Ob Labor & Birth

Front 1

When does labor and birth happen?

Back 1

When the baby is mature enough to handle extrauterine life but is not too big to cause a problem.

Front 2

labor

Back 2

physiologically--
• process of moving the fetus, placenta, and membranes out of the uterus

clinically--
• progressive contractions (longer, faster, stronger) resulting in progressive cervical change (dilation & effacement)

Front 3

factors affecting labor

Back 3

• passenger- baby
• passageway- cervical canal
• powers- contractions
• position
• psychological response

Front 4

fetal lie

Back 4

**relationship b/w the long axes of the fetal & maternal spine

• longitudinal
• transverse; cannot deliver
• oblique; baby is oriented diagonally and usually covert during labor process >> longitudinal

Front 5

fetal presentation

Back 5

**part of fetus that will enter the pelvis first

• cephalic/vertex
• breech, e.g. butt, foot
• shoulder

Front 6

fetal head

Back 6

feel for suture lines to determine head positions--
• posterior- 2 branches
• anterior- 3 branches

**suture lines exist for ease of birth pressure >> molding

Front 7

fetal attitude

Back 7

**relationship of fetal body parts to reach other

• flexed; when flex, baby's head is size of pelvis
• extended
• military

Front 8

fetal positioning

Back 8

**relationship of denominator (landmark) of the presenting part to the four quadrants of the mother's pelvis

"junk in the trunk"
1/ baby on R or L side of mother's pelvis?
2/ landmark/presenting part? think of fetal attitude
3/ is the butt/spine anterior/posterior/transverse?

Front 9

fetal station

Back 9

**relationship of presenting part to the ischial spines of maternal pelvis

• cm bove or below
• @ station 0, baby is in true pelvis and makes commitment to deliver

Front 10

passageway

Back 10

• bony pelvis- cannot be changed
• birth canal
• soft tissues

Front 11

pelvis type

Back 11

gynecoid--
• normal; 50% of females
• good prognosis for VD

android--
• male pelvis; 23% of females
• angular & narrow
• poor prognosis for VD

anthropoid--
• longer AP diameter
• 24%, good prognosis for VD

platypelloid--
• shorter AP diameter
• 3%, poor prognosis for VD

Front 12

maternal position

Back 12

• affects adaptation to labor
• encourage frequent position changes to (+) perfusion, comfort, & relieves fatigue

Front 13

positive positions for labor

Back 13

**all upright >> gravity aids labor
"hands & knees" position takes pressure off perineum

Front 14

birthing positions

Back 14

**squatting position is best b/c it opens up pelvic outlet

• lateral recumbent takes pressure off perineum
• medical model tries to mimic squatting during contractions w/ stirrups

Front 15

powers

Back 15

primary powers--involuntary
• uterine contractions >> cervical changes

secondary powers--voluntary
• expulsive uterine contractions
• maternal pushing efforts

Front 16

ferguson's reflex

Back 16

urge to push @ station 0

Front 17

primary powers

Back 17

characteristics--
• frequency
• duration
• intensity

Front 18

Which part of the cervix stretches out during effacement?

Back 18

cervical canal

Front 19

T/F. Primips efface before they dilate.

Back 19

True; multips do both at the same time and delivery more quickly

Front 20

true v. false labor

Back 20

quality of contractions--
• false labor- contractions w/o cervical change; cervix should be anterior and thinning
• if mom is "LCP" long closed posterior >> not anytime soon

location of contractions--
• true labor is @ funds
• false labor is @ groin/leg

response to movement/position change--
• true labor does not stop w/ activity; false labor will

Front 21

impending labor s&s

Back 21

• lightening
• stronger braxton-hicks
• mucus plugs
• bloody shows
• cervical ripening
• burst of energy
• SROM
• GI upset

Front 22

lightening

Back 22

• baby drops down cervical canal >> pressure on sciatic nerve >> shooting pain down lower extremities
• lightens mom's load >> she can breathe better

Front 23

braxton-hicks

Back 23

**false labor contractions

• uterus is practicing
• not as painful
• promotes cervical ripening
• starts @ 4-5 mos

Front 24

mucus plugs

Back 24

**occludes cervical canal

• estrogen has build-up secretion that prevents bacteria from entering
• attached to baby's capillaries; when it passes during effacement/dilation >> bloody show

Front 25

stages of labor

Back 25

• starts w/ first true sign of labor
• most placental delivery is within 30 mins; if longer than one hour >> manual removal

Front 26

1st stage of labor

Back 26

**for onset of regular uterine contractions to full dilation; include three phases; total duration can be prolonged for total of one hour w/ anesthesia

1/ latent
2/ active
3/ transition

Front 27

2nd stage of labor

Back 27

**full dilation to birth of fetus

• the pushing stage
• physiological; ferguson's reflex

Front 28

cardinal movements

Back 28

1/ engagement

2/ descent

3/ flexion
for smallest head diameter

4/ internal rotation
fetal head must rotate to fit the diameter of pelvic cavity

5/ extention
due to resistance of pelvic floor, mechanical movement of vulva opening, & pressure from synthesis pubis

6/ restitution
shoulders of fetus enters pelvis and remains oblique when head rotates to AP diameter through internal rotation >> head becomes twisted and will untwist once pressure is gone

7/ external rotation
as shoulders rotate into AP diameter >> head is turned further to one side

8/ lateral flexion

Front 29

3rd stage of labor

Back 29

**from birth of newborn to birth of placenta

Front 30

placental separation

Back 30

**can be spontaneous or manually removed

signs--
• change in shape as uterus contracts & appears more globular
• gush of blood from vessel dilation
• cord lengthening
• change in position of uterus

Front 31

placenta, membranes, & cord

Back 31

dunkin side--
• maternal
• vascular, attached to uterine wall

schultz side--
• newborn side
• attached to umbilicus

wharton's jelly--
• protective covering of vessels

Front 32

T/F. Placenta of a smoker is smaller than that of a non-smoker.

Back 32

False; it is larger b/c smoking causes vasoconstrictions >> placenta needs to increase surface area to deliver sufficient blood

Front 33

4th stage of labor

Back 33

**maternal stabilization/homeostasis

• physical readjustment; first hour is most critical >> monitor for PPH
• initial bonding & interaction w/ baby
• initiate feeding

Front 34

perception of pain

Back 34

factors include--
• culture
• anxiety/fear
• previous birth experience
• childbirth preparation

>> when medicating, earlier is better to decrease anxiety and fear

Front 35

nonpharmacological relief

Back 35

• relaxation/breathing techniques
• imagery
• music
• touch
• hydrotherapy
• TENS
• accupressure
• heat & cold
• hypnosis
• biofeedback
• aromatherapy

**senses are heightened during delivery, esp. in transitional phase >> coping mechanisms may no longer work >> make sure you get rid of item when mom no longer wants it

Front 36

pharmacological relief

Back 36

systemic analgesia--
• opioids
• ataractics; tranquilizer, analgesic potentiator
• barbituates
• benzodiazapines

anesthesia--
• local, general
• pudendal block- used during sutures
• spinal anesthesia
• epidural block
• combined spinal-epidural blocks
• general anesthesia

Front 37

Why is having an antagonist so important when administering narcotics?

Back 37

**narcan is narcotic antagonist

narcotics (-) RR, HR, and perfusion >> want an antagonist just in case

Front 38

analgesics v. anesthetics

Back 38

analgesia--
• relief of pain w/o total loss of feeling or muscle movement
• usually offered to women in labor or s/p surgery or delivery

anesthesia--
• blockage of all feelings, i.e. pain
• mainly used during surgical procedures, e.g. cesarean delivery

Front 39

systemic analgesics

Back 39

**not given right before delivery b/c they slow baby’s reflexes & breathing

• often given as IM or IV
• act on nervous system

ADEs--
• nausea
• drowsiness/trouble concentrating

Front 40

local anesthesia

Back 40

• provides numbness or loss of sensation in small area
• does not lessen pain of contraction
• used during episiotomy
• does not affect baby; usually no side effects

Front 41

regional anesthesia

Back 41

**most effective during labor

epidural analgesia--
• aka epidural block causes loss of feelings in lower areas of body while patient remains awake & alert
• can be given soon after start of contractions or later as labor progresses
• can increase dose of anesthetics for cesareans or if vaginal birth requires forceps or vacuum extractions

spinal block--
• rapid effects but only lasts 1-2 hours
• much thinner needle; smaller dose of drug
• injected into sac of spinal fluid below spinal cord
usually only given once during labor >> usually given during delivery

combined spinal-epidural blocks--
• has both effects; fast acting & longer lasting
• injected into spinal fluid & into space below the spinal cord
• some women are able to walk after the block is in place

Front 42

general anesthesia

Back 42

**loss of consciousness
used when regional block is not possible; often used for urgent cesarean deliveries

Front 43

anesthesia for cesarean births

Back 43

factors--
• health of mother and baby
• why cesarean is performed

Front 44

epidural placement

Back 44

• given in epidural space below spinal cord
• back is curved outward and patient is not allowed to move

Front 45

systemic analgesia risks

Back 45

• fetal depression
• prolonged labor
• n/v >> give zofran
• itchiness >> give benadryl

Front 46

anesthesia risks

Back 46

• maternal hypotension >> RN should be nearby to administer IV fluids if needed
• fetal bradycardia
• prolonged labor; (-) urge to push during 2nd stage

Front 47

OB rules

Back 47

1/ massage fundus
2/ turn on L side to (+) perfusion; IV; O2
3/ is baby better off in or out?
4/ what happens in previous pregnancy will happen in another

Front 48

L&D admission

Back 48

• if unable to obtain prenatal record >> urine test
• fetal movement is sign of baby's well being

Front 49

How can you tell if membrane is ruptured?

Back 49

swab and analyze under a microscope >> amniotic fluid looks like a fern tree

Front 50

admission assessment

Back 50

fundal height measurement--
• @ 20 wks, umbilicus will start to ascend 1 cm/wk
• measured from fundus to synthesis pubis

leopold's maneuvers--
• feel baby inside the uterus to see what position s/he is in

urine dip--
• glucose >> DM?
• protein >> BP, kidney function?
• ketones >> dehydration?

Front 51

rupture of membranes

Back 51

• SROM or AROM
• note time, color, odor, & amount; anything w/ a foul odor indicates infection
• check FHR & perform vaginal exam to check for cord prolapse
• if meconium is in fluid, prepare suction for birth & call peds

Front 52

1st stage management (active phase)

Back 52

• check patient q 15-30 mins
• document FHR and contractions q 15-30
• BP q 1-2 hours
• temperature q 4 hrs if membranes intact v. q 1-2 hrs if membranes ruptured; if membrane ruptured > 12 hours, give antibiotics
• void q 2 hrs
• frequent position change

Front 53

2nd stage management

Back 53

• FHR q 5 mins or b/w contractions
• BP q 5-15 mins
• support & encourage
• positional changes
• room preparation; make sure laryngoscope is present in case infant aspirates on meconium

Front 54

perineal outcomes

Back 54

>> intact, laceration, episiotomy

whether you tear or not depends on--
• previous tears
• nutrition- high protein diet decreases risks

Front 55

types of episiotomies

Back 55

midline (MLE)--
• goes into perineal body >> high risk of going through rectum
• better healing, less pain

mediolateral (RML/LML)--
• goes into gluteal muscles
• slower healing, more pain
• more blood loss

Front 56

Why can't the fundus be pushed during contractions?

Back 56

It may cause uterine expulsion.

Front 57

3rd stage management

Back 57

PIT--
• 1000 cc w/ 20 units of PIT; 100-125 cc/hr
• mother will usually get 2 bags

Front 58

giving report to PP RN

Back 58