Chapter lecture notes on Labor and Delivery PDF

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Labor and Delivery Normal Labor and Delivery ProcessesSigns Preceding Labor (Does not imply labor has started!)  Lightening  Urinary Frequency  Backache  Stronger Braxton Hicks Contractions  Flu-like symptoms or fatigue  Surge of energy (nesting)  Slight weight loss  Bloody show  Cervical r...

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Labor and Delivery Normal Labor and Delivery Processes Signs Preceding Labor (Does not imply labor has started!)  Lightening  Urinary Frequency  Backache  Stronger Braxton Hicks Contractions  Flu-like symptoms or fatigue  Surge of energy (nesting)  Slight weight loss  Bloody show  Cervical ripening  Loss of mucous plug Couple of other terms to know  Braxton Hicks contractions – short usually not painful, tightening or contractions of uterus. Should have less than 6 in an hour – goes away with change in activity  ROM (Date/time, color, amount, odor) We need to know this for all pregnant or laboring patient. If their bag of waters (or membranes) are intact (BOWI or I) or ruptured and if ruptured for how long = can indicate risk factors.  Document always!! Standard Protocols Typically:  If ROM – she will remain in the hospital  If in labor will be on the monitor  Most of the time if admitted, she will have IV, labs (CBC with platelets, Type and screen, UA at minimum - may have a lot of prenatal labs completed at this time if no previous prenatal care)  May be NPO or ice chips/Clear Liquids  While on monitor -document: FHR, variability, accels/decels, contraction pattern (frequency, duration, intensity or absence of….) A word about Group Beta Strep (GBS)  ACOG, AAP and CDC recommend all women get tested (vaginal and rectal swab) at 34-37 weeks)  If positive: woman is treated in labor (unless C/S is planned and her membranes are still intact) Causes Of Labor (Therories) The first 5 Ps of Labor We don’t know what causes it – but know what affects it.  The Passenger (Fetus and placenta)  The Passage (birth canal: soft tissues and boney pelvis)  The Powers (contractions)  Position (maternal)  The Psyche (psychological response) The Passenger Sutures and Fontanelles:  Allow molding of the fetal head (caput succedaneum, cephalohematoma)  Serve as landmarks to assess fetal attitude and position  Vertex: The smallest diameter of the fetal head (suboccipitobregmatic) should move through the

pelvis. Feto-pelvic Relationships We’ll talk more about these in a minute  Fetal presentation  Fetal attitude  Fetal lie  Fetal Position Passenger Fetal Presentation: (All pictures are in your text) The part of the fetal body that enters the pelvis first and leads through the birth canal.  Cephalic (95%) head 1st want in this position  Breech (3%) butt  Shoulder (2%) ` Passenger Fetal Attitude: The relationship of fetal parts to each other  The relationship of the fetal parts to each other:  Vertex (flexed) (A) chin on the chest  Military (extended) (B) kinda straight chin up takes a long time  Brow or Face (extended) (C&D) c might be possible by turning in the position but d is almost impossible to make it out Passenger Fetal Lie: The relationship of the fetal spine to the maternal spine  Vertical lie - cephalic or breech (tauko mathi or tala)  Horizontal or transverse lie (tauko side ways) Passenger Fetal Position : The relationship of the presenting part to the maternal pelvis  OA: Occiput Anterior - optimal position for labor  OP: Occiput Posterior - prolongs first and second stage labor; typically causes “back labor” (belly nira mukh)  OT: Occiput Transverse - causes arrest of descent at the ischial spines Passenger Fetal Station (engagement) Floating (ballotable) = -4 -3 -2 -1 0 +1 +2 +3 +4 = Crowning 0 = At Ischial Spines

The Passageway  The bony pelvis - joints are softened by the hormone relaxin  (4 types: gynecoid, android, anthropoid, platypelloid)  The soft tissues - cervix, vagina, perineum - estradiol, progesterone, relaxin, and prostaglandins increase tissue size and elasticity The Powers  Uterine contractions cause effacement and dilation  You DON’T have to check dilation every hour!!  Hydrostatic force of the membranes and amniotic fluid facilitate effacement and dilation  Secondary - bearing down efforts (pushing) in the second stage facilitates expulsion. These have no effect on dilation, but help with expulsion. The Position  Affects maternal and uteroplacental perfusion

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Affects maternal perception of pain Basic physics - Affects fetal position and rotation in the pelvis Effects of Recumbent Position lying down supine position  Aortocaval compression leading to maternal hypotension and fetal distress  Narrower birth canal  Loss of pelvic mobility  Loss of gravity  Less efficient contractions  Greater discomfort and pain  Slower progress of labor  Supine Hypotension Benefits of Lateral Recumbent Position side ways position  Provides rest  Corrects aortocaval compression  Can be used to facilitate rotation of baby  Facilitates interventions - Monitoring, regional anesthesia Benefits of Upright Positions in Labor  Utilize gravity to speed labor progress  Provide more maternal control  Decrease pain and discomfort  Facilitate rotation of fetus through the pelvis  Allow more interaction with labor support persons Upright Positions for labor  Semi-reclining  Sitting (chair or rocking chair)  Standing  Walking  Lunges  Squatting

The Psyche “You can do it!”  Every woman wants to know that she is doing well, that the baby is doing well, and that she can handle labor. Stages of Labor Stages and Phases 1st Stage – Closed cervix to 10cm dilated 1st Stage Phases:  Latent or early phase  Active Phase  Transition 2nd Stage – Pushing and birth of baby 3rd Stage – Delivery of Placenta 4th Stage - Recovery

The First Stage From onset regular contractions to completely dilated Effacement and Dilation  The latent phase - thick to 100% effaced, 0-3 cm dilated; cervix moves from posterior to anterior; can take hours or days  The active phase - 3-7 or 8 cm dilated; approximately 1 hour per cm in nullipara, faster in multipara  Transition - 7 or 8 to 10 cm dilated; most rapid and most uncomfortable phase Dilation, Effacement & Station  Dilation – how open is the cervix (0-10cm)  Effacement -how thin is the cervix (Long/Thick – 100%)  Station – how high or low the presenting part is IE: 5/30%/-2 Physiologic Effects of Labor Cardiac - increases workload; increases heartrate; BP may increase during contractions but should remain the same otherwise  Respiratory - increased oxygen demand; affected by pain and anxiety  GI - slowed bowel motility; prolonged gastric emptying; vomiting common in labor True Labor vs Flase Labor  True Labor  Contractions get stronger and more regular  Progressive cervical dilatation on vaginal exam  Bloody show??  Rupture of membranes – is this really labor? 

False Labor  Contractions slow or stop with changes in activity  No change in cervical exam after 1-2 hour trial

When to come to the hospital  When contractions are q 5 minutes in the nullipara  When they are q 10 minutes in the multipara—usually there is “blood show”  When membranes rupture (pH - > 6.5 means nitrazine paper is blue, while urine is usually around 5– 6) Cultural factors  Verbal response  Body language  Discomfort level and expectations  Who is the expected labor support person  Some cultures: Due to modesty – should only have female provider see her like “that” End of 1st stage  First Stage is over when mom reaches 10cm dilation  If mom has sensation – she can start pushing (2nd Stage)

 If her Epidural is preventing her from feeling her contractions – “labor down” The Second Stage: Pushing  Expulsion of the fetus by uterine and abdominal forces 

Closed-Glottis vs. Open Glottis Pushing  Problems with Closed Glottis Pushing  Increased intrathoracic pressure  Decreased maternal venous return  Maternal hypotension  Decreased cardiac output  Decreased uterine blood flow  Fetal hypoxia and acidosis

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Benefits of Open Glottis Pushing  Woman-directed  Characterized by sounds - breathing or grunting  Decreases CV changes  Allows gentle delivery of the head

Second Stage Labor Phases (although not usually talked about in stages like 1 st stage labor)  Latent – rest and calm, passive descent of fetus, “laboring down”  Descent – strong urge to bear down  Transition – presenting part is on the perineum Positions for Delivery  Lithotomy Position  Causes aortocaval compression  Narrows birth canal  Stretches perineum  Prolonged or poor positioning in stirrups can cause vascular and nerve damage  Most convenient for the obstetrician Alternatives to lithotomy position: Alternative Positions for Birthing:  Semi-recumbent, no stirrups  Side-lying  Hands and Knees  Squatting  Change positions to facilitate rotation Protecting the Perineum  Massage  Lubricants  Warm Packs  Open-glottis, short, gentle pushes  Don’t use lithotomy position  Controlled crowning Hold On! We’re not done!!

The Third Stage: The Placenta  Usually delivers spontaneously within 10-15 minutes (can be up to one hour).  Pitocin Bolus  Cord blood for fetal blood type or cord gases may be drawn before or after delivery of placenta  Examine placenta for appearance; birth attendant may want to send it to pathology  Family is often interested in the placenta The Fourth Stage: Recovery  VS q 15 minutes  Check fundus and lochia q 15 minutes; massage if indicated  Ice pack to perineum if injured or edematous  Warm blanket for maternal comfort  Observe for S/S hemorrhage  Assess perineum - REEDA (redness, edema, ecchymosis, drainage, and approximation of edges) Promote bonding and initiate breastfeeding  Assess sensation and strength after epidural  Accompany on first ambulation - dangle first and observe for dizziness  Measure first void  Teach peri care Labor and Birth Complications Labor Dystocia – long, difficult, or abnormal labor The Powers (hypotonic ctx)  The Passage (small pelvic structures)  The Passenger(LGA)  Position (OP)  The Psyche (Fighting the process)

Associated with: Epidural analgesia Multifetal pregnancy Maternal Exhaustion Ineffective maternal pushing Large fetus Abnormal presentation Induction of Labor (not always done for medical reasons!) - the chemical or mechanical initiation of contractions before their spontaneous onset for the purpose of bringing about the birth (23% of labors in 2011, more than doubled since 1990) CDC Augmentation of Labor - the stimulation of uterine contractions after labor has started spontaneously but progress is unsatisfactory

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Bishop Score  Nulliparas – 9 or more  Multiparas – 5 or more - May 2009 ACOG Poster on efficacy of Bishop Score

Chemical Agents for Cervical Ripening  Prostaglandin E1 - Cytotec (misoprostol)  Prostaglandin E2 – Cervidil, Prepidil (dinoprostone)  Mechanical Methods of Cervical Ripening  Balloon catheters  Hydroscopic dilators – Laminaria, Lamicel  Amniotomy  Membrane Stripping There will be questions about Pitocin on Exam 2 and ATI. Please see document posted on “Pitocin Math”. Oxytocin Induction/Augmentation  Contraindicated in cases where vaginal delivery is inadvisable  Hazards – uterine hyperstimulation (tachysystole), water intoxication, tumultuous labor with tetanic contractions, placental abruption, uterine rupture, cervical lacerations, PP hemorrhage, consequent fetal effects Oxytocin Induction/Augmentation  Administration – titrated IV drip via pump piggybacked in most proximal port of IV line o Dosage – 1-2 mU/minute, increased by 1-2 mU q 30-40 minutes  Monitor – CTX frequency, duration, intensity, and uterine resting tone; FHR pattern, maternal VS, labor progress o Discontinue if signs of fetal distress Uterine Tachysystole  Signs – CTX frequency 90 seconds, uterine resting tone > 20 mmHg; non-reassuring FHR tracing o Interventions – Turn off infusion, turn Mom to side, O2 via face mask, IV fluid bolus, notify primary care provider, may need to give Terbutaline; document responses to

actions Shoulder Dystocia Failure to deliver the fetal shoulders by the usual cardinal movements after the head has been born  Risk factors  Increased size of fetus, maternal obesity, excessive maternal weight gain, contracted pelvic outlet, protracted labor  Maternal complications - trauma to pelvis or birth canal  Fetal complications - fractures clavicle, brachial plexus palsy, asphyxia, death  S/S - delay in delivery of shoulders following delivery of the head, “Turtle sign”  Management  McRobert’s maneuver and Suprapubic pressure  NO FUNDAL PRESSURE!  Generous episiotomy  Anticipate resuscitative support of baby  Hands and knees  Possible cesarean section Umbilical Cord Prolapse  Condition when a loop of the umbilical cord lies beside or below the presenting part of the fetus  Risk factors - long cord, anything that prevents engagement of the fetal head in the cervix (malpresentation, CPD, multiple gestation, polyhydramnios, congenital anomalies)  Amniotomy should be delayed until head engages in cervix.  Fetal consequences - compression of cord leading to asphyxia or death  S/S - visualization of the cord at the vaginal introitus, palpation of pulsing cord on vaginal examination, fetal distress on monitor tracing  Management  Knee-chest or trendelenburg position, lifting fetal presenting part off cord, emergency cesarean delivery Uterine Rupture  Tearing or opening of the uterus into the abdominal cavity, usually at the site of a scar from previous uterine surgery  Risk factors - previous uterine surgery (cesarean section, myomectomy), tumultuous labor, multiparity combined with pitocin administration, obstructed labor, excessive fundal pressure, use of forceps, violent pushing, shoulder dystocia, trauma  Maternal complications - pain, hemorrhage, DIC, death  Fetal complications - hemorrhage, death  S/S - abdominal pain, failure to progress, palpable fetal parts on Leopold’s maneuvers, fetal distress, retraction of fetal presenting part, sudden loss of uterine tone to palpation or on monitor  Management  Emergency cesarean section  Anticipate fluid or blood replacement  Resuscitative support for baby Anaphylactoid Syndrome of Pregnancy (Amniotic Fluid Embolism)  Amniotic fluid containing particles of debris enters maternal circulation  Occurs in 1 in 15,000-20,000 pregnancies  Risk factors - multiparity, abruptio placentae, short tumultuous labors, oxytocin augmentation or

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induction, macrosomia, IUFD, operative birth. Maternal complications - acute respiratory distress, cyanosis, cardiovascular collapse, profound shock, coma, DIC, and death Maternal mortality is 86%. S/S - acute respiratory distress, cyanosis, CV decompensation, bleeding. Management Oxygen Ventilator support ABGs Blood and blood products Heparin Invasive hemodynamic monitoring CPR Immediate delivery

Preterm Labor  Labor occurring prior to the completion of 37 weeks of gestation.  The major cause of preterm delivery.  Affects 1 in 10 births in the U.S.  Causes at least 75% of neonatal deaths not due to congenital malformations.  Rate of preterm births has not changed over the past 40 years.  Infants born weighing less than 1,500 g are approximately 200 times more likely to die in the first year of life than those weighing more than 2,500 g.  Those surviving are 10 times more likely to be neurologically impaired.  Preterm births disproportionately contributes to developmental delay, visual and hearing impairment, chronic lung disease, and cerebral palsy.              

Risk factors: low socioeconomic status, poor nutrition nonwhite race low pre-pregnancy weight multiple gestation- only 1.1% of all pregnancies result in 10% of preterm births. History of previous preterm birth. 1 or more spontaneous 2nd trimester abortions Uterine anomalies Polyhydramnios UTI’s PROM Chorioamnionitis Placental hemorrhage, Maternal age extremes (younger than 16, older than 40) Maternal behaviors linked to increased rates of preterm deliveries.  Smoking  Cocaine use  Poor prenatal care  Preterm Labor

Maternal factors not linked to preterm delivery:  Women working outside of the home

 Coitus (intercourse) and orgasm (pelvic rest is dx this pregnancy)  Preterm Labor  Other conditions which could lead to preterm delivery:  Preterm premature rupture of membranes  Maternal medical or obstetrical complications  Antepartum fetal compromise Not always due to PPROM – PPRM with infection, medial or OB complication, fetal compromise Uterine causes:  unicornate and bicornate uterus. 

Cervical incompetence

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DES exposure Infectious causes STD’s and GBS

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Preterm Labor Risk assessment: Several risk-scoring systems have been looked at but have been found to have a very poor predictive value. Cervical dilation has been looked at for determining chances of preterm delivery. Conclusion: there is no predictive advantage to routine cervical exams in pregnant women at average risk.

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Signs & Symptoms of PTL  Regular uterine contractions (6 or more in an hour)  Lower abd cramping (may be mistaken for gas)  Low back pain/discomfort – similar to menstrual cramps  Change in vaginal discharge/ROM  Pelvic pressure Fetal Fibronectin  The glue that holds it all together  In cervical secretions up to 22 weeks and again at about 34 weeks –  If present btn 22-34 may indicate she is at risk for PTL  More predictive that she WILL NOT deliver within next 2 week if FFN test is negative. Preterm Labor Management:  HYDRATION  Tocolysis  Magnesium sulfate 

Beta-mimetic agents

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Terbutaline Indomethacin

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Nifedipine

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Adjunctive Therapy Corticosteroid Therapy (effects within 48hrs of administration, repeat every 7 days)

Nursing Actions for Preterm labor  IV, MgSO4  Monitor DTRs/VS/I&O  Monitor serum mag levels  4-6mEq/l: therapeutic  10mEq/l: loss of DTRs  15mEq/l: respiratory depression  25mEq/l: cardiac arrest     

Terbutaline (beta adrenergic agonist) Side effects: increased HR, nervousness, N/V, increased blood/urine glucose, decreased K+ levels, cardiac arrhythmias, pulmonary edema Indomethacin: Maternal side effect: Increased bleeding time, risk to exacerbate hypertensive disorders Fetal side effects: oligohydramnios, premature closure of ductus arteriosus

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Ensure mom knows how to palpate uterine contractions and other signs of PTL Antepartum bedrest: controversial Teach mom about ROM

Preterm Labor Delivery DON”T HAVE TO KNOW THESE NUMBER – here just to hep you understand how prolonging pregnancy even 1 -2 weeks has gigantic benefits!!!  If preterm delivery is imminent, decisions must be made in regard to the intrapartum management of the low birth weight fetus.  Survivability of fetus at varying gestations: rare (usually with larger infants)  22 weeks 23 weeks0-8% 15-20%  24 weeks50-60%  25 weeks 26-28 wksup to 85% > 90%  29 weeks      

Delivery at a facility capable of providing the highest quality of care for the infant is imperative for achieving an optimal perinatal outcome. Aggressive obstetrical and neonatal interventions have had minimal effects on the survival of infants born at 22-23 weeks gestation. Criteria for current viability threshold is 24 weeks gestation or 600 g weight. Preterm Labor Criteria for transport if mother is stable for transport. It is always best if the obstetricians and pediatricians come to an agreement for gestational age which can be safely delivered at the facility in question. Usually driven by pediatrics. Want to deliver at hospital that will be safest for mother & fetus!!!

Emergency childbirth  1. Position woman.  2. Reassure.  3. Use gloves if possible.  4. Use under pad of some sort  5. Don’t touch perineum unnecessarily.

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6. As crowning occurs, you may attempt to slow the birth—somewhat! 7. Check for cord. 8. Support head during external rotation. 9.- 12. Baby will be slippery—place on mom’s abdomen after it is born—placental resuscitation, dry, stimulate to breathe, cover. Wait for placenta...