• Way to evaluate maternal-fetal relationship
• Done in 3rd trimester and L&D
• Palpate abdomen to identify:
• Number of fetuses
• Presenting part
• Fetal lie and attitude
• Degree of descent into pelvis
• Point of maximal intensity of FHR

• Ensure woman's bladder is empty
• Position supine with knees slightly bent
• Stand on R side if R handed, L side if L handed
• Review specific maneuvers (PPT and book)

1. Passenger (fetus and placenta)
2. Passageway (birth canal)
3. Powers (contractions)
4. Position of the mother
5. Psychological response

1. Size of fetal head
2. Fetal presentation
3. Fetal lie
4. Fetal attitude
5. Fetal position
1. Engagement
2. Station

• Posterior fontanel: 6-8 weeks postpartum
• Anterior fontanel: 18 months postpartum

Classic, head first

Makes up 96% of births

Buttocks or feet first

Makes up 3% of births

Shoulder first

Makes up 1% of births

Definite C-section

AKA vertical lie

Spines of mom and fetus are parallel 

AKA horizontal lie

Spine of fetus is perpendicular to mom's

The relationship of the fetal body parts to each other

Usually the classic fetal position in utero

Deviation from this normal attitude--> labor difficulties

9.25-9.5 cm

Widest point of the head when occipit is presenting part

1. ROA = right occiput anterior
2. LOA = left occiput anterior
3. ROT = right occiput transverse
4. LOP = left occiput posterior

The relationship of the presenting part to an imaginary line drawn b/w the ischial spines

• 0 station = at the level of the spines
• -1 = 1 cm above the spines (up to -5)
• +1 = 1 cm below the spines (up to +5)
• Birth imminent at +4 or +5

When the largest part of the presenting part has passed through the maternal pelvic inlet/ brim (into the true pelvis)

Fetal Engagement = 0 station

Baby has dropped

• Bony pelvis
• Soft tissues
• Vagina
• Perineium
• Pelvic floor muscles

1. Gynecoid
2. Android
3. Anthropoid
4. Platypelloid

Round

Classic female type

Good for delivery

Heart shape

Resembles the male pelvis

Not good for delivery

Oval shape

Resembles anthropoid apes

Good for delivery

Flat shape

Not good for delivery

Soft tissue

Plays no part in childbearing

Involuntary contractions

Dilate and efface the cervix

Bearing down efforts

Voluntary

Passing of the mucus plug (operculum)

Sign of oncoming labor

Spontaneous rupture of membranes

25% of women have this occur

Artificial rupture of membranes

Due to placement of internal monitor

Sometimes to augment labor (not recommended, only done if baby or mom in distress)

Pale, straw color

500 - 1200 mL

Slightly alkaline (pH 6.5-7.5)

Can be used if woman is unsure if her membranes rupture or she peed accidentally

Urine: slightly acidic (yellow-green paper)

Amniotic fluid: slightly alkaline (blue paper)

• Monitor FHR for several minutes !!! (very important, esp. with AROM)
• If AROM occurs before engagement, cord could be prolapsed
• If meconium stained--> report IMMEDIATELY
• May not cause issue if breech vaginal birth (won't reach baby's mouth)

• Relieve pressure on cord (FIRST PRIORITY)
• Put gloved hand in vagina to push fetus up and off cord
• Knee-chest position
• C-section
• Rapid vacuum extraction delivery

1. Frequency (how often are they occuring?)
2. Duration (how long do they last?)
3. Intensity (how strong are they?)
4. Interval (how long is the resting phase b/w?)

• Mild: fundus is easy to indent with fingertips (like a nose)
• Moderate: fundus is difficult to indent, firm (like a chin)
• Strong: fundus is rigid, board-like, almost impossible to indent (like a forehead)

• Time labor began (onset of contractions)
• Vital signs
• Vaginal exam (cervix, fetal descent, membranes)
• FHR data, position, and status
• Leopold's maneuvers
• Uterine activity
• Allergies, current meds
• Problems with pregnancy
• Last time she ate/ drank

• Vital signs
• Uterine activity
• FHR
• Behavior, appearance
• Mood, energy level
• Elimination
• Emesis
• Vaginal exam info (if done)

• First stage: vitals q30min (low risk), q15min (high risk)
• Active phase: focus on FHR, contractions, behavior
• Transition phase: focus on behavior
• Second stage: q5min, every contraction and FHR
• Third stage: q15min, apgar at 1 & 5 min; focus on placental separation and bleeding

• Clear liquids PO during early labor, tapering to ice chips
• Women will regulate their intake well (usually)
• IV bolus before epidural insertion and PRN

• Bladder: encourage voiding q2h
• Bowel: may come out during delivery, just wipe away

1. Latent phase
2. Active phase
3. Transitional phase

• From 0-3 cm dilation
• Effacement progresses, not descent
• 8-10 hours long
• Mom is alert, happy, sleeps, walks around

• 4-7 cm dilation
• Rapid cervical dilation, increased fetal descent
• 1.2 cm/hr primigravida, 1.5 cm/hr multipara
• 3-5 hours long
• Contraction duration 60 seconds, 2-4 min. apart
• Concentrates now

• 8-10 cm dilation
• Rapid cervical dilation, increased fetal descent
• 30 min. - 1 hour long
• Contractions 70-90 sec. long, 30-60 sec. apart
• DO NOT MESS WITH MOM

• From full dilation to delivery of fetus
• About 20 min. for multipara, 50 min. for nullipara
• Sweating, shaking, vomiting, increased bloody show, restlessness all common
• Vaginal exam when mom says she's naseous, wants to push, increased bloody show, etc.
• Indicates beginning of this stage !!

Strong urge to bear down

When presenting part presses on stretch receptors of pelvic floor, oxytocin is released and provokes stronger, more expulsive contractions

• Nonreassuring FHR 
• Inadequate uterine relaxation
• Vaginal bleeding
• Infection
• Prolapsed cord

• Includes bradycardia, tachycardia, irregular rhythm, absent FHR
• Place in side-lying position and discontinue Pitocin (if given)
• Increase IV fluid rate
• Begin O2

• Indication: contractions lasting >90 seconds, rest interval < 2 minutes
• Discontinue Pitocin (if given)
• Side-lying position
• Increase IV fluid rate
• Give analgesic

• Anticipate emergency C/S
• NO VAGINAL EXAMS

• Indication: maternal temp >100.4, FHR tachycardic
• Start IV antibiotic
• Amniotic fluid or urine culture
• Birth warranted

• Position to relieve pressure (knee-chest, finger pressing fetus up off cord)
• Increase IV fluids
• Monitor FHR, O1
• Prepare for C/S

When the widest part of the baby's head (biparietal) distends the vulva

Biparietal diameter = 9.25 - 9.5 cm

• Surgical incision of perineum
• Done at end of second stage of labor
• Nonreassuring fetal tracing, shoulder dystocia, tears may result if not done
• Controversial--depends on doc
• Mediolater--> pelvic floor problems later in life, midline more common

• 1st degree: through skin and superficial structures, up to muscle
• 2nd degree: through muscle of perineal body
• 3rd degree: through anal sphincter
• 4th degree: into anal rectal wall

• Applying manual pressure on the perineum
• Used to control birth of the head
• Done to prevent tears by relieving pressure slightly

• Umbilical cord wrapped around the neck
• Common
• Not an issue unless it's tight
• If tight, clamp (2 places) and cut

• Suction mouth first, then nose
• Done before full expulsion from vagina (as soon as head is out, before first breath)
• Removes mucus, blood, or meconium

• From birth of the baby through birth of placenta
• From 3-5 min up to 1 hour long
• The longer this lasts, the greater risk of hemorrhage
• Signs of placental separation:
• Gush of blood
• Lengthening of cord
• Globular, discoid uterus

• From delivery of placenta to stabilization of mom
• Lasts about 2-4 hours
• Primary concern--> excess bleeding
• Think massage of fundus, urination, breastfeed, monitor; may need meds to contract uterus

110-160 bpm

Slight, temporary accelerations and decelerations common during birth

• Cardiac output increases (blood emptied from uterus into peripheral vessels)
• BP increases (increased blood volume)
• RR increases (increased O2 demands)
• Proteinuria 1+ may occur (b/c of breakdown of muscle tissue)
• WBC count increase (due to stress of labor)

Nursing Care of Mom

Immediately Postpartum

• Place baby to breast (skin-skin, promote oxytocin)
• Check fundus every 15 min.
• Expel clots from uterus
• Apply clean pad and ice pack to perineum
• Do NOT allow mom's bladder to fill (have her void)
• Provide clean linens, gown, and warmed blanket
• Clean area under mom's butt
• Check status of leg movement (epidurals)

• Appearance, Pulse, Grimace, Activity, Respirations
• Done at 1 & 5 minutes (sometimes 10 if low score at 5)
• See chart 24-1 (page 551) or slide 70 in ppt

Nusing Care of Newborn

Immediately Postpartum

• APGAR Score (1 and 5 min.)
• Airway (suction mouth then nose)
• Protect from heat loss (dry and swaddle or place under warmer)
• Vital signs
• ID Bands with mom
• Measurements

• HR: 100-160 bpm (apical for 1 minute)
• RR: 30-60 (for 1 minute)
• Temp: 97.6-98.9 (axillary)

• Head circumference: 33-35 cm
• Chest circumference: 2-5 cm less than head
• Length: 45-55 cm
• Weight: 2500-4000 gm

• Opthalmic Erythromycin in both eyes
• Protects against gonorrhea and chlamydial infections in the eyes
• Vitamin K shot (IM, Vastus Lateralis)
• Activates clotting factors 

• Cradling
• Football hold
• Lying down

• Cross mom and fetal blood-brain barrier and placenta
• Can cause respiratory depression, decreased alertness, and delayed sucking in infants
• IV administration
• Give with potentiating drug to use less

• Most commonly used opiod agonist in labor worldwide
• Less popular in U.S.
• May relax cervix
• Overcomes inhibitory factors
• Onset 30-60 seconds after IV administration

Potent, short-acting opiod agonist analgesic

Onset 2 minutes after IV administration

Most common opiod in U.S. for labor

Provides pain relief without significant respiratory depression in mom and baby

Opiod antagonist

Reverses opiod induced respiratory depression in mom or baby if necessary

Sometimes used to relieve itching from epidurals

• Numbs perineum before episiotomy or repair
• Usually lidocaine or another "caine"
• May combine with epinephrine to reduce bleeding (vasoconstrictor)

• Lumbar epidural: most effective and most common in U.S. in labor for pain, chosen by 50%+ of women
• C/S: block from T10-S5
• Vaginal: block from T8-S1
• Epidural catheter placed into epidural (potential) space
• No mixing meds with CSF (no brain effects)
• PCEA (patient controlled epidural analgesia) common

Disadvantages of Epidural

• Movement is limited, leg weakness
• Dizziness, sedation
• Hypotension--MOST COMMON
• Often give IV bolus of fluids before giving epidural to counteract this

• Tachycardia
• Bradycardia
• Variability in the FHR
• Accelerations
• Decelerations: early, late, variable

• Interpret FHR and contraction patterns
• Initiate appropriate nursing interventions
• Notify PCP/ nurse-midwife with nonreassuring FHR or contraction pattern
• Document outcome of interventions

• Basline FHR in normal range (110-160 bpm)
• Accelerations with fetal movement

Non-reassuring FHR Patterns

(associated with fetal hypoxia)

• Tachycardia (>160)
• Progressive increase or decrease in basline
• Progressive decrease in variability
• Late decelerations
• Absence of variability of FHR
• Prolonged deceleration
• Severe bradycardia (<70 bpm)
• Severe variable decelerations (<60 for >30-90 sec)

• Ultrasound transducer
• Watches FHR
• Tocotransducer 
• Watches UC's (uterine contractions)
• Can provide continuous or intermittent monitoring
• Doesn't require ROM or dilation

• Spiral electrode
• Placed in baby's scalp 
• Monitors FHR
• Intrauterine pressure catheter (IUPC)
• Montiors UCs
• Continuous monitoring, more accurate than external
• Requires ROM, dilated cervix, and presenting part low enough to reach

• FHR >160 bpm for >10 min
• Early sign of fetal hypoxia
• Result of:
• Maternal fever (#1 cause !!)
• Maternal/ fetal infection
• Response to drugs (atropine, vistaril, terbutaline, cocaine, methamphetamines)

• FHR <110 bpm for >10 min
• Late sign of fetal hypoxia
• Result of:
• Maternal hypotension
• Analgesics

• Irregular fluctuations in the baseline of FHR
• Reassuring: moderate (6-25 bpm)
• Non-reassuring:
• Absent (0-2 bpm)
• Minimal (3-5 bpm)
• Marked (>25 bpm)

Causes of Decreased Variability

(absent and minimal)

• Hypoxemia, acidosis, CNS depressants
• Fetus in sleep state (doesn't usually last >30 min)

• Mild hypoxia
• Cocaine, methamphetamines
• Fetal stimulation:
• Uterine palpation, uterine contraction, fetal/ maternal activity

• FHR increase of >15 bpm for >15 sec.
• Returns to baseline <2 min from beginning of accel.
• If resulting from fetal movement--good sign ! indicates fetal well being
• Can result from pressure on butt

• Deceleration begins after contraction (usually at peak) and resolves after contraction is over
• Occurs in response to insufficient placental perfusion (utero-placental insufficiency)
• Related to fetal hypoxemia !!
• Baby isn't getting enough O2
• Non-reassuring

• Give O2, 8-10 L/min
• Side-lying position
• Elevate legs to correct maternal hypotension
• Increase IV fluid rate
• Stop Pitocin (if given)

• Abrupt decrase occuring at any time during contraction phase (no relation)
• Decelerates <15 bpm below baseline, lasts >15 sec.
• Returns to baseline <2 min
• U, V, or W shaped pattern (peaks)
• Most commonly due to cord compression (severe/ prolonged tight Nuchal cord, prolapsed cord, short cord, knot in cord)

• Change mom's position side to side
• Give O22
• If during 2nd stage, discourage pushing (give fetus time to recover)
• Assist with amnio-infusion (if ordered)
• Assit with vaginal assisted or C/S birth (if pattern can't be corrected)

• Infusing fluid into uterus via intrauterine catheter
• Done to supplement amount of amniotic fluid OR dilute/ flush out meconium
• NS or lactated ringer's solution, warmed (body temp)
• ROM necessary
• Infused through IUPC (bolus or continuous)
• Risk over-distending the uterus

Left Occiput Anterior (LOA)

The back of the baby's head and spine is on mom's left-hand side and towards mom's abdomen