomen
• Dilate & efface • No cervical
  cervix            changes
• “show” usually • “show” not
  is present        present
   2 Common signs of Active
          Labor
• 1. Strong, Regular Contractions
• 2. R.O.M.
     Uterine Contractions
• Involuntary
• Can be felt at uterine fundus
• Documented according to
  frequency, duration and
  intensity
    Rupture of membranes
• B.O.W. Bag of Waters
• 1000cc or 1 qt. By 40th week
• Prior to delivery sac must break
• SROM or AROM
        4 Stages of Labor
1. Dilation & Effacement
 * begins w/ onset of true labor
 *ends w/ complete dilation of
   cervix
Primip ~ 10-12 hrs Multip 6-8 hrs
      First Stage of Labor
• Has 3 distinct phases:
 1. Latent  excited
 2. Active apprehensive
 3. Transitional irritable &
  frustrated
   2. Delivery or Expulsion


• Begins w/ complete dilation of
  cervix & ends w/ birth of newborn
Primip ~ 30 mins.- 2 hrs
Multip ~ 20 mins.- 1.5 hrs.
          3. Placental

Begins w/ delivery of newborn &
 ends w/ delivery of placenta

 (usually 5-20 mins.) for both
 primiparas and multiparas
    4. Recovery/Stabilization
begins after delivery of placenta &
 ends w/ pt. being in stable
 condition
most crucial time for hemorrhage

(~ 2-4 hrs. After delivery)
     2 distinct cervical changes

1. Dilation
   Cervical os begins to open
   Meas. In cm from 1-10
   Complete dilation nec. to expel fetus
   Solely the result of contractions
2. Effacement
Refers to thinning & shortening of
  cervix
Normally long & thick
Now shortens or thins
Meas. in % (100%=complete)
       Station,Lie,Position &
            Presentation
1. Station
 Means level of descent of fetal
   presenting part in birth canal
 Measured in relation to the level of
   ischial spines
 Vertex is most common presentation
At station 0, fetal head is
 engaged
Other stations are 1-3 cm
 above (-) or below (+) station 0
              2. Lie
Denotes the position of the
 fetal spinal cord (long part) to
 that of the woman
Normal lie is longitudinal
Tranverse lie cannot be
 delivered
           3. Position
 refers to the relationship of the
 presenting fetal part to a
 quadrant of the maternal pelvis
Most favorable position is
 LOA
          4. Presentation
• Refers to part of fetus that first
  enters birth canal
• 96% are cephalic or vertex
  presentation
• Other presentations are breech,
  face, shoulder
Admission Assessment
        and
     Related
   Nursing Care
       DETERMINE…..
• EDC
 The frequency & duration of
  contractions
 If any bleeding
 The time of ROM (amt &
  color)
 VS
 Check lung sounds & heart of
  woman
 Obtain FHR fetal monitor
 Do a SVE
 Determine Drug allergies
  Emotional & Physical Support

• Keep bladder empty
• VS @ regular intervals
• Breathing exercises
• Support person
         Relief of Discomfort
a.   Epidural block
b.   Saddle block
c.   Caudal block
d.   Pudental block
e.   Paracervical or Cervical block
             Nursing Alert
•   Inability to move legs
•   Numbness in legs
•   Ringing in ears
•   Dizziness
•   Metallic taste
•   Hypotension or seizures
         Fetal Monitoring
• Purpose:
  - is to record fetal H.R. with
    contractions & relaxation
  - is to detect early warning
    signs of fetal distress
      Monitoring may be:
• External ( Indirect )
• Internal ( Direct )
     Evaluation of Monitor
         Information
• Accelerations
Transient inc. of the FHR of 15
  BPM or more.
Accelerations of 60 BPM or
  more is considered a
  complication
        Decelerations
 Are slowing of the FHR
Are a normal response of the
 fetus to labor & should
 mirror the pattern of
 contraction.
Caused by head compression
       Normal Variability

• Change in FHR from beat to beat
• Normal range is 2-10 beats/min
     Decreased Variability
-Little or no fluctuation in
  FHR
 May indicate fetal nervous
  system abnormality OR
Maternal use of CNS
  depressants
     Signs of Fetal Distress

• Increase or decrease in baseline
  FHR
• Decrease in baseline variability
• Tachycardia
• bradycardia
• Persistent late decelerations
• Severe variable decelerations
• Greenish-stained amniotic fluid
• Prolapsed cord
    Second Stage of Labor
Bearing down feeling
Rectum dilates, perineum
 bulges
Crowning occurs
Perineal prep
Prepare for Delivery
Coaching
Episiotomy
     Delivery of Newborn


1. Nose & mouth are suctioned
2. Check for nuchal cord
3. Note time of delivery
        Care of Newborn
A. Establish & maintain airway
B. Stimulate respirations
C. Position to prevent aspiration
D. Provide warmth
E. Determine APGAR Score
        F. Cord Care

* secure clamps
* assess cord for bleeding
* Triple Dye to prev. infection
* swab stump w/ alcohol after
  each diaper chanage
• Teach family not to submerge
  the baby in tub water until the
  cord falls off
 (usually 10-14 dys)
      G. Identification


* ID bands on ankle & wrist

* Footprinting (babies foot &
mothers right thumb
       H. Health Record

* contains vital statistics ie:
   sex, hour of birth, condition
   and type of delivery

 * complete before leaving DR
I. Protection Against Disease
 * EES or tetracycline to eyes
 * IM injection of Vit. K
J. Bonding
 * promotes attachment
     Third Stage of Labor
Extends from the time the
 newborn is delivered until the
 placenta & membranes are
 expelled
Can last up to 30 min., usually
 takes 5-20 min.
    A. Delivery of Placenta
1. “Shiney Schultze
placenta expelled w/ shiny side
 out
2. “Dirty Duncan”
placenta expelled w/ dull side out
3. Placental examination
4. Oxytocic administration
 helps uterus to contract, reduces
 the chances of postpartum
 hemorrhage, promotes
 hemostasis
Nursing Care during   3 rd   Stage
 Massage fundus
 Cleanse perineum
 Remove legs from stirrups
 Change gown, apply peripad
 Provide warmth
    Fourth Stage of Labor
• Involution begins
• 6 week process
Nursing Care during   4 th   Stage

1. Assess VS – q 15 min x 1-2
   hours
2. Check fundus
3. Check perineum
4. Check lochia
5. Check for 1st void
6. Check for signs of
 hemorrhage
6. Patient Education Teach….

 perineal care
Fundal massage
Fluid intake/voiding
Breasts
constipation
 after pains
Nursing/breast feeding
Complications of Labor &
       Delivery
   A. Premature Rupture of
         Membranes
• Small leak in BOW causing a
  rupture of membranes
• May be difficult to diagnose
• Complications are: Premature
  labor,Intrauterine infection &
  malpresentations, prolapsed cord
              Treatment
•   Hospitalization
•   Assessment of woman & fetus
•   Determine fetal maturity
•   Induce labor if fetus is mature
      B. Premature Labor
• Labor that occurs before the 37th
  week
• Prematurity leading cause of
  infant mortality
• Tx is Bedrest, Tocolytic drugs
     C. Precipitate L & D
Labor is brief < 3 hours
Contractions unusually
 severe
May be so rapid getting to
 delivery room is impossible
        Nursing Care
• Never prevent delivery
• Assist with birth
• Make sure neonate is
  breathing
          Complications
• For mother:
(perineal laceration, hemorrhage,
  infection & uterine rupture)
For baby:
(anoxia, subdural hematoma &
  fractures)
      D. Uterine Rupture
• One of the most serious
  complications – very rare
• Predisposing factors/causes
1. previous C/S or uterine scar
2. severe tonic contractions
3. Dystocia
4. Injudicious use of oxytocic
 drugs
5. CPD (Cephalopelvic
 Disproportion)
    Symptoms of Rupture
• Sharp, tearing pain F/B
  sudden cessation
• Anxiety
• Signs of shock
• Hypotension
          E. Dystocia
• Prolonged, difficult & painful
  labor
• Does not result in dilation or
  effacement
• Exhausts woman & predisposes
  to death
      Causes of Dystocia
1. Uterine inertia
  - insufficient, uncoordinated
   contractions that do not
   produce effective dilation
AKA– “ Hypotonic dystocia”
2. Cephalopelvic Disproportion
   ( CPD)
--presenting part, usually fetal
  head is too large for pelvis
3. Abnormal fetal positions &
 presentations
   Management for Abnormal
  Positions & Presentations….
1. Version (Leopold’s
   Maneuvers)
2. Forceps assisted delivery
3. Vacuum assisted delivery
4. C/S
       F. Cord Problems
A. Prolapsed Cord
 umbilical precedes the baby
 Serious complication
 May cut off fetal circulation
 Requires emer. C/S
        B. Nuchal Cord
• Cord wrapped around neck
• If discovered before labor,
C/S is done
*If not, forceps are used to speed
  delivery & cord cut immediately
Other Considerations of
  Labor & Delivery
     A. Induction of Labor
Reasons for induction:
a. Possibility of fetal death
   without labor
b. Worsening signs of PIH
c. A large or post term fetus
d. Maternal DM
     The Induction Process
• Drugs may be administered
  parenterally, orally, or vaginally
• Oxytocin most common
• (PGE) Prostaglandin E 
  (Cervidil)
• Amniotomy
Nursing Care during Induction

1. Note the time of amniotomy,
   color & amount of fluid
2. Monitor fetus for signs of
   distress
3. Frequent VS & emotional &
   physical support
    B. Emergency Delivery
Never to be delayed
Remain calm & deliver baby
Follow aseptic technique
Double tie cord
Keep baby warm, ensure
 breathing
        C. Lacerations
• Tears in perineal tissue &
  anus
• Common w/ precipitous
  delivery
• Classified by degrees:
1°--perineal skin & vaginal
 mucous membrane
2°--involves muscles of perineal
 body
3°--involves anal sphincter
4°--extends to anal canal
   D. Operative Obstetrics
• Version
• Forceps
• Vacuum
• C-section
E. Cesarean Delivery

      Post Op
       Care
• Assess VS
• Observe lochia, incision &
  fundus
• I & O for 24-48 hrs
• Advance diet as tolerated
• Perineal care
• Early ambulation &
  breathing exercises

				
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