MODULE 2 INTRAPARTUM

PROCESSES OF LABOR AND BIRTH

• KEY FACTORS RELATED TO PROGRESS OF LABOR• FORCES OF LABOR• INTRAPARTAL ASSESSMENT AND

CARE OF MOTHER AND FETUS• CARE OF MOTHER AND INFANT IN

LABOR, DELIVERY, AND IMMEDIATE POST PARTUM• BIRTH RELATED PROCEDURES

MODULE 2 PART 1KEY FACTORS RELATED TO

PROGRESS OF LABOR

KEY FACTORS RELATED TO PROGRESS OF LABOR

• PASSAGEWAY (BIRTH CANAL)• PASSENGER (FETUS)• POSITION OF THE MOTHER AND FETUS• PHYSIOLOGICAL FORCES OF LABOR• PSYCHOSOCIAL CONSIDERATIONS

BIRTH PASSAGE

• SIZE OF PELVIS• TYPE OF PELVIS• CERVICAL DILATATION, EFFACEMENT• ABILITY OF VAGINA AND INTROITUS TO

EXPAND

BIRTH PASSAGE

• FOUR CLASSIC PELVIC TYPES• GYNECOID

• ANDROID

• ANTHROPOID

• PLATYPELLOID

BIRTH PASSAGE

CERVICAL DILATATION AND EFFACEMENT

• DILATATION—MEASURED IN CENTIMETERS FROM 0 TO 10–0 CM—CERIVX CLOSED–10 CM—FULL DILATATION

• EFFACEMENT—MEASURED IN PERCENTAGE 0 TO 100%

Figure 15–11a Effacement of the cervix in the primigravida. Beginning of labor. There is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid.

Figure 15–11b Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head.

Figure 15–11c Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic fluid exerts hydrostatic pressure.

Figure 15–11d Complete effacement and dilatation.

UTERINE AND CERVICAL CHANGES

• UPPER UTERINE SEGMENT THICKENS AND PULLS UP

• LOWER SEGMENT EXPANDS AND THINS OUT• EFFACEMENT• CAUSES OF UTERINE CHANGES– ESTROGEN STIMULATES MUSCLE CONTRACTIONS– COLLAGEN IN CERVIX BROKEN DOWN– INCREASED WATER CONTENT OF THE CERVIX

MODULE 2 PART 2THE PASSENGER (FETUS)

• FETUS (PASSENGER)–SIZE OF FETAL HEAD–FETAL ATTITUDE–FETAL LIE–FETAL PRESENTATION–IMPLANTATION SITE OF

PLACENTA

PASSENGER

• FETAL HEAD• SUTURES– FRONTAL– SAGITTAL– CORONAL– LAMBOIDAL

– MOLDING– FONTANELLES

Figure 15–2 Superior view of the fetal skull.

PASSENGER

LANDMARKS OF FETAL SKULL• MENTUM• SINCIPUT• ANTERIOR FONTANELLE (BREGMA)• VERTEX• POSTERIOR FONTANELLE• OCCIPUT

Figure 15–4a Typical anteroposterior diameters of the fetal skull. When the vertex of the fetus presents and the fetal head is flexed with the chin on the chest, the smallest anteroposterior diameter (suboccipitobregmatic) enters the birth canal.

Figure 15–6a Cephalic presentation. Vertex presentation. Complete flexion of the head allows the suboccipitobregmatic diameter to present to the pelvis.

Figure 15–6c Brow presentation. The fetal head is in partial (halfway) extension. The occipitomental diameter, which is the largest diameter of the fetal head, presents to the pelvis.

PASSENGER

FETAL LIE AND PRESENTATION• FETAL LIE-- Relation of long axis of fetus

to long axis of the mother–Longitudinal–Transverse

• FETAL PRESENTATION—the body part of the fetus that first enters the pelvis

PASSENGER (PRESENTATION)

CEPHALIC PRESENTATION (95%)• VERTEX—SUBOCCIPTOBREGMATIC

• MILITARY--OCCIPITOFRONTAL

• BROW--OCCIPITOMENTAL

• FACE--SUBMENTOBREGMATIC

PASSENGER (PRESENTATION)

BREECH PRESENTATION (3%)• COMPLETE—HIPS FLEXED, KNEES FLEXED• FRANK—HIPS FLEXED, KNEES EXTENDED• FOOTLING—HIPS & FEET EXTENDED,

FEET,FOOT PRESENT TO MATERNAL PELVIS• KNEELING—HIPS EXTENDED, KNEES FLEXED

PASSENGER (PRESENTATION)

SHOULDER (TRANSVERSE) PRESENTATION (2%)

• TRANSVERSE LIE—SHOULDER IS USUAL PRESENTING PART

• COMPOUND—USUALLY ARM OR HAND PRESENTING ALONG PRESENTING PART

MODULE 2 PART 3POSITION OF MOTHER AND

FETUS

POSITION OF FETUS IN RELATION TO MOTHER’S PELVIS

ENGAGEMENT• WHEN THE WIDEST DIAMETER OF THE

PRESENTING PART HAS REACHED OR PASSED THE PELVIC INLET

• ENGAGEMENT USUALLY CORRESPONDS TO O STATION

• FLOATING—WHEN PRESENTING PART IS ENTIRELY OUT OF THE PELVIS AND FREELY MOVABLE IN THE INLET

Figure 15–8 Measuring the station of the fetal head while it is descending. In this view the station is 22/23.

POSITION

STATION• RELATIONSHIP OF FETAL PRESENTING

PART TO THE LEVEL OF THE ISCHIAL SPINES–THE ISCHIAL SPINES ARE O STATION–ABOVE THE SPINES IS A NEGATIVE VALUE–BELOW THE SPINES IS A POSITIVE VALUE

MODULE 2 PART 4A PHYSIOLOGICAL FORCES OF

LABOR

PHYSIOLOGIC FORCES OF LABOR–CONTRACTION PHASES---INCREMENT,

ACME, DECREMENT–DESCRIBED WITH FREQUENCY,

DURATION, AND INTENSITYPRIMARY AND SECONDARY FORCES OF

LABOREFFECTIVENESS OF PUSHINGDURATION OF LABOR

Figure 15–10 Characteristics of uterine contractions.

SIGNS OF LABOR• LIGHTENING• “BRAXTON HICKS” CONTRACTIONS• CERVIAL CHANGES• BLOODY SHOW• RUPTURE OF MEMBRANES• SUDDEN BURST OF ENERGY• WEIGHT LOSS• N&V, DIARRHEA, BACKACHE

TRUE LABOR/FALSE LABOR

• TRUE• CONTRACTIONS

REGULAR, INCREASE IN DURATION & STRENGTH

• INTERVAL SHORTENS• DILATATION &

EFFACEMENT PROGRESS

• INTENSITY INCREASES WITH WALKING

• FALSE• CONTRACTIONS

IRREGULAR, NO CHANGE IN DURATION, STRENGTH

• INTERVAL IRREGULAR OR NO CHANGE

• NO DILATATION OR EFFACEMENT

• WALKING LESSENS OR HAS NO EFFECT ON CONTRACTIONS

MODULE 2 PART 4BSTAGES OF LABOR

• FIRST STAGE OF LABOR–STARTS WITH BEGINNING OF

REGULAR CONTRACTIONS TO FULL DILATATION

• FIRST STAGE IS DIVIDED INTO THREE PHASES: LATENT, ACTIVE, AND TRANSITION

PHASES OF LABOR—FIRST STAGE

• LATENT---0--3 CENTIMETERS, CONTINUING EFFACEMENT

• ACTIVE---4--7 CENTIMETERS, COMPLETE EFFACEMENT

• TRANSITION 8--10 CENTIMTERS ENGAGEMENT

CONTRACTION CHARACTERISTICS• LATENT PHASE–MILD—10-30MIN. LASTING 20-40 SECONDS–MODERATE—5-7MIN. LASTING 30-40

SECONDS

• ACTIVE PHASE–MODERATE TO STRONG—2-3 MIN. LASTING

40-60 SECONDS

• TRANSITION– STRONG—1-1/2-2 MIN. LASTING 60-90

SECONDS

PSYCHOLOGIC ADAPTIONSTO LABOR: LATENT PHASE

• FEELS ABLE TO COPE WITH DISCOMFORT• MAY BE RELIEVED THAT LABOR HAS

FINALLY STARTED• USUALLY ABLE TO TALK THROUGH

CONTRACTION• IS ABLE TO RECOGNIZE AND EXPRESS

FEELING OF ANXIETY

PSYCHOLOGIC ADAPTIONSTO LABOR: ACTIVE PHASE

• ANXIETY INCREASES• FEARS LOSS OF CONTROL• MAY HAVE DECREASED ABILITY TO COPE• LESS TALKATIVE

PSYCHOLOGIC ADAPTIONS TO LABOR: TRANSITION PHASE

• WITHDRAWS INTO HERSELF• DOUBTS ABILITY TO COPE• APPREHENSIVE AND IRRITABLE• TERRIFIED OF BEING ALONE• DOES NOT WANT ANYONE TO TALK TO

HER OR TOUCH HER• DIFFICULT TO CONCENTRATE ON TASK

SECOND STAGE OF LABOR

–BEGINS WITH COMPLETE CERVICAL DILATATION AND ENDS WITH THE BIRTH OF THE INFANT

THIRD STAGE OF LABOR

BEGINS WITH BIRTH OF INFANT AND ENDS WITH THE DELIVERY OF THE PLACENTA

FOURTH STAGE OF LABOR

BEGINS WITH DELIVERY OF PLACENTA TO 4 HOURS AFTER

LABOR REVIEW

• DESCRIBE THE FIVE CRITICAL FACTORS THAT INFLUENCE LABOR IN THE ASSESSMENT OF A MOTHER’S AND FETUS’ PROGRESS IN LABOR AND BIRTH, GIVING TWO EXAMPLES OF EACH

MODULE 2 PART 5MATERNAL PHYSIOLOGIC

ADAPTION TO LABOR

• RENAL -- >IN RENIN, PLASMA RENIN ACTIVITY, ANGIOTENSIN

• VOIDING CAN BE AFFECTED BY EDEMA,DISPLACEMENT

• GI—DECREASED MOTILITY, DELAYED STOMACH EMPTYING

• CARDIAC OUTPUT INCREASES

• WBC CAN INCREASE TO 25,000mm

• BP INCREASES

• ACID/BASE BALANCE—MAY SEE > Ph EARLY IN LABOR

INTRAPARTAL NURSING ASSESSMENT

• HISTORY–PERSONAL DATA–HX PREVIOUS ILLNESS–PROBLEMS IN PRENATAL PERIOD–PREGNANCY DATA–INFANT FEEDING METHOD CHOSEN–ANY PRENATAL EDUCATION ?–BIRTH PLAN

MATERNAL PSYCHOSOCIAL HISTORY

• POVERTY• NUTRITION• PRENATAL CARE• CULTURAL BELIEFS• ENVIRONMENT• USE OF DRUGS/ALCOHOL• DOMESTIC VIOLENCE

MATERNAL PSYCHOSOCIAL ISSUES

• EMOTIONAL STATUS• SOCIOCULTURAL BELIEFS• PREVIOUS CHILDBIRTH EXPERIENCE• SUPPORT• MENTAL AND PHYSICAL PREPARATION

INTRAPARTAL ASSESSMENT-- STAGE ONE

• VITAL SIGNS• WEIGHT• LUNGS• FUNDUS• EDEMA• HYDRATION• PERINEUM

INTRPARTAL ASSESSMENT STAGE ONE

• LABOR STATUS• FETAL STATUS• LAB VALUES• CULTURAL INFLUENCES• RESPONSE TO LABOR• CHILDBIRTH PREPARATION• ANXIETY• SUPPPORT

LABOR EVALUATION METHODS

• CERVICAL ASSESSMENT–VAGINAL EXAM•DILATATION• EFFACEMENT• STATION

Figure 16–2 To gauge cervical dilatation, the nurse place the index and middle fingers against the cervix and determines the size of the opening. Before labor begins, the cervix is long (approximately 2.5 cm), the sides feel thick, and the cervical canal is closed, so an examining finger cannot be inserted. During labor, the cervix begins to dilate, and the size of the opening progresses from 1 cm to 10 cm in diameter.

FETAL ASSESSMENT

• FETAL POSITION– PALPATION—LEOPOLD’S MANEUVER– INSPECT SIZE AND SHAPE OF WOMAN’S

ABDOMEN– VAGINAL EXAM TO DETERMINE PRESENTING

PART – FETAL HEART RATE– ULTRASOUND

Figure 16–4 Top: The fetal head progressing through the pelvis. Bottom: The changes that the nurse will detect on palpation of the occiput through the cervix while doing a vaginal examination. Source: Myles, M. F. (1975). Textbook for midwives (p. 246). Edinburgh, Scotland: Churchill-Livingstone.

Figure 16–5d Fourth maneuver: Facing the woman’s feet, place both hands on the lower abdomen and move hands gently down the sides of the uterus toward the pubis. Note the cephalic prominence or brow.

GROUP EXERCISE

LIST THREE POTENTIAL PROBLEMS RELATED TO:PASSENGERPOSTIONPASSAGEWAYPHYSIOLOGICAL FORCES OF LABORPSYCHOSOCIAL ISSUES

MODULE 2 PART 7AFETAL HEART RATE (FHR)

MONITORING

• ELECTRONIC FETAL HEART RATE MONITOR--DOPPLER• BASELINE RATE—120-160BPM• WHAT CAUSES:–FETAL TACHYCARDIA–FETAL BRADYCARDIA

• ELECTRONIC MONITORING OF CONTRACTIONS

–TOCO—EXTERNATION ASSESSMENT OF CONTRACTIONS– IUPC—INTERNAL ASSESSMENT OF

CONTRACTIONS

EXTERNAL MONITORING

• EXTERNAL—ULTRASONIC TRANSDUCER (DOPPLER)–HIGH FREQUENCY SOUND WAVES

REFLECT MECHANICAL ACTION OF FETAL HEART

• DIFFICULT TO OBTAIN CONTINUOUS, ACCURATE RECORD AT TIMES

Figure 16–8 Electronic fetal monitoring by external technique. The tocodynamometer (“toco”) is placed over the uterine fundus. The toco provides information that can be used to monitor uterine contractions. The ultrasound device is placed over the area of the fetal back. This device transmits information about the fetal heart rate. Information from both the toco and the ultrasound device is transmitted to the electronic fetal monitor. The fetal heart rate is displayed in a digital display (as a blinking light), on the special monitor paper, and audibly (by adjusting a button on the monitor). The uterine contractions are displayed on the special monitor paper as well.

INTERNAL FHR MONITORING

–MEMBRANES MUST BE RUPTURED–CERVIX SUFFCIENTLY DILATED–PRESENTING PART LOW ENOUGH FOR

PLACEMENT

–SMALL ELECTRODE ATTACHED TO PRESENTING PART–MOST ACCURATE APPRAISAL OF FETAL

WELL-BEING IN LABOR

Figure 16–9a Technique for internal, direct fetal monitoring. Spiral electrode.

Figure 16–9b Attaching the spiral electrode to the scalp.

FHR MONITORING• VARIABILITY

–BEAT TO BEAT CHANGES IN FETAL HEART RATE–INDICATION OF AN INTACT CNS•ABSENT•MODERATE•MARKED

Figure 16–10 Normal fetal heart rate pattern obtained by internal monitoring. Note normal FHR, 140 to 158 beats/min, presence of long- and short-term variability, and absence of deceleration with adequate contractions. Arrows on bottom of tracing indicate beginnings of uterine contractions.

Figure 16–11a Short- and long-term variability. Increased LTV; STV present.

Figure 16–11b Average LTV; STV absent.

Figure 16–11c Absent LTV; STV present.

Figure 16–11d Absent LTV; STV absent.

FHR MONITORING

• ACCELERATIONS

• DECELERATIONS

–EARLY–LATE–VARIABLE

Figure 16–12 Types and characteristics of early, late, and variable decelerations. Source: Hon, E. (1976). An introduction to fetal heart rate monitoring (2nd ed., p. 29). Los Angeles: University of Southern California School of Medicine.

• V C

• E H

• A O

• L P

FETAL ASSESSMENT• SCALP STIMULATION

• FETAL BLOOD SAMPLING (FBS)• NORMAL SCALP pH > 7.25, 7.20-7.25

BORDERLINE, <7.20 NONREASSURING–MEMBRANES MUST BE RUPTURED–CERVIX DILATED 2-3CM–PRESENTING PART -2 STATION OR LOWER

MODULE 2 PART 8NURSING INTERVENTIONS

IN FIRST AND SECOND STAGES OF LABOR

FIRST STAGE-- LATENT PHASE

–DILATATION, EFFACEMENT, STATION–MEMBRANE ASSESSMENT–COMFORT LEVEL–VS, FHR–UTERINE CONTRACTIONS EVERY 30-60 MIN.–TEACHING

LATENT PHASE

–ENCOURAGE AMBULATION–ENCOURAGE VOIDING Q2H–COMFORT MEASURES–NUTRITION OFFER FLUIDS–PAIN ASSESSMENT–EPIDURAL MONITORING– IDENTIFY AND OBSERVE SUPPORT

PERSON(S)

FIRST STAGE-- ACTIVE PHASE

– ENCOURAGE TO VOID Q1-2 HOURS–AUSCULTATE FHR Q15-30 MIN.–PALPATE CONTRACTIONS Q15 MIN.–VAGINAL EXAMS TO ACESS PROGRESS– EPIDURAL MONITORING, VS Q15-30 MIN.– START IV INFUSION IF UNABLE TO

TOLERATE FLUIDS–ACCESS COLOR AND ODOR OF AMNIOTIC

FLUID

FIRST STAGE-- TRANSITION

• PALPATE CONTRACTIONS Q15 MIN.• STERILE VAGINAL EXAMS TO ACCESS LABOR

PROGRESS• ASSESS FHR EVERY 15-30 MIN., DEPENDING

ON RISK FACTORS• ASSIST WITH BREATHING• KEEP WOMAN FROM PUSHING UNTIL 10 CM.• STAY WITH PATIENT!

INTRAPARTAL NURSING INTERVENTIONS SECOND AND THIRD STAGE OF LABOR

• SECOND AND THIRD STAGE OF LABOR• ENCOURAGMENT, ASSIST WITH

PUSHING,DO NOT LEAVE PATIENT– ASSIST WITH DELIVERY– DELIVERY OF PLACENTA– APGAR SCORE, IMMEDIATE CARE OF

NEWBORN– PITOCIN INFUSION

MODULE 2 PART 9INTRAPARTUM NURSING

INTERVENTIONSTHE DELIVERY

• THE DELIVERY–PUSHING

–BIRTHING POSITIONS

–LABOR SUPPORT

Figure 15–13 Mechanisms of labor. A, B, Descent. C, Internal rotation. D, Extension. E, External rotation.

INTRAPARTAL NURSING CARE: THE THIRD STAGE

• DELIVERY OF THE PLACENTA–SCHULTZ MANUEVER–DUNCAN MANUEVER

PLACENTA ACCRETARETAINED PLACENTA

INTRAPARTAL NURSING CARE: THE FOURTH STAGE

–VS–FUNDUS–LOCHIA–PERINEUM/ABDOMINAL INCISION–BLADDER–COMFORT LEVEL–COMFORT MEASURES—WHAT ARE

THEY?

INTRAPARTAL NURSING CARE: THE FOURTH STAGE

–CONTINUE PITOCIN ADMINISTRATION---WHY?–PAIN MEDICATION–DIET–HEMODYNAMIC CHANGES

• CULTURAL CONSIDERATIONS

ADAPTION TO EXTRAUTERINE LIFE• IMMEDIATE CARE OF THE NEWBORN–RESPIRATORY ASSESSMENT

–CIRCULATORY ASSESSMENT

–THERMOREGULATION—HOW WOULD YOU ACHIEVE THIS?

IMMEDIATE CARE OF THE NEWBORN• APGAR SCORE• MAINTAIN RESPIRATIONS• PROVIDE AND MAINTAIN WARMTH• UMBILICAL CORD CARE• CORD BLOOD COLLECTION• HANDS OFF ASSESSMENT• NEWBORN IDENTIFICATION• FACILITATE ATTACHMENT

IMMEDIATE POSTPARTUM CARE OF MOTHER

• VS• HEMODYNAMIC CHANGES• FUNDUS, LOCHIA• VOIDING STATUS• EPISIOTOMY/LACERATION ASSESSMENT• PAIN

MODULE 2 PART 10MATERNAL ANALGESIA AND

ANESTHESIA

MATERNAL ANALGESIA & ANESTHESIA

• PAIN PERCEPTION AFFECTED BY:–PREVIOUS EXPERIENCE–CULTURAL EXPECTATIONS, BELIEFS–FATIGUE, FEAR, ANXIETY–ENVIRONMENT–SUPPORT SYSTEM

MATERNAL ANALGESIA

• STADOL• DEMEROL• MORPHINE

• OPIATE ANTAGONIST—NARCAN

• REGIONAL ANALGESIA

MATERNAL ANESTHESIA

• REGIONAL ANESTHESIA

– EPIDURAL

–CONTINUOUS EPIDURAL

– SPINAL

Figure 18–3c Tip of needle in epidural space. Source: Bonica, J. J. (1972). Principles and practice of obstetric analgesia and anesthesia (p. 631). Philadelphia: Davis.

A

B C D

Figure 18–4 Levels of anesthesia for vaginal and cesarean births. Source: Reprinted with permission of Ross Laboratories, Columbus, OH. From Clinical Education Aid No. 17.

MATERNAL ANESTHESIA

• LOCAL INFILTRATION

• PUDENDAL

• GENERAL

ANALGESIA AFTER DELIVERY

• EPIDURAL NARCOTIC ANALGESIA (DUROMORPH)– CONTRAINDICATIONS

– SIDE EFFECTS

– DOSAGE

MODULE 2 PART 11ABIRTH RELATED PROCEDURES

BIRTH RELATED PROCEDURES• AMNIOTOMY

–ARTIFICIAL RUPTURE OF MEMBRANES (AROM

– SPONTANEOUS RUPTURE (SROM)

AMNIOTOMY

AFTER 3CM MAY SHORTEN LABOR (AROM) CAN BE A STIMULATION OF LABOR

FHR ASSESSED BEFORE AND AFTER AROM—WHY?

BIRTH RELATED PROCEDURES

• LABOR INDUCTION—STIMULATION OF UTERINE CONTRACTIONS

• INDICATED INDUCTION—WHAT CONDITIONS WOULD WARRANT AN INDICATED INDUCTION?

• ELECTIVE INDUCTION

BIRTH RELATED PROCEDURES

• ELECTIVE INDUCTIONS–INCREASE IN LAST 10 YEARS–CONTROVERSY, CONTROVERSY!!!!!!!–RISKS–EVIDENCE BASED PRACTICE—LATE

PRETERM NEWBORNS-- 34-37 WEEKS

BIRTH RELATED PROCEDURES• LABOR INDUCTION: STRIPPING OF

MEMBRANESADVANTAGES: LABOR USUALLY OCCURS WITHIN

24HOURSDISADVANTAGES:

CAN BE PAINFULUTERINE CONTRACTIONSBLOODY DISCHARGE

BIRTH RELATED PROCEDURES

LABOR INDUCTION/AUGMENTATIONRISKS:• HYPERSTIMULATION OF THE UTERUS• UTERINE RUPTURE• WATER INTOXICATION• NONREASSURING FETAL HEART RATE PATTERNS

BIRTH RELATED PROCEDURES

• CERVICAL RIPENING—PROSTAGLANDIN E2–RISKS•UTERINE HYPERSTIMULATION•NONREASSURING FETAL STAUS•HIGHER INCIDENCE OF POSTPARTUM

HEMORRHAGE•UTERINE RUPTURE

BIRTH RELATED PROCEDURES

• CERVICAL RIPENING– ADVANTAGES• SHORTER LABOR• LOWER REQUIREMENTS FOR OXYTOCIN IN

LABOR• VAGINAL BIRTH IS USUALLY ACHIEVED WITHIN

24 HOURS• INCIDENCE OF CESAREAN BIRTH IS REDUCED

• VERSION–EXTERNAL• EXTERNAL MANIPULATION

–INTERNAL •USED TO DELIVER SECOND TWIN

DURING VAGINAL BIRTH IF NOT DESCENDING OR IN DISTRESS--RARE

MODULE 2 PART 11BBIRTH PROCEDURES

BIRTH RELATED PROCEDURES

• VACUUM EXTRACTION–SUCTION CUP PLACED ON FETAL

OCCIPUT–PUMP IS USED TO CREATE SUCTION–TRACTION IS APPLIED–FETAL HEAD SHOULD DESCEND WITH

EACH CONTRACTION

INDICATIONS FOR VACUUM EXTRACTION–PROLONGED SECOND STAGE OF LABOR

–NONREASSURING FETAL HEART RATE PATTERN–USED TO RELIEVE PUSHING EFFORT

(MATERNAL FATIGUE)–WHEN ANALGESIA INTERFERES WITH

ABILITY TO PUSH EFFECTIVELY–BORDERLINE CPD (CEPHALO-PELVIC

DISPROPORTION)

BIRTH RELATED PROCEDURES

• VACCUM EXTRACTION

–MATERNAL RISKS

–NEONATAL RISKS

EPISIOTOMY

• SURGICAL INCISION OF PERINEUM TO ENLARGE OUTLET

• RESEARCH—EVIDENCE BASED PRACTICE• PREVENTATIVE MEASURES• TWO TYPES:– MEDIAN– MEDIOLATERAL

BIRTH RELATED PROCEDURES• INDICATIONS FOR CESAREAN BIRTH–CPD–PLACENTAL ABRUPTION–ACTIVE GENITAL HERPES–UMBILICAL CORD PROLAPSE– FAILURE TO PROGRESS IN LABOR–PROVEN NONREASSURING FHR PATTERN–COMPLETE PLACENTA PREVIA

BIRTH RELATED PROCEDURES• INDICATIONS FOR CESAREAN BIRTH• BREECH PRESENTATION• PREVIOUS CESAREAN BIRTH•MAJOR CONGENITAL ANOMALIES• CERVICAL CERCLAGE• NON-REASSURING FHR PATTERNS

BIRTH RELATED PROCEDURES

• CESAREAN BIRTHSKIN INCISIONS• TRANSVERSE (PFANNENSTIEL)• VERTICAL• UTERINE INCISIONS–TRANSVERSE–SELHEIM (LOWER UTERINE SEGMENT)–CLASSIC (UPPER SEGMENT OF CORPUS)

BIRTH RELATED PROCEDURES

• PREPARATION FOR C-BIRTH

–MAJOR SURGERY

–SPINAL ANESTHESIA

– MANY TIMES PARENTS HAVE LITTLE TIME TO PREPARE PSYCHOLOGICALLY

BIRTH RELATED PROCEDURES• AMNIOINFUSION– INCREASES FLUID VOLUME IN UTERUS BY

INSTILLATION OF NORMAL SALINE INTO THE UTERUS–DECREASES PRESSURE ON THE CORD—

VARIABLE DECELERATIONS–PROMOTES INCREASED PERFUSION TO

FETUS–CAN DILUTE HEAVY MECONIUM FLUID–USED IN PRETERM LABOR WITH PPROM

BIRTH RELATED PROCEDURES

• VBAC (VAGINAL BIRTH AFTER CESAREAN)• CRITERIA:–PREVIOUS C-BIRTH, LOW TRANSVERSE

UTERINE INCISION–AN ADEQUATE PELVIS–NO OTHER UTERINE SCARS OR PREVIOUS

UTERINE RUPTURE–AN IN HOUSE PHYSICIAN AND

ANESTHESIOLOGIST