LABOR & DELIVERYLABOR & DELIVERY

Prof. Unn HidleProf. Unn HidleUpdated Spring 2010Updated Spring 2010

Suggested audio-visual material:Suggested audio-visual material:

Leopold’s Maneuver (Video)Leopold’s Maneuver (Video) Labor and Delivery: the LDR – Normal Labor and Delivery: the LDR – Normal

Vaginal Delivery (Video)Vaginal Delivery (Video) C-section (Video)C-section (Video) Electronic Fetal Monitoring (Video)Electronic Fetal Monitoring (Video)

Suggested Websites:Suggested Websites:

International Cesarean Action Network (for International Cesarean Action Network (for information of c-sections, VBACs, etc.):information of c-sections, VBACs, etc.): http://www.ican-online.orghttp://www.ican-online.org

To correct fetal positioning at home:To correct fetal positioning at home: http://www.spinningbabies.comhttp://www.spinningbabies.com

Choices in Childbirth (this site has a lot of Choices in Childbirth (this site has a lot of statistical information on NY state hospitals statistical information on NY state hospitals obstetrical interventions):obstetrical interventions): http://www.choicesinchildbirth.orghttp://www.choicesinchildbirth.org

Critical factors in labor & birthCritical factors in labor & birth

The passageThe passage The fetusThe fetus The relationship between the passage and The relationship between the passage and

the fetusthe fetus The forces of laborThe forces of labor The psychosocial considerationThe psychosocial consideration

The Birth PassageThe Birth Passage

The true pelvis is divided into 3 sections:The true pelvis is divided into 3 sections:- the - the inletinlet, the , the pelvic cavitypelvic cavity (midpelvis), and (midpelvis), and

the the outletoutletThe four classic types of pelvis are: The four classic types of pelvis are:

gynecoid, android, anthropoid and platypelloidgynecoid, android, anthropoid and platypelloid.. The gynecoid, or female, pelvis is most common The gynecoid, or female, pelvis is most common

Size of the pelvis:Size of the pelvis:Diameters of the pelvic inlet, midpelvis or pelvic Diameters of the pelvic inlet, midpelvis or pelvic cavity, and outletcavity, and outlet

Ability of the cervix to dilate and effaceAbility of the cervix to dilate and efface

Pelvic TypesPelvic Types

The Fetus The Fetus

Fetal head (size and presence of Fetal head (size and presence of molding)molding)

Fetal attitudeFetal attitude Fetal lieFetal lie Fetal presentationFetal presentation Placenta (implantation site)Placenta (implantation site)

Fetal headFetal head The fetal skull or cranium consists of the face, the The fetal skull or cranium consists of the face, the

base of the skull and the vault of the cranium or roof.base of the skull and the vault of the cranium or roof. The bones of the face and cranial base are well fused The bones of the face and cranial base are well fused

and essentially fixedand essentially fixed

MoldingMolding refers to the cranial bones overlapping refers to the cranial bones overlapping under pressure during laborunder pressure during labor

SuturesSutures of the fetal skull are membranous spaces of the fetal skull are membranous spaces between the cranial bones. between the cranial bones.

FontanellesFontanelles are the intersections of the cranial are the intersections of the cranial sutures. These sutures allow for molding of the fetal sutures. These sutures allow for molding of the fetal head. head.

FontanellesFontanelles The The anterior fontanelleanterior fontanelle is diamond is diamond

shaped and measures about 2-3cm. It shaped and measures about 2-3cm. It permits growth of the brain by remaining permits growth of the brain by remaining unossified for as long as 18 months.unossified for as long as 18 months.

The The posterior fontanelleposterior fontanelle is much smaller is much smaller and closes within 8-12 weeks after birthand closes within 8-12 weeks after birth

FontanelleFontanelle

Fetal attitudeFetal attitude

Fetal attitude is the relation of the Fetal attitude is the relation of the fetal parts to one another. fetal parts to one another.

The normal attitude of the fetus is The normal attitude of the fetus is one of moderate flexion of the head, one of moderate flexion of the head, flexion of the arms onto the chest, flexion of the arms onto the chest, and flexion of the legs onto the and flexion of the legs onto the abdomenabdomen

Fetal LieFetal Lie

Fetal lie refers to the relationship of the Fetal lie refers to the relationship of the cephalocaudal (spinal column) axis of the fetus cephalocaudal (spinal column) axis of the fetus to the cephalocaudal axis of the woman.to the cephalocaudal axis of the woman.

A A longitudinal lielongitudinal lie occurs when the occurs when the cephalocaudal axis of the fetus is parallel to cephalocaudal axis of the fetus is parallel to the woman’s spinethe woman’s spine

A A transverse lietransverse lie occurs when the occurs when the cephalocaudal axis of the fetus is at a right cephalocaudal axis of the fetus is at a right angle to the woman’s spineangle to the woman’s spine

Fetal lie? Attitude?Fetal lie? Attitude?

Fetal lie? Attitude?Fetal lie? Attitude?

Fetal lie? Attitude?Fetal lie? Attitude?

Fetal PresentationFetal Presentation Fetal presentation is determined by fetal lie and by the Fetal presentation is determined by fetal lie and by the

body part of the fetus that enters the pelvic passage first, body part of the fetus that enters the pelvic passage first, the the presenting part

Fetal presentation may be Fetal presentation may be cephaliccephalic (most common), (most common), breechbreech, or , or shouldershoulder

Breech and shoulder presentations are referred to as Breech and shoulder presentations are referred to as malpresentations as they are associated with difficulties malpresentations as they are associated with difficulties during labor during labor

Of note, some cephalic presentations are considered Of note, some cephalic presentations are considered malpresentations, i.e. military or face. However, the malpresentations, i.e. military or face. However, the overall cephalic categoryoverall cephalic category is the is the PREFERREDPREFERRED presentation.presentation.

Examples of presentationsExamples of presentations

Cephalic PresentationCephalic Presentationincludes all of the following:includes all of the following:

97% of births97% of births Fetal head presents itself to the passageFetal head presents itself to the passage ““Subcategories” of cephalic presentation includes:Subcategories” of cephalic presentation includes:

VertexVertex presentation: Occiput is the presenting part – most presentation: Occiput is the presenting part – most common typecommon type

MilitaryMilitary presentation: The fetal head is neither flexed nor presentation: The fetal head is neither flexed nor extendedextended

Brow PresentationBrow Presentation: The fetal head is partially extended: The fetal head is partially extended Face presentationFace presentation: The fetal head is hyperextended: The fetal head is hyperextended

Breech PresentationBreech Presentation 3% of births3% of births Sacrum Sacrum is the landmark to be notedis the landmark to be noted Frank BreechFrank Breech: the fetal hips are flexed and the knees : the fetal hips are flexed and the knees

are extended. The buttocks of the fetus present to the are extended. The buttocks of the fetus present to the maternal pelvismaternal pelvis

Complete BreechComplete Breech: the fetal knees and hips are both : the fetal knees and hips are both flexed; the thighs are on the abdomen and the calves flexed; the thighs are on the abdomen and the calves are on the posterior aspect of the thighsare on the posterior aspect of the thighs

Footling BreechFootling Breech: the fetal hips and legs are extended, : the fetal hips and legs are extended, and the feet of the fetus present to the maternal pelvis and the feet of the fetus present to the maternal pelvis (single or double footling) (single or double footling)

Shoulder PresentationShoulder Presentation

Also called a Also called a transverse lietransverse lie Most frequently, the shoulder is the Most frequently, the shoulder is the

presenting part and the presenting part and the acromion acromion processprocess ( (AA) of the scapula is the ) of the scapula is the landmark to be notedlandmark to be noted

Functional Functional relationships of relationships of

presenting part and presenting part and passagepassage

EngagementEngagement

Engagement of the presenting part occurs when the Engagement of the presenting part occurs when the largest diameter of the presenting part reaches or largest diameter of the presenting part reaches or passes through the pelvic inletpasses through the pelvic inlet. .

Engagement can be determined by vaginal, rectal Engagement can be determined by vaginal, rectal examination or abdominal palpationexamination or abdominal palpation

With abdominal palpation, if hands can pass between With abdominal palpation, if hands can pass between the fetal head and the pelvic inlet (converge), the the fetal head and the pelvic inlet (converge), the fetus is not engaged (fetus is not engaged (ballottmentballottment))

Usually, the Usually, the point of engagement is station zeropoint of engagement is station zero Engagement confirms the adequacy of the pelvic inletEngagement confirms the adequacy of the pelvic inlet

Station Station Station refers to the Station refers to the relationship of the presenting part to an

imaginary line drawn between the ischial spines of the of the maternal pelvis.maternal pelvis.

The ischial spines as a landmark have been designated as zero The ischial spines as a landmark have been designated as zero station (the exact point of engagement)station (the exact point of engagement)

If the presenting part is higher than the ischial spines, a If the presenting part is higher than the ischial spines, a negative number is assigned, noting cm above zero stationnegative number is assigned, noting cm above zero station

Positive numbers are used to indicate that the presenting part Positive numbers are used to indicate that the presenting part has passed the ischial spineshas passed the ischial spines

Station -5 is the pelvic inlet, and station +4 is the outlet (pelvic Station -5 is the pelvic inlet, and station +4 is the outlet (pelvic floor)floor)

Station -4 means the presenting part is floating (Station -4 means the presenting part is floating (ballottmenballottmentt))

Fetal PositionFetal Position

Fetal position refers to the relationship of a Fetal position refers to the relationship of a designated landmark on the presenting fetal designated landmark on the presenting fetal part to the front, sides, or back of the part to the front, sides, or back of the maternal pelvismaternal pelvis

The landmark on the fetal presenting part is The landmark on the fetal presenting part is related to 4 imaginary quadrants of the pelvis: related to 4 imaginary quadrants of the pelvis: left anterior left anterior ((LALA),), right anterior right anterior ((RARA),), left left posterior posterior ((LPLP),), and right posterior and right posterior ((RPRP))

The landmark chosen for vertex presentations The landmark chosen for vertex presentations is the occiput is the occiput ((OO),), and the landmark for face and the landmark for face presentation is the mentum presentation is the mentum ((MM))

In breech presentations, the sacrum In breech presentations, the sacrum ((SS)) is the is the designated landmarkdesignated landmark

In shoulder presentation, the acromion process In shoulder presentation, the acromion process ((AA)) on the scapula is the landmark on the scapula is the landmark

TO COMBINE THE NOTATIONSTO COMBINE THE NOTATIONS:: Three notations are used to describe the fetal position:Three notations are used to describe the fetal position: Right (Right (RR) or left () or left (LL) side of the maternal pelvis) side of the maternal pelvis The landmark of the fetal presenting part: occiput (The landmark of the fetal presenting part: occiput (OO), ),

mentum (mentum (MM), sacrum (), sacrum (SS) or acromion process () or acromion process (AA)) Anterior (Anterior (AA), posterior (), posterior (PP), or transverse (), or transverse (TT), depending on ), depending on

whether the landmark is in the front, back, or side of the pelviswhether the landmark is in the front, back, or side of the pelvis Of note, the term dorsal (Of note, the term dorsal (DD) refers to fetal position in ) refers to fetal position in

transverse lie, it refers to the fetal backtransverse lie, it refers to the fetal back

A few examplesA few examples

Position: Position: LOALOA = _________ = _________ Lie: _____________Lie: _____________ Presentation: _____________Presentation: _____________ Attitude: _______________Attitude: _______________

Position : Position : RADPRADP = ________ = ________ Lie : __________________Lie : __________________ Presentation: _____________Presentation: _____________ Attitude: ________________Attitude: ________________

Position: Position: RMARMA = _________ = _________ Lie: ____________________Lie: ____________________ Presentation: _____________Presentation: _____________ Attitude: _________________Attitude: _________________

Position: Position: RSARSA = ___________ = ___________ Lie: __________________Lie: __________________ Presentation: ______________Presentation: ______________ Attitude: ________________Attitude: ________________

How can nurses benefit How can nurses benefit from this knowledge?from this knowledge?

Leopold’s maneuvers Leopold’s maneuvers

Leopold’s maneuvers are a Leopold’s maneuvers are a systematic way to evaluate the systematic way to evaluate the maternal abdomenmaternal abdomen

Examiner can determine fetal Examiner can determine fetal position and presentationposition and presentation

Leopold’s ManeuverLeopold’s Maneuver

FETAL MONITORFETAL MONITOR

Fetal Heart Rate monitoringFetal Heart Rate monitoring

Placement of FHR Placement of FHR monitormonitor

Assisting with external Assisting with external version of fetus version of fetus

Electronic monitoring of Electronic monitoring of contractionscontractions

Tocodynamometer or “Tocodynamometer or “TOCOTOCO” is an external ” is an external monitoring device for uterine contractionsmonitoring device for uterine contractions

It is positioned against the fundus of the uterus and It is positioned against the fundus of the uterus and held in place with an elastic beltheld in place with an elastic belt

The toco contains a flexible disk that responds to The toco contains a flexible disk that responds to pressurepressure

When the uterus contracts, the fundus tightens and When the uterus contracts, the fundus tightens and the change in pressure against the toco is amplified the change in pressure against the toco is amplified and transmitted to the electronic fetal monitorand transmitted to the electronic fetal monitor

Fetal Heart Rate MonitoringFetal Heart Rate Monitoring

TachycardiaTachycardia BradycardiaBradycardia Variability: LTV versus STVVariability: LTV versus STV AccelerationsAccelerations Decelerations: Decelerations: Early, Late & VariableEarly, Late & Variable

Fetal Heart Rate MonitoringFetal Heart Rate Monitoring

Baseline rate: Baseline rate: Refers to the average FHR observed during Refers to the average FHR observed during

a 10-minute period of monitoring.a 10-minute period of monitoring. Normal range is 120-160 BPMNormal range is 120-160 BPM >160 BPM = tachycardia>160 BPM = tachycardia <120 BPM = bradycardia<120 BPM = bradycardia

Fetal TachycardiaFetal Tachycardia

Fetal BradycardiaFetal Bradycardia

Causes of fetal tachycardiaCauses of fetal tachycardia Early fetal hypoxiaEarly fetal hypoxia

Compensation for reduced blood flowCompensation for reduced blood flow Maternal feverMaternal fever

Accelerates the metabolism of the fetusAccelerates the metabolism of the fetus Maternal dehydrationMaternal dehydration Beta-sympathomimetic drugsBeta-sympathomimetic drugs

Atropine, terbutaline and other drugs with cardiac stimulant effectAtropine, terbutaline and other drugs with cardiac stimulant effect AmnionitisAmnionitis

Fetal tachycardia may be first sign of intrauterine infectionFetal tachycardia may be first sign of intrauterine infection Maternal hyperthyroidismMaternal hyperthyroidism

TSH may cross the placenta and stimulate fetal heart rateTSH may cross the placenta and stimulate fetal heart rate Fetal anemiaFetal anemia

Heart rate is compensating to improve tissue perfusionHeart rate is compensating to improve tissue perfusion

Causes of Fetal BradycardiaCauses of Fetal Bradycardia

Late (profound) Late (profound) fetal hypoxiafetal hypoxia Maternal hypotensionMaternal hypotension

Results in decreased blood flow to the Results in decreased blood flow to the fetusfetus

Prolonged Prolonged umbilical cord umbilical cord compressioncompression

Fatal arrhythmiaFatal arrhythmia

VariabilityVariability

Baseline variability is a measure of the interplay (the Baseline variability is a measure of the interplay (the push-pull effect) between the sympathetic and push-pull effect) between the sympathetic and parasympathetic nervous systems (adequate parasympathetic nervous systems (adequate oxygenation promotes normal function of the oxygenation promotes normal function of the autonomic nervous system and helps the fetus adapt autonomic nervous system and helps the fetus adapt to the stress of labor).to the stress of labor).

VariabilityVariability = The = The FETUS FETUS isis RESPONDING RESPONDING to to multiple factors which constantly speed and slow the multiple factors which constantly speed and slow the heart rate; heart rate; adapting to the stress of labor = adapting to the stress of labor = A GOOD THING!!!

There are two types of variability:There are two types of variability:

Short-term variability (STV)Short-term variability (STV) = the beat-to-beat change in = the beat-to-beat change in FHR. It represents fluctuations of the baseline. STV can FHR. It represents fluctuations of the baseline. STV can onlyonly be measured via internal (scalp electrode) means and is be measured via internal (scalp electrode) means and is classified as either classified as either present or absent.present or absent.

Long-term variability (LTV)Long-term variability (LTV) = the waviness or rhythmic = the waviness or rhythmic fluctuations (called cycles) of the FHR tracing which occurs fluctuations (called cycles) of the FHR tracing which occurs 3-5 times/minute. LTV can be classified as 3-5 times/minute. LTV can be classified as absent, decreased, absent, decreased, average, increased, or markedaverage, increased, or marked. . Most importantly, even if FHR patterns are abnormal, if Most importantly, even if FHR patterns are abnormal, if variability is normal, the fetus is usually not suffering from variability is normal, the fetus is usually not suffering from cerebral asphyxiacerebral asphyxia

Causes of decreased variabilityCauses of decreased variability

Hypoxia and acidosisHypoxia and acidosis Decreased blood flow to the fetusDecreased blood flow to the fetus

Administration of certain drugsAdministration of certain drugs Demerol, Valium or other CNS depressants Demerol, Valium or other CNS depressants

Fetal sleep cycleFetal sleep cycle During fetal sleep, LTV is decreasedDuring fetal sleep, LTV is decreased

Fetus of Fetus of less than 32 weeks gestation less than 32 weeks gestation

Causes of increased variabilityCauses of increased variability

Early mild hypoxiaEarly mild hypoxia – compensatory – compensatory mechanismmechanism

Fetal stimulationFetal stimulation – stimulation of – stimulation of autonomic nervous system, i.e. autonomic nervous system, i.e. palpation, vaginal examination etc.palpation, vaginal examination etc.

AccelerationAcceleration

TransientTransient increases in the FHR (>15 bpm increases in the FHR (>15 bpm above the baseline, lasting >15 seconds), above the baseline, lasting >15 seconds), normally caused by fetal movement normally caused by fetal movement (think about the NST)(think about the NST)

It often accompany uterine contractions, It often accompany uterine contractions, usually due to the fetal movement in usually due to the fetal movement in response to the pressure of the response to the pressure of the contractioncontraction

FHR AccelerationsFHR Accelerations

DecelerationDeceleration

Periodic Periodic decreasedecrease in FHR from the normal baseline in FHR from the normal baseline They are categorized as early, late, and variable They are categorized as early, late, and variable

according to the time of their occurrence in the according to the time of their occurrence in the contraction cycle and their waveformcontraction cycle and their waveform

Early decelerationEarly deceleration = when the fetal head is = when the fetal head is compressed, cerebral flood flow is decreased which compressed, cerebral flood flow is decreased which leads to central vagal stimulation. The onset of early leads to central vagal stimulation. The onset of early deceleration occurs before the onset of the uterine deceleration occurs before the onset of the uterine contraction. contraction. Usually benignUsually benign

Early decelerationsEarly decelerations

Late decelerationLate deceleration = caused by uteroplacental = caused by uteroplacental insufficiency resulting from decreased blood flow and insufficiency resulting from decreased blood flow and oxygen transfer to the fetus through the intervillous oxygen transfer to the fetus through the intervillous spaces during uterine contraction. Occurs after the spaces during uterine contraction. Occurs after the onset of a uterine contraction. Non-reassuring sign. onset of a uterine contraction. Non-reassuring sign. (Nursing function – prepare for C-section)(Nursing function – prepare for C-section)

Variable decelerationsVariable decelerations = occur if the = occur if the umbilical cord umbilical cord becomes compressed,becomes compressed, this reducing blood flow this reducing blood flow between the placenta and fetus. The peripheral between the placenta and fetus. The peripheral resistance in the fetal circulation increases, causing resistance in the fetal circulation increases, causing fetal hypertension. Non-reassuring sign. Further fetal hypertension. Non-reassuring sign. Further assessment of this pattern is necessary. assessment of this pattern is necessary.

Late decelerationsLate decelerations

Variable decelerationsVariable decelerations

Possible nursing interventionsPossible nursing interventions Report findingsReport findings Change maternal position (left side)Change maternal position (left side) Oxygen administration if indicated (6-8L via mask)Oxygen administration if indicated (6-8L via mask) Usually discontinue OxytocinUsually discontinue Oxytocin Assist with vaginal exam (i.e. possibility of prolapsed Assist with vaginal exam (i.e. possibility of prolapsed

cord)cord) Increase IVF if indicated for hydrationIncrease IVF if indicated for hydration Prepare for vaginal delivery or C-sectionPrepare for vaginal delivery or C-section Explain to mother and familyExplain to mother and family Be a support-roleBe a support-role

THE END!THE END!