Passenger - Fetus and placenta

Passageway - Birth Canal

Powers - Contractions

Position - Maternal Position

Psychological

Larger

Diamond Shaped

3 cm x 2 cm

Closes by 18 months after birth

Smaller

Triangular

1 cm x 2 cm

Closes by 6-8 weeks after birth

When does fundal heigh drop?

Lightening

Cephalic

Head first

Breech

Buttocks or feet first

Shoulder

Shoulder first

Vertex

When the presenting part is the occiput

Most wanted

Transverse

unable to deliver vaginally

Back of the fetus is rounded so the chin is flexed on the chest, the thighs are flexed on the abdomen, and the legs are flexed at the knees, arms are crossed over the thorax and the umbilical cord lies between the arms and legs

Deviations from normal flexion may cause difficulty in childbirth

Largest transverse diameter - indicator of fetal head size

In well-flexed cephalic presentation, the biparietal diameter will be the widest part of the head entering the pelvic inlet

Relationship of the presenting part to the four quadrants of the mother's pelvis

Fetal Position

1st letter- location of the presenting part to the maternal pelvis

R - Right

L - Light

Fetal Position

2nd letter - presenting part of the fetus

O - Occiput

S - Sacrum

M - Mentum (chin)

Sc - Scapula (shoulder)

Fetal Position

3rd letter - location of the presenting part in relation to the maternal pelvis

A - Anterior (face toward spine)

P - Posterior (face toward pubic)

T - Transverse

Measure the degree of descent of the presenting part of the fetus through the birth canal

Measured in centimeters

If 1 cm above the ischial spines minus 1 (-1)

Level of the ischial spines zero (0)

If 1 cm below the ischial spines plus 1 (+1)

Birth is imminent when station is +4/+5

Gynecoid - classic femal type

(most common easiest for baby to get out)

Android - resembles the male pelvis

Anthropoid - resembling the pelvis of anthropoid apes

Platypelliod - flat pelvis

A woman who has received training and whose sole objective is to provide supportive care to women in labor

(massage, breathing, talk, hand on comfort tech)

Intensity Maternal Perception

Mild

Feels like touching end of nose

Uterus is easy to indent at peak of contraction

Intensity Maternal Perception

Moderate

Feels like touch to the chin

Uterus is firm at peak of contraction

Intensity

Maternal perception

Strong

Feels like a touch to the forehead

Uterus is hard at peak of contraction - it cannot be dented

Membranes must be ruptured to use

Soft uterus, using palpation

<10 mmHg using IUPC

If intrauterine pressure is greater than 50-70 mmHg, the maternal blood flow to the placenta (intervillous spaces) is stopped

If IUPC is 30 mmHg, the maternal blood flow from the placenta (intervillous spaces) is stopped

Interval - every 2 minutes

Duration - 90 seconds or less

Intensity - moderate to strong

Relaxation period - at least 30 seconds

Resting tone - 10 mmHg or less and uterus is soft to palpation

Primary Powers

Cervical dilatation

Effacement

Station (descent)

Cervical dilatation 0-10cm

Effacement 0-100%

Station (descent) -4 to +4

Engaged = 0 station

Shortening and thinning of the cervix during the first stage of labor

Cervix is typically 2-3 cm long and 1 cm thick

Only a thin edge of the cervix can be palpated once effacement is complete

Measured in percentage 0% - 100%

100% fully effaced

Enlargement or widening of the cervical opening

Diameter of the cervix increase from less than 1 cm to full dilation, 10 cm

When the cervix is fully dilated, it can no longer be palpated

Full cervical dilation marks the end of the first stage of labor

When the presenting part reaches the pelvic floor, the contractions change in character to expulsive

Laboring woman feels an involuntary urge to push

She should only begin pusing when she feels the urge to push (Labor Down)

Frequent changes in position relieve fatigue, increase comfort, and improve circulation

Upright - good for gravity

walking and dance of labor

Squatting - open pelvis

Sidelying

Support of birthing ball - open pelvis

Treat with

Support

Education

Anesthesia/analgesia

Signs of Labor

Premonitory signs of labor (8)

Lightening

Return of urinary frequency

Backache

Stronger Braxton-Hicks contractions

Bloddy show-increased  vaginal discharge

Spontaneous rupture of membranes

Surge of energy

Weight loss

1st Stage of Labor

Latent phase

0-3 cm

0-2+

Contraction every 5-10 min, mild intensity, lasting 30-45 seconds

1st Stage of Labor

Active Phase

4-7 cm

Average dilation 1.2 cm/hr

40-80% effacement

Fetal descent 2+-4+

Intense contraction q 2-2.5 mins

lasting 40-60 sec

Increase in pain

1st Stage of Labor

Transition phase

8-10 cm

100% effacement

Contractions intense

q 1-2 min lasting 60-90 sec

Feels exhausted

Bloody show

N/V, backache, diaphoresis, and trembling

1st Stage Nursing Care

Latent Phase

Assess for progress on admission

Rest

Walk

Assessment: BP, P, R - 30-60 mins

Temp - 2-4 hours (Assess every 2 hrs w/ROM)

Uterine activity and FHR - 30-60 mins

Emotional support (Dad and Family)

Teach about what to expect

Physical Support: Comfort measures, ice chips, popsicles, empty bladder every 2 hrs

1st Stage Nursing Care

Active Phase

4-7 cm

BP, P, R - every 30 minutes

Temperature every 2 hours

Uterine activity and FHR - every 15-30 minutes

1st Stage Nursing Care

Transition Phase

BP, P, R - every 15-30 minutes

Temperature - every 2 hours

Uterine activity - every 10-15 minutes

FHR - every 15-30 minutes

Presence: Do not leave patient alone

Positive words and actions

Communicate with calm short directions

Expect some N&V

Expect irritability

Notify doctor of progress

Rupture of Membranes

AROM

Rupture of Membranes

SROM

Rupture of Membranes

PROM

First assess FHR

What color is fluid?

If meconium stained/note that

If blood tinged/monitor mom closely could be placenta pulling away

Do not do a lot of physical exams

May notice lanugo and fetal squamous cells

At risk for prolapsed cord

Labor Pain-Physiology

Visceral

1st stage of labor

Lower abdomen related to contractions

Labor Pain - Physiology

Somatic

2nd Stage

Vagina and perineum

Decreased blood supply to uterus

Increased pressure and stretching of the pelvic structures

Cervical dilatation and stretching

Injection of small amounts of sterile water with a fine needle into four locations on the lower back to relieve back pain

Effective in early labor

Singing will occur for 20 to 30 seconds

Treatment can be repeated

Pharmacologic Management

Systemic Analgesics

Demerol, stadol, nubain, fentanyl

Crosses the fetal blood-brain barrier

Newborn effects: Respiratory depression, decreased alertness, delayed sucking

Pharmacologic Management

Opiod Antagonist

Narcan

Reverses the opioid-induced respiratory depression in the mother or the newborn

Pharmacologic Management

Pudenal Nerve Block

Administered late in the 2nd stage of labor

Used with episiotomy or forceps

Pharmacologic Management

Spinal Anesthesia

Utilized in cesarean births

Provides anesthesia from the nipple line to the feet

Pharmacologic Management

Epidural Anesthesia

Most effective pharmacologic pain relief mehod for labor that is currently available

Relief of pain from uterine contractions and birth

Local anesthetic: bupivacaine

Opiod analgesic: fentanyl/sufentanil

Injection is between L4 & L5

Hypotension                                  Assymetrical block

Local anesthetic toxicity*                Fever

*Lightheadedness                          Urinary retention

*Dizziness                                    Pruritis

*Tinnitus                                      Limited movement

*Metallic taste                              Longer 2nd stage of labor

*Numbness of the tongue or mouth   Increased use of Pitocin

*Bizarre behavior                           Increased likelihood of medically

*Slurred speech                            assisted birth

*Convulsions

*Loss of consciousness

High or total anesthesia

Monitor B/P - Hypotension likely (to counteract trendelenberg position - head lwr)

Maintain IV - Bolus of 500-1000 ml prior

Continuous fetal monitoring

Assess for bladder fullness - empty q 2 hrs

Unable to bear weight

Reposition on bed-many possible positions

Occiput Posterior (OP)

Position

Back labor

Dx by vaginal exam-palpating suture lines

Research indicates that dx by by Ultrasound is promising and leads to earlier dx, therefore nursing interventions can be initiated earlier leading to OA position

Sims posture on the same side as the fetal spine facilitated the fetus' rotation to OA

If fetus is LOP - turn mother to left side

ROP - turn mother to right side

2nd Stage of Labor

Expulsion

Ctx q 2-3 min

2nd Stage of Labor

Phase 1 Early

2nd Stage of Labor

Phase 2 active

Increased intensity of ctx

Descent-passive (laboring down)

push only when feel urge

Urge to push present as fetal head reaches perineal floor

2nd Stage of Labor

Phase 3 transition

Complete dilatation

Sudden burst of energy

Shorter duration with multips than primips

Intense ctx q 2 min, lasting 60-90 sec

Increase in bloody show

Perineum flattens w/bulging rectum and vagina

Urge to push

Involuntary bearing down

Shaking of extremities

Increased restlessness

2nd Stage of Labor

Early Phase

Lasts 20-30 min

Rest

Recover from transition

Ice chips

2nd Stage of Labor

Active Phase

Laboring down or delayed pushing

Intensity increases

Bear down with the urge to push

(For 6 to 8 seconds)

(3 bearing down efforts per contraction)

(Exhale while bearing down)

Open glottis

2nd Stage of Labor

Transition Phase

Uncontrollable urge to push

Crowning of head

Burning sensation

Provide continuous suppor and encouragement

Asssess FHR, turn on warmer (when crowning)

Position is semi-fowlers with a wedge behind back

Change position every 30 min

No stirrups

Throne position of bed

Birthing ball

Pull on towel or tug toy on squatting bar

Do not encourage

(breath holding, counting, pulling knees back, valsalva, or closed glottis)

Engagement

Descent

Flexion

Internal Rotation

Extension

External Rotation

Expulsion

HR/Assessed by auscultation or palpating umbilical cord

RR rate/effort - auscultated or by observed movement of respiratory effort

Muscle tone/based on degree of flexion and movement of extremities

Reflex irritability (response to stimulation)/based on response to bulb syringe

Color/Based on observation of pallor, cyanotic, or pink

Scored at 1 and 5 minutes of life receiving scores of 8/10 or 9/10-scores of 7/10 and above are "normal"

Most have one point taken off for color acrocyanosis: blue color of hands and feet

Apgar Scoring Table (0-2 pts each)

Used as a tool to evaluate newborn's transtition to extrautuerine life

Sign                         0                    1                    2

Heart rate           Absent         Slow (<100)              >100

Respiratory rate   Absent         Slow, weak cry        Good Cry

Muscle tone         Flaccid         Some flexion of          Well flexed

                                   extremities

Reflex irritability    No response  Grimace                Cry

Color                  Blue, pale      Body pink                  Completely pink

                                    extremties blue

3rd Stage of Labor

After birth to delivery of placenta

placenta

about 30 minutes after delivery

signs placental separation has occured (uterine shape changes from disc to globe, small gush of blood, apparent lengthening of umbilical cord, sesation of fullness in vagina, uterine fundus at umbilicus)

Sometimes manual removal is required

First 1-2 hours after birth

Recovery

Assess for hemorrhage

Promote bonding

Assist with first breastfeeding

Postpartum assessment every 15 minutes

The birth of a fetus through a trans-abdominal incision in the uterus

Can be elective, scheduled, unplanned or emergent

Purpose:  preserve the life or health of the mother and her fetus

Fetal macrosomia, advanced maternal age, obesity, gestational diabetes, and multifetal pregnancy

fewer VBAC

Cesearean on request or demand

A primary cesarean birth w/out a medical or obstetric indication

Many women belief that it will prevent future problems w/pelvic support or sexual dysfunction

Evidence is insufficient to support these claims

Blood tests-CBC, blood type, Rh status, maternal VS, FHR, informed consent, ensure NPO status

IV and fluids are started to prevent maternal hypotension

SCDs, Foley catheter, shave pubic hair

Support person: surgical scrubs, booties, hair cover, and mask. Support person will typically be allowed into the OR once spinal anesthesia has been completed

C-Section Risks

Maternal

C-Section Risks

Fetal

Epidural - usually because laboring epidural

(more sensory less motor, increase meds)

Spinal - most common

(motor/sensory block, decrease meds)

Combination

General - seldom used unless crash, significant fetal distress, prolapsed cord)

Woman is positioned so that her uterus is displaced laterally to prevent compression of the inferior vena cava (wedge or tilting table to one side)

The woman may feel cold beta dyne cleaning solution, but should not feel sharp pain

She may feel pressure as the baby is born

Vertical - extending from near the umbilicus to mons pubis

Transverse - In lower abdomen

Transferred to the recovery room

Transient tachypnea of the newborn common

Keep warm by skin to skin w/Dad in full view of Mom

Frequent VS, pain control, airway patency, and postpartum care, fundus, bleeding, return of sensation

Discharged to postpartum care once she is alert, oriented, and able to move all her extremities

Pain management for incisional and gas pain (Diet progression per nurse assessment)

Duramorph (synthetic morphine), Benadryl or small doses of Narcan (itching)

First 24 hours will have pain relief from spinal opioids, IV medications/PCA

After 24 hrs:

D/C Foley-measure first void (6-8 hrs)

Ambulate (sit, march, walk) in hall

PO pain medications

Nurse montiros dressing/drainage til removal

Shower after dressing removed (physician removes)

Splint incision when moving or coughing

Use relaxing techniques

Apply ice for the first 24 hours (even after), then heat as necessary

Walk

Do not eat or drink gas-forming items

Do not use straws increases gas

chew simethicone as prescribed

Lie on the left side

Rock in a rocking chair

A long, difficult, or abnormal labor is known as dysfunctional labor, or dystocia.

Dystocia Causes

Powers

Dystocia Causes

Passage

Alterations in the pelvic structure

HPV-genital warts blocking vagina

Obesity

Dystocia Causes

Passenger

Fetal causes that include abnormal presentation or position, anomalies, excessive size, and number of fetuses

Ascynclitic (head not in correct position)

(OP) - occiputposterior - back labor

Dystocia Causes

Position

Maternal position during labor and birth

(way she lies)

Dystocia Causes

Psychological

Responses of the mother to labor related to past experiences, preparation, culture, heritage, and support systems

Not pusing, total anxiety, abuse issues

Hypertonic uterine dysfunction

defined as uncoordinated uterine activity

Tachysystole Management

with reassuring FHR

Reposition to side lying

IV fluid bolus-500 ml

If uterine activity not returned to normal after 10 minutes, decrease Pitocin

Tachysystole Management

with non-reassuring FHR

D/C Pitocin immediately

Reposition to side lying

IV fluid bolus - 500 ml

Oxygen 10L per nonrebreather

0.25 mg Terbutaline SQ (not used that often-smooth muscle relaxant-short acting)

Notify physician

The woman initially makes normal progress into the active phase of labor; then the contractions become weak and inefficient or stop altogether

Occurs when the pressure of the UC is insufficient (<25 mmHg) to promote cervical dilation and effacement

IUPC inserted to monitor strength of contractions

Pitocin

Amniotomy (Break bag of waters)

Empty bladder (urinate frequently)

Ambulation

Position changes

Hydration

The presence of a personal nurse who provides constant emotional and physical support is the only component associated with shorter labors and lower rates of C-section.

Labor that lasts less than 3 hours from the onset of contractions to the time of birth

Women report feeling frustrated when nurses did not believe them when they reported their readiness to push

Uterine rupture

Lacerations of birth canal

Amniotic fluid embolism (relatively rare)

Post partum hemorrhage (more common)

Hypoxia, caused by decreased periods of uterine relaxation, or rarely, intracranial trauma related to the rapid birth

Facial bruising

Analgesics

Exhaustion

Inadequate hydration or food intake

Augmentation with Pitocin

AROM

Assisted vaginal birth

Positioning

Ambulation

Fetal dystocia may be caused by excessive fetal size (macrosomic)

Malpresentation (OP, Asynclitic, face presentation)

Multifetal pregnancy

Fetal anomalies

Neonatal asphyxia

Fetal injuries or fractures

Maternal vaginal laceration

Can cause post partum hemorrhage

Assisted vaginal birth often necessary

Disproportion between the size of the fetus and the size of the mother's pelvis

Fetus can not fit through the maternal pelvis to be born vaginally

Fetal size (macrosomia-4000g or more)

Presentation and position (malposition of the presenting part)

Size and shape of the maternal pelvis

Quality of the uterine contractions

Cephalic Disproportion

Fetal macrosomia risk factors

Maternal diabetes

Obesity

Multiparity

Large size of one or both parents

Cephalopelvic Disproportion

Assessment findings

Malposition found during vaginal examination

Is not accurately predicted

Cephalopelvic Disproportion

Medical Management

Facilitating rotation of fetal head

Hands and knees, squatting, pelvic rocking, stair climbing, lateral position (lie toward the side in which the fetus should turn)

Lunges

Related to the contraction of one or more of the three planes of the pevis

Inlet contraction

Mid-pelvis contraction

Outlet contraction

or any combination of these planes

Caused by congenital abnormalities

Maternal malnutrition

Neoplasms

Lower spinal disorders

An immature pelvic size redisposes some adolescent mothers to pelvic dystocia

Uniqueness of pelvic shape not very common

Shoulder Dystocia

Condition in which the head is born, but the anterior shoulder cannot pass under the pubic arch

(Dread)

What are the risk factors for shoulder dystocia?

Read pre-natal hx look for risk factors

Excessive fetal size

Maternal pelvic abnormalities

Maternal diabetes

Hx of shoulder dystocia with another pregnancy

Prolonged second stage of labor (not going as predicted)

Shoulder Dystocia Complications

Fetal

Fetal injuries are usually caused by asphyxia related to the delay in completing the birth or by trauma from the maneuvers used to accomplish the birth

Brachial plexus (Erbs palsy)(if recognized and treated early 80-90% heal completely)

Phrenic nerve injuries

Fracture of humerus or clavicle (asymmetrical movement)

Shoulder Dystocia Complications

Maternal

Postpartum hemorrhage

Rectal Injuries

Shoulder Dystocia Management

1. Supra pubic pressure (attempting to push the anterior shoulder under the symphysis pubis, do not push top of fundus down)

2. McRoberts manueuver (pt pull legs back)

3.  Maternal position changes (hands and knees, squatting position, lateral recumbant)

Nursing Actions for

Shoulder Dystocia Management

Call for additional assistance

Apply supra pubic pressure

Assist mother with position changes

Chemical or mechanical initiation (AROM or stretching cervical os with foley bulb) of uterine contractions before their spontaneous onset for the purpose of bringing about birth

Elective or Medically

Labor Induction

Factors to Consider

Parity

Status of membranes: ruptured or intact (deliver with in 24 hrs of rupture)

Status of the cervix: favorable or unfavorable

Hx of previous cesarean births

Not before 39 weeks

Continuous fetal monitoring

Cervial ripening with Prostin (Prostaglandin) "Cervidil"

Amniotomy-breaking "the bag of waters" (needs some dilation)

Pitocin administration (now getting earlier than 3-4 cm)

A rating system to evaluate indicibility

When the Bishop score is ≥8, induction is typically successful

                                          Score                                  

                              0                1               2                3          

Dilation (cm)                0                1-2          3-4              ≥5

Effacement (%)            0-30           40-50        60-70           ≥80

Station (cm)                -3                -2            -1,0             +1, +2

Cervical consistency      Firm            Medium      Soft             Soft

Cervix position           Posterior     Mid-positon  Anterior       Anterior 

Hypertensive complications of pregnancy

Fetal death

Chorioamnionitis

Diabetes Mellitus

Postterm pregnancy (+42 weeks)

IUGR (Intrauterine Growth Restriction)

Premature rupture of membranes with established fetal maturity

Acute, severe fetal distress

Should presentation

Transverse lie, breech

Floating fetal presenting part (moves up/dwn, not engaged)

Uncontrolled hemorrhage

Placenta previa (covering cervical os)

Previous uterine incision that prohibits a trial of labor

Grand multiparity (+5 babies)

Multiple gestation

Suspected cephalopelvic disproportion

Breech presentation

Chemical: Prostaglandin E1 (Cytotec) - tablet intravaginally PO 50 mcg or Vaginally 25 mcg q 4 hrs

Prostaglandin E2 (Cervidil) - insert into posterior fornix of vagina - romove after 12 hours

Mechanical: Balloon catheter-Releases endogenous prostaglandins

Hydroscopic dilators-absorb fluid and dilate the cervix

Other methods: Nipple stimulation, sexual intercourse, castor oil, stripping membranes

The digital separation of the chrionic membrane from the wall of the cervix and lower uterine segment during a vaginal exam done by a primary care provider to stimulate labor

AROM during a vaginal examination with amnihook

Only perform when cervix is ripe and presenting part is engaged or cord prolapse possible

Assess FHR during and after procedure

Monitor temperature at least every hour

Pain

Abruptio placentae

Uterine rupture

Unecessary cesarean birth caused by non-reassuring FHR, postpartum hemorrhage, and infection

Intravenous (IV) fluids

Bed rest

Continuous electronic monitoring

Increase pain medication use and epidural anesthesia

Amniomoty

Prolonged stay in labor unit

IV Pitocin administered piggyback to main IV placed on a pump

Ice chips only (monitor I&O)

No supine position

Continuous fetal monitoring

Assess FHR and B/P prior to increasing Pitocin

Increase by 1 mU every 30 minutes (or what is ordered) to q 20 minutes

Operative Vaginal Delivery

Vacuum-assisted delivery

Attachment of a vacuum cup to the fetal head, using negative pressure to assist in the birth of the head

Encourage the woman to still push during the contraction

Caput

Cephalhematoma

Scalp lacerations

Subdural hematoma

Perneal, vaginal, or cervical lacerations

Soft-tissue hematomas (won't see a drop of blood but can have PPH with these)

Operative Vaginal Delivery

Forceps-assisted delivery

An instrument with 2 curved blades is used to assist in the birth of the fetal head

woman's cervix should be fully dilated, presenting part must be engaged, and membranes must be ruptured

blades are positioned by the physician with the blades placed in front of the baby's ears

Vaginal Birth after Cesarean (VBAC)

Benefits and Risks

Success rate 70-80%

Benefits: shorter maternal hospital stay, less blood loss, fewer infections, and fewer thomboembolic events

Risks:  uterine rupture, hysterectomy, operative injury, post partum hemorrhage, and neonatal morbidity (injury)

One previous low-transverse cesarean birth

Clinically adequate pelvis

No other uterine scars or history of previous rupture

Physician immediately available to perform emergency cesarean (rupture of uterine scar)

Availability of anesthesia and personnel for emergency cesarean birth

Induction of labor with an unfavorable cervix

Cesarean section

Prolonged labor

Postpartum hemorrhage d/t distension of uterus

Traumatic birth

Macrosomia

Aging of placenta

Oligohydraminos

Meconium stained fluid

Dysmaturity syndrome: dry, cracked, peeling skin

long nails

meconium staining of the skin, nails and umbilical cord

Previous preterm labor

Multiple fetuses

Socioeconomic level, education, nutrition, age >17 or <35, race, infection <2 losses in 2nd trimester

Saliva test for increased estrogen

Fetal fibronectin (protein in cervical mucous)

Absence is reasurring

Performed at 24-34 weeks

90-95% accurate if don't see

Presence doesn't necessarily mean anything

Uterine contractions q 10 min or more

Continuing for 1 hr or more

May or may not be painful

Back pain

Lower abdominal cramping w/wo diarrhea

Suprapubic pain or pressure

Pelvic pressure

Urinary frequency (Sudden change or increase in freq)

Contractions in thighs

Vaginal discharge changes (increased amt, may be thicker, may be watery, bloody, or brown)

ROM

Preterm Labor Education

S/Sx taught at every prenatal visit

Self Care: for an hour

Rest on side for 1 hr

Time contractions

Drink 2-4 cups of water

Relaxation/breathing techniques

Call Dr. or Midwife

If contractions subside, rest

Do not return to work

If longer than 1 hr <6 in 1 hr

note: dehydration causes uterine irritability, make sure hint of yellow

Magnesium Sulfate (smooth muscle relaxer)

Terbutaline (Brethine)

Calcium Channel Blockers such as Procardia (blocks Ca+ so muscle can't contract, can use at home and long term)

Prolapse of the umbilical cord is when the cord lies belowthe presenting part of the fetus

THIS IS AN OBSTETRICAL EMERGENCY

Most common: Frank (visible) prolapse immediately after ROM (can be occult, hidden)

Long Cord

Malpresentation

Unengaged presenting part

Variable or prolonged deceleration during uterine contraction

Woman reports feeling the cord after membranes rupture

Sense of fullness

Cord is seen or felt in or protruding from the vagina

*Monitor FHR after ROM

Relieve pressure on the cord by putting a sterile, gloved hand into the vagina and holding the presenting part off of the umbilical cord

Assist woman into a Trendelenburg or knee-chest position so gravity can assist keeping pressure off of the umbilical cord

TOL for attempted VBAC

Classic Incision (need transverse incision and cephalic presentation)

Labor Induction (Can rupture w/Pitocin stress can rupture)

Multiple prior cesarean births

Multiparity

Trauma

Common interventions for a patient having an induction include all except:

Intermittent FHR Monitoring

Bedrest

IV fluids

Increased pain meds or epidural

Labor that lasts less than 3 hours from onset of labor to birth is categorized as:

Turmultuous labor

Emergency labor

Precipitous labor

Abruptio labor

Fetal dystocia may be caused by excessive:

Uterine activity

Fetal size or malpresentation

Dilatation or malpresentation

Uterine distention because of fetal anomalies

Detect baseline rhythm and increase or decrease in FHR

Full min after UC ends

Fetal Assessment

Intermitten fetal heart rate auscultation

Take maternal pulse simultaneously to decerease confusion between maternal and fetal heart rates

Baseline rate

Rhythm

Increases

Decreases

The frequency, duration, tone, and intensity of contractions can be assessed by palpation:

Mild or 1+ (easily dented) nose

Moderate or 2+ (can slightly indent) chin

Strong or 3+ (cannot indent uterus) forehead

Know feel before (resting tone)

Assessment Frequency

Low Risk

Intermittent FHR auscultation

Immediately after contractions

Every 30 min in active first stage labor

Every 15 min in second stage

Contractions are palpated

Assessment Frequency

High Risk

HTN, Pitocin, Epidural HTN, Diabetes, Pre-existing pathology-disease or infection

Continous electronic fetal monitoring

Document every 15 min in active phase 1st stage

Document every 5 min in 2nd stage

Internal monitoring on people on Pitocin to detrmine sufficient pressure

Utero-placental unit

Autonomic nervous system (stimulus)

Position, Epidural & Pitocin

Baroreceptors

Central nervous System

Chemoreceptor

Acidodic

Hormonal Regulation

Utero-placental Insufficiency

Head compression

FHR Categories

Category I

Normal

Strongly predictive of normal fetal acid-base balance. They may be followed in a routine manner and no action is required.

FHR Categories

Category II

FHR Categories

Category III

FHR tracings are abnormal. They are predictive of abnormal fetal acid-base status and require prompt evaluation.

Depending on the clinical situation intrauterine resuscitation should be initiated.

Minimum or absent variability

Category I FHR tracings include all of the following:

Normal

Baseline rate 110-160 bpm

Baseline variability moderate

Late or variable deceleration absent

Early decelerations absent or present

Category II - Indeterminate

FHR tracings include all FHR tracings not categorized as category I or III

They include any of the following:

Bradycardia not accompanied by absent variability

Tachycardia

Minimal baseline variability

Absent baseline variability not accompanied by recurrent decelerations

Marked baseline variability

Absence of induced accelerations

Recurrent variable decelerations with minimal or moderate variability

Prolonged decelerations

Recurrent late decerlations with moderate variability

Variable decelerations with other characteristics

Category III - Abnormal (non-reassuring)

FHR tracings are either

Absent variability with any of the following:

recurrent late decelerations

recurrent variable decelerations

bradycardia

sinusoidal pattern

FHR pattern Interpretation

Interpretation of baseline variability

Interpretation of periodic and episodic changes: Decelerations

Early, variable, late

No distinction between long and short-term

Variability is measured from the peak to the trough of FHR fluctuation of baseline

Document present or absent

Absent, Minimal, Moderate, Marked

Absent Variability

Causes of Absent/Minimal Variability

Congenital anomalies

Preexisting neurological injury

CNS depressant medications

Tachycardia

Extreme prematurity

Fetus is in sleep state

Moderate Variability

Amplitude range of 6-25 bpm

Considered normal

Indicates normal fetal acid-base balance

Amplitude range is greater than 25 bpm

Unclear as to the significance of marked variability at this time

Don't want for very long

Not always indicative of problem but needs watching

Reassuring FHR Parameters

Baseline:  110-160 bpm

Variability: moderate

Accelerations: present

Periodic changes:

Early decelerations

Accelerations with contractions

Variable decelerations lasting no more than 30-45 sec. with normal baseline, variability and shoulders

Reflects normal, irregular changes/fluctuations in FHR baseline related to autonomic/cerebral and brain stem function and indicates:

A mature fetal neuological system

A measure of fetal reserve

Adequate oxygen perfusion to brain stem

Does not include accelerations or declerations

A regular, smooth, undulating wavelike pattern

Occurs with severe fetal anemia

Not good

Presence is highly indicative of Normal fetal acid-base balance, significant of fetal well-being

Document present or absent

Decelerations

Categorized as:

related to head compression

A gradual decrease in associated with uterine contraction, the onset, nadir (lowest point), and recovery are coincident with the beginning, peak, and ending of the contraction

A mirror image

Considered benign

Early Decelerations

Caused by:

Head compression resulting from:

Uterine contractions

Vaginal examination

Fundal pressure

Placement of internal mode of monitoring

Significance: Normal pattern, no intervention req'd

Related to uteroplacental insufficiency

A gradual decrease (defined as onset of deceleration to the nadir in 30 or greater seconds); associated with uterine contraction delayed in timing, with the nadir of the decleration occuring after the peak of contraction

Begins after the contraction has started

Does not return to baseline until after the contraction is over

Ominous sign if uncorrectable or associated with absent or minimal variability or tachycardia

Late Decelerations

Uteroplacental Insufficiency

Persistent and repetitive late decelerations indicate the presence of fetal hypoxemia stemming from insufficient placental perfusion during uterine contractions

If recurrent and sustained, can lead to metabolic acidosis

Uteroplacental Insufficiency caused by:

Uterine tachysystole

Maternal supine hypotension

Epidural or spinal anesthesia

Placenta previa

Abruptio placentae

Hypertensive disorders

Postmaturity

IUGR

Diabetes mellitus

Intraamniotic infection

Change maternal position

Correct hypotension

Increase rate of IV

Palpate uterus for tachysystole

Discontinue Pitocin

Oxygen at 10L by nonrebreather

Notify physician or midwife

LION PIT

Variable Deceleration

Related to umbilical cord compression

Variable waveform usually with rapid onset and offset; decrease below baseline at least 15 bpm, lasting at least 15 sec and no longer than 2 min from onset to return

May occur during, after, in-between contractions

Nadir and duration varies, but usually related to strength and duration of contraction

A "typica" variable maintains baseline, variability and is preceded and followed by brief accelerations/shoulds

U, V, or W shaped

May be preceded or followed by brief accelerations of the FHR known as shoulders to compensate

Umbilical cord compression caused by the

following:

Maternal position with cord between fetus and maternal pelvis

Cord around fetal neck, arm, leg, or other body part

Short cord

Knot in cord

Prolapsed cord (depending on placement)

Variable Deceleration

Occur in 50% of all labors and usually are transient and correctable

Interventions:

Change position

D/C position

O2 at 10L nonrebreather

Notify physician or midwife

Assist with vaginal or speculum examination to assess for cord prolapse

Assist with amnioinfusion if ordered

Caused by a disruption in fetal oxygen supply

Prolonged cord compression, profound uteroplacental insufficiency, sustained head compression

The presence and degree of hypoxia are thought to correlate with the depth and duration of the deceleration, how abruptly it returns to baseline, and how much variability is lost during the deceleration

Tachycardia, bradycardia, or unidentifiable/wandering

Absent variability

Absence of accelerations

Late decelerations

Fetal pulse-oximetry is not effective in determining fetal outcome-no change in C/S rate

Interventions for nonreassuring FHR patterns

LION PIT

These interventions maximize intravascular volume, uterine perfusion, placental exchange, and oxygen delivery to the fetus

Intrauterine Resuscitation

When a nonreassuring FHR pattern is identified, assessment may include:

Cervical exam to assess for:

Umbilical cord prolapse

Rapid cervical dilation

Rapid descent of fetal head

Assess uterine activity for uterine tachysystole

Assess maternal VS, especially:

Maternal temperature for maternal fever

Maternal blood pressure for hypotension

Change maternal position (left or right lateral) to minimize or correct cord compression, decrease frequency of UCs and improve uterine blood flow

Administer IV bolus of fluid to maximize intravascular volume and improve uteroplacental perfusion

Administer O2 at 10 L/min via face mask to improve fetal oxygen status. Reduce uterine activity if UCs are too frequent because there may be insufficient time for blood to perfuse placenta

Infusion of room-temperature isotonic fluid into the uterine cavity if the volume of amniotic fluid is low

Amnioinfusion has been used to resolve variable FHR deceleration by correcting umbilical cord compression as a result of oligoydraminos

Intensity and frequency of uterine contractions should be continually assessed during the procedure

Alter pushing efforts, or stop the woman from pushing, or having woman push with every other or every third UC to provide time for fetus to recover when FHR is nonreassuring during the second stage

Support woman and family to decrease anxiety or pain, and improve uterine blood flow and maximize oxygenation to fetus

Ominous FHR patterns are associated with fetal acidemia

The presence of one of the ominous patterns warrants immediate bedside evaluation by a physician who can initiate a cesarean birth

Nursing Interventions for non-reassuring (abnormal) FHR

Position changes

Oxygen administration 8-10 L/min by nonrebreather mask

Increase IV fluids

D/C Pitocin if running

Terbutaline may be ordered to quiet uterus

Continue to assess and document

Notify physician, nurse midwife, NICU, anesthesia

Prepare for amniinfusion when variable decelerations are present

The study of a single gene or gene sequences and their effects on living organisms

Is a contributing factor in virtually all human illness

The study of the entire DNA structure of all of an organism's genes, including functions and interactions of genes

Broad categorization of all that influences the genome

Compare this concept to the Information Technology concept tht includes all those things that influence the transmission of information using technology

Genetic make-up of an individual

This is what you are made of

Observable expression of the individuals genotype

This is what you see

Schematic arrangements of the chromosomes within a cell to demonstrate their numbers and morphologic features

Determine the number and structure of chromosomes

Lung Cancer                  Smoking

Skin Cancer                   Sun exposure

Diabetes                        Obesity

Heart disease                 Diet

Alzheimers                     No longer learning

Map the complete set of instructions for genes within the cell nucleus

Completed by both public and private scientists in 2000

National and International effort

Francis Collins led the Human Genome Project

Outcomes of the Human Genome Project

Key findings:

All humans are 99.9% identical at the DNA level

30,000-40,000 genes make up the human genome

Assumption was that humans were more evolved with approximately 80,000-150,000 genens

Huntington disease

Breast cancer

Colon cancer

Alzheimer disease

Achondroplasia

Cystic fibrosis

Genetic tests for 1672 inherited conditions are commercially available

The use of genetic information to individualize drug therapy

To reduce adverse drug reactions

P450

A family of genes that control how fast an oral med is metabolized

Rapid metabolizers-don't keep the drug in their system very long therefore it may be less effective and it will have fewer adverse effects

The drug is poorly metaboized therefore it stays in the system longer and can lead to more adverse effects and even toxic effects

An individual may need a smaller dose which will still be effective, and not lead to toxic levels

Example: Gleevac is a drug used to treat chronic myeloid leukemia (CML). Caused by a translocation between chromosome 9 and 22 creating an oncogene

CML develops

This drug blocks the new protein produced by this oncogene-remission occurs in 90% of patients with CML

Basic genetic concepts and principles

Clinical presentations tht may indicate a genetic condition

Common genetic conditions

Availability of genetic services

Informed decision making about genetic testing and therapeutic options

Risks for discrimination, stigmatization, altered self-esteem, and altered family dynamics associated with diagnosis of genetic condition or a genotype for adult onset disorders

How to obtain a 3 generation family history and construct the corresponding pedigree

Trisomies-non-disjunction

Downs Syndrome

Newborn screening-almost all of the inborn errors of metabolism are autosomal recessive

Cystic Fibrosis

Single Gene Disorders

Potential patterns of inheritance for single-gene disorders

Autosomal dominant

Autosomal recessive

X-linked dominant (fragile X)

X-linked recessive (color blind, hemophilia)

Combination of genetic and environmental factors

Congenital malformations:

Cleft lip and palate

Neural tube defects

Cancer

Diabetes

Heart Disease

Alzheimer's disease

Most other diseases

Only one copy of a variant allele is needed for phenotypic expression

Vertical pattern of inheritance is seen (does not skip a generation)

Males and females are equally affected

Examples: Marfan syndrome, neurofibromatosis, myotonic dystrophy, Stickler syndrome, Treacher Collins syndrome, achondroplasia

Both genes of a pair must be abnormal for the disorder to be expressed (trait is expressed when two carriers each contribute a variant allele to the offspring)

Heterozygous individuals have only one variant allele and are unaffected (known as carriers)

Chance of a trait occurring is 25%

Horizontal pattern of inheritance

Usually observed in one or more siblings, but not in earlier generations

Males and females are equally affected

Examples: IEM (inborn error of metabolism): PKU, galactosemia, maple syrup urine disease.

Tay-Sachs disease, sickle cell anemia, CF

Occur in males and heterozygous females

X-inactivation-affected females are usually less severely affected compared to males

Females are more likely to transmit the affected allele to their offspring

Heterozygous females have a 50% chance of transmitting the variant allele to each offspring

May be lethal in males

Examples: Vitamin D- resistant rickets, fragile X syndrome

Few X-linked dominant disorders identified d/t lethality

Carried on the X chromosome

Females may be heterozygous or homozygous for traits

Males are hemizygous since they only have 1 X chromosome, with no alleles on the Y chromosome

Most often occur in male offspring

Male receives the disease-associated allele from his carrier mother

Female carriers have a 50% probability of transmitting the disease-associated allele to offspring

An affected male can pass the disease associated allele to daughters, not sons

The daughter will be a carrier if they receive a normal X from their mother

The daughter will only be affected if they receive a disease-associated allele on the X chromosome from both their mother and father

Examples: Hemophilia, color blindness, Duchenne muscular dystrophy

Provide non-directional (gives just facts & statistics but not what means) counseling about genetic testing

Provide information on risk for the future

Cancer predisposition

Prenatal

Especially age-related risk for chromosomal abnormalities

Prepared with a Master's degree in gentic counseling

Diagnosis of a genetic condition

Family history

Physical exam looking for dysmorphology or other clues

Geneticists are physicians with fellow-ships in gentics

At least 3 generations

Record current and past health status

Include mental illness (depression)

Pregnancy losses (miscarriage)

In addition to ones suggested

Informed decision making

Non-directional counseling (give no opinion only info)

Family Genes

Refer when 2+ are present

F family characteristics are obvious

G groups of anomalies (3 or more)

E extreme presentation (early onset or abnormally severe)

N neurologic abnormalities

E exceptional pathology (rare findings)

S surprising lab values (hypocalcemia, chromosomes, etc)

Diagnostic Testing-do I have the gene?

Carrier testing-do I carry the gene but my other gene prevents me from having the disease

Predictive testing-what are my chances of getting the disease

Pre-symptomatic testing-do I have the gene but it's just not affecting me yet, but certainly will (Huntington disease)

Predisposition testing-if the test is positive, it is not 100% that I will get the disease (BRCA 1)

Provide emotional support to families during the genetic counseling process

Provide basic info about patterns of inheritance

Identify patients who might benefit from genetic information/services

Provide accurate information about what is involved in genetic evaluation/counseling before referral is made

Find accurate, current information about gentic information for the patient and family

Access to Credible Genetics Resources Network

Identify patient's current knowledge and find out what they need to know first and find it

Identify community resources for the patient and family

Maintain confidentiality

Protect privacy

Use child first language:

The child with Down syndrome

Not A Down's child

Use neutral words

Use gene alteration or gene mutation

NOT defective or mutant

Down syndrome NOT Down's Syndrome

http://agree.mc.duke.edu/index.html

Accessible genetics research ethics education

Family impact

Target screening for populations with increased incidence of a particular genetic condition

Discrimination

GINA

G genetic

I information

N non-discrimination

A act

This legislation would prohibit discrimination on the basis of genetic information with respect to health insurance and employment

GINA provides strong, enforceable protections against the misuse of genetic information-the definition of which includes family health history-in both health insurance coverage and employement decisions

Informed consent necessary prior to blood being drawn for testing

Target populations where a gentic disease has an increased incidence so that early screening and treatment can occur.

Generally most insurance underwriters approve payment on a case by case basis

Encourage patients to contest a decline of coverage