Maternal/OB

Without fear

• Breathing techniques for relaxation; to break the
• fear-tension-pain syndrome

• Psychoprophylactic Method (PPM) Neuromuscular control – conscious relaxation –
• 1998 Lamaze International . “Mothers know how to give birth”

• Husband Coached Childbirth environment control; meds
• discouraged

• 1. labor to begin on it’s own
• 2. Freedom of movement throughout LABOR
• 3. Continuous labor support-does not have to be a nurse
• 4. No routine interventions
• 5. Nonsupine positions for birth-vena cava syndrome
• 6. No separation of mom and babe; promote breastfeeding

• ◦Passenger (fetus and placenta)
• ◦Passageway (birth canal)
• ◦Powers (contractions)
• ◦Position of mother
• ◦Psychologic response

• ◦Size of fetal head
• ◦Fetal presentation
• ◦Fetal lie
• ◦Fetal attitude
• ◦Fetal position

• –Bony pelvis
• –Lower uterine segment
• Cervix
• Pelvic floor muscles
• Vagina
• Introitus (external opening to the vagina)

• ◦Gynecoid – round shaped (SVD), classic female type; 50% of females
• ◦Android – heart shaped (C/S), resembling the male pelvis; 23%
• ◦Anthropoid – oval shaped (C/S), resembling the pelvis of anthropoid apes; 24%
• ◦Platypelloid – flat shaped (SVD), the flat pelvis; 3%

• a.After labor begins, uterine body becomes a thick and muscular upper segment, and thin-walled passive muscular segment
• b.Physiologic retraction ring – separates the above segments
• c.The cervix effaces (thins) and dilates (opens) to allow fetus to descend into the vaginal canal

• –Effacement-measured in %
• Dilation-measured in cm
• Ferguson reflex-when the head is hitting the perineum floor

Bearing-down efforts

• ◦Position affects woman’s anatomic and physiologic adaptations to labor
• ◦Frequent changes in position
• Relieve fatigue
• Increase comfort
• Improve circulation
• ◦Laboring woman should be encouraged to find positions most comfortable to her

• }Labor: process of moving fetus, placenta, and membranes out of uterus and through birth canal
• }Various changes take place in woman’s reproductive system in days and weeks before labor begins
• }Labor can be discussed in terms of mechanisms involved in process and stages woman moves through

• onset of regular contractions to full dilation
• Latent 0-3 cm
• Active 4-7 cm
• Transition 8-10 cm

• full dilation to birth
• phases-
• latent 0 to +2 station
• descent +2 to +4
• transitional +4 to birth

birth to delivery of placenta

• next two hours after placenta delivery
• Reestablishment of homeostasis
• Observation for complications

• Engagement
• Descent
• Flexion
• Internal rotation
• Extension
• –Restitution and external rotation
• Expulsion (birth)

the fetal presenting part as its’ widest diameter reaches the level of the ischial spines of mother’s pelvis

the descent fetal presenting part through true pelvis

Flexion of fetal head so that the smallest head diameters pass through the pelvis

to allow the largest fetal head diameters to match the largest maternal pelvic diameters

of the fetal head, allowing the shoulders to rotate internally to best fit the mother’s pelvis

of the fetal shoulders and fetal body

• Visceral pain
• Somatic pain

• ◦Culture
• ◦Anxiety & fear
• ◦Previous experience – difficult, painful
• ◦Childbirth preparation – family support

• causes
• 1) cervical dilation and effacement
• 2) uterine ischemia
• a.Pain impulses during this stage – transmitted via T11-T12
• b.Visceral pain = from cervical changes and uterine ischemia
• c.Visceral pain – located over lower portion of abdomen, radiates to lumbar area of back and down thighs

• during this stage of expulsion, woman experiences perineal or somatic pain
• a.Pain impulses during this stage – transmitted via S1-S4
• b.Somatic pain – results from stretching of perineal tissue to allow passage of fetus, and from traction on peritoneum and uterocervical supports during contractions

• also called afterpains; similar to stage I
• a. Pain localized w/cramping and a tearing/bursting sensation resulting from distention and laceration of cervix, vagina and perineal tissue

• saturation point of which the brain cannot absorb anymore pain
• Limited number of sensations or messages can travel through sensory nerve pathways to the brain at one time.
• Can reduce or block pain by closing hypothetic gate in the spinal cord
• Perception of pain
• stimuli diminished

• }Relaxation, Visualization, Imagery, Music, Massage, Energy Work
• }Conscious Breathing, Hypnosis
• }Water therapy
• }Transcultaneous E N S
• }Acupressure/acupuncture
• }Heat/cold, Aromatherapy, Biofeedback
• }Intradermal water block-

• 1.Cleansing breath – relaxed breathing in through nose and out through mouth
• 2.Slow paced breathing: approximately 6-8 breaths per minute
• a.“In-2-3-4/Out-2-3-4 . . .”
• 3.Modified paced breathing: approximately 32-40 breaths/minute
• a.In-Out/In-Out/In-Out. . .
• 4.Patterned paced breathing – same rate as modified
• a.3:1 or 4:1 breathing pattern
• b.Coach called breathing – helps for concentration

• used as tool to help woman maintain control during contractions
• a.Stage One – promotes relaxation of abdominal muscles to help enlarge abdominal cavity
• b.Stage Two – increases abdominal pressure to assist in expulsion of fetus

• Cross the blood-brain barrier- to provide central analgesic effects
• ◦Cross placental barrier
• Effects of fetus
• Classes include:
• ◦Narcotic analgesics
• ◦Mixed narcotic agonist-antagonist compounds-still do affect baby less but also leave the body faster
• ◦Analgesic potentiators
• ◦Narcotic antagonists
• ·IV is immediate effect

remains major form of analgesia for relief of labor pain; when regional anesthesia no available

• a.Maternal dosage
• b.Pharmacokinetics of specific drug
• c.Route and timing of administration
• d. IV preferred over IM – onset of drug faster and more reliable

• ◦Narcotic analgesics (meperidine, fentanyl)
• ◦Mixed narcotic agonist-antagonist compounds-(Stadol, Nubain) still do affect baby less but also leave the body faster
• ◦Analgesic potentiators (tranquilizer type drugs, Phenergan, vistaril)
• ◦Narcotic antagonists (Narcan)

• }Complete lumbar epidural block – requires block from T-12 to S-5
• }Disadvantages of epidural
• ◦Need for IV line, occasional dizziness, weakness of the legs
• ◦Difficulty emptying bladder, shivering

• }Anesthetic – injected via 3rd, 4th or 5th lumbar interspace into arachnoid space and mixes with CSF
• }Commonly used for c-sections
• }Complications
• ◦General
• ◦Postspinal headache
• Blood patch procedure
• }Advantages

marked hypotension, decreased cardiac output and placental perfusion, and respiratory inadequacy

• a.Ease of administration, absence of fetal hypoxia
• b.Maternal consciousness maintained, no blood loss

• a.Allergy to anesthetic
• b.Hypotension, respiratory paralysis

• leakage of CSF from puncture site
• a.headache, auditory and visual problems for weeks
• b.Initial treatment – analgesics, bed rest, caffeine, increased fluid intake (150 ml/hr)
• c.Prolonged problems – autologous blood patch – repairs tear in dura mater of spinal cord

• }Advantages
• ◦No maternal hypotension
• ◦Mom feels contractions but no pain
• ◦Early ambulation post c-section
• Allows Mom to care for infant
• –Facilitates bladder emptying
• ◦Side effects
• Nausea, vomiting, pruritus
• –Urinary retention, delayed respiratory depression

• }Rarely used for uncomplicated vaginal delivery or c-section
• }Preoperative prep
• }Recovery room nursing care:
• ◦Maintain an open airway
• ◦Maintain cardiopulmonary functions
• ◦Prevent postpartum hemorrhage
• ◦Facilitate parent-child attachment

• }Heart rate
• ◦Normal range 110-160 beats/min
• }Circulation – affected by:
• ◦Maternal position, uterine contractions
• ◦Blood pressure, umbilical cord blood flow
• }Respiration – review the changes that occur to prepare fetus to initiate breathing immediately after birth

• a.Fetal lung fluid is cleared from air passages during labor and vaginal birth
• b.Fetal oxygen pressure (Po2) falls
• c.Arterial carbon dioxide pressure (PCo2) rises
• d.Arterial pH falls
• e.Bicarbonate level falls
• f.Fetal respiratory movements decrease during labor

• a.Perform Leopold’s maneuvers to identify fetal presentation and position
• b.Place listening device over area of maximum intensity and clarity of fetal heart tones
• c.Palpate abdomen for absence of uterine activity to count FHR between contractions
• d.Count maternal radial pulse while listening to FHR; to differentiate from infant’s
• e.Count FHR 30-60 seconds between contractions to identify baseline rate
• f.Auscultate FHR during contraction and 30 seconds after end of contraction; to identify increases and decreases

• examiner should place hand over fundus before, during and after contraction
• a.Intensity – describe as mild, moderate or strong
• b.Contraction – measured in seconds, from beginning to end of ctx
• c. Frequency – measured in minutes from beginning of one contraction to beginning of next ctx

must be maintained during labor to prevent fetal compromise and promote newborn health after birth

reduction of blood flow thru maternal vessels, reduction of oxygen content in maternal blood, alterations in fetal circulation, reduction in blood flow to the intervillous space in the placenta

• a.Contractions occurring every 2-5 minutes, lasting less than 90 seconds
• b.Contractions are moderate to strong in intensity, as evidenced by palpation
• c.Contractions intensity is < 100 mm Hg, as measured by intrauterine pressure catheter
• d.30 seconds or more should elapse between end of one contraction and beginning of the next
• e.Between contractions uterine relaxation should be detected by palpation or by average intrauterine pressure of 15 mm Hg or <

to identify and differentiate the reassuring patterns from the nonreassuring patterns, which may be indicative of fetal compromise

• a.Fetal hypoxemia – a deficiency of oxygen in the arterial blood. If uncorrected, hypoxemia can lead to severe fetal hypoxia
• b.Fetal hypoxia – an inadequate supply of oxygen at the cellular level

• a.Progressive increase or decrease in baseline rate
• b.Tachycardia of 160 beats per minute or more
• c.Progressive decrease in baseline variability
• d.Severe variable decelerations – FHR < 60 bmp lasting longer than 30-60 sec., with rising baseline, decreasing variability, or slow return to baseline
• e.Late decelerations of any magnitude, especially those that are repetitive and uncorrectable, with decreasing variability or rising baseline FHR
• f.Absence of FHR variability
• g.Prolonged deceleration - > 60-90 seconds
• h.Severe bradycardia - < 70 BPM

• Baseline- ranges 110-160 beats/minute
• ◦Tachycardia - > 160 beats/minute
• ◦Bradycardia - < 110 beats/minute

average rate during 10 minute segment that excludes periodic or episodic changes, periods of marked variability, and segments of baseline that differ by > 25 bpm

early sign of fetal hypoxia; resulting from maternal or fetal infection, maternal hyperthyroidism, fetal anemia, or response to drugs

a later sign of fetal hypoxia, occurs before fetal demise; resulting from placental transfer of drugs, prolonged compression of umbilical cord, maternal hypothermia, maternal hypotension

• 1.based on visualization of amplitude in the peak to trough segment in beats/minute
• a.Absent or undetected variability
• b.Minimal - > undetected but not > 5 beats/minute
• c.Moderate – 6-25 beats/minute
• d.Marked - > 25 beats/minute

• a.Increases intrathoracic pressure t reduces venous return t increases venous pressure
• b.Cardiac output and blood pressure m and pulse rate o temporarily
• c.During this period; fetal hypoxia can occur
• d.Process is reversed when mother takes a breath

• }increased WBC, temperature and respirations
• }Proteinuria
• }decreased gastric motility, absorption of food
• }decreased blood glucose

• }History-prenatal record:
• ◦potential complications ?
• ◦last food/fluid intake?
• ◦Ask re: spontaneous rupture of membranes (SROM).
• }Vitals
• }Labs
• ◦blood,
• ◦Urine

• ◦Number of fetuses
• ◦Presenting part, fetal lie, fetal attitude
• ◦Degree of presenting part’s descent into the pelvis

• differentiates amniotic fluid, which is slightly alkaline, from urine and purulent material which are acidic
• a.Membranes intact 5.0 – 6.0 (acidic)
• b.Membranes ruptured 6.5 – 7.5 (alkaline)
• c.Document as positive or negative

• Sterile procedure; often hastens labor
• ◦Check color (what does it mean?)
• 1.Color – pale straw colored with white particles
• 2.Viscosity and odor – watery and lacks strong odor
• 3.Amount – expected amount of 500-1200 ml

• ◦Potentially hazardous (cord prolapse)
• ◦Nitrazine test for pH

• Sudden change in UC’s
• }Request for pain meds (often 1st sign)
• }Change in behavior (transition), vomits
• }ROM
• }Urge to defecate
• ®Check FHT & do vag exam

• ◦Non-reassuring FHR patterns
• ◦Inadequate uterine relaxation
• ◦Vaginal bleeding
• ◦Infection
• Prolapse of cord

• Begins with anticipation of birth
• ◦Full cervical dilation & effacement
• }Phases (check station)
• ◦Latent – rest and relative calm
• ◦Descent – strong urges to bear down
• ◦Transition – presenting part of head is on perineum

• most common = midline
• ◦d/t crowning, anesthesia not needed
• ◦minimal bleeding
• }[From readings: know laceration degrees]
• }“Circle of fire” with birth of head

• a.Midline (median) – most common in US
• i.Third degree laceration/extension – midline episiotomy extending through renal sphincter
• ii.Fourth degree – extending into anal canal
• Mediolateral – greater blood loss, more difficult to repair

• a.First degree – laceration extends through the skin and structures superficial to muscles
• b.Second degree – laceration extending through muscles of perineal body
• c.Third – laceration continues through anal sphincter muscle
• d.Lacerations can also involve anterior rectal wall

• }Infant placed on abdominal or warmer
• }Cord clamped & cut
• }Nurse performs:
• ◦drying, applies cap
• ◦does APGAR scoring 1min. and 5min.
• }If stable, wraps & presents infant to parents (critical for bonding)

• 1.Checking airway and APGAR scoring
• 2.Identification procedures
• 3.Checking cord for three vessels

• }Placenta delivered by attendant (spontaneously or manually extracted)
• ◦Nurse notes time
• }attendant inspects placenta: intact? quality?
• }Promote uterine involution:
• ◦Prepare Pitocin if ordered, fundal massage
• ◦Baby to breast
• }Perineal suture (but give mom attention)

• 1.Goal – prompt separation and expulsion of placenta, achieved in safest and easiest manner
• 2.Placenta separation
• a.Firmly contracting fundus
• b.Change in uterus from discoid to globular ovoid shape
• c.Sudden gush of dark blood from introitus
• d.Lengthening of umbilical cord
• e.Vaginal fullness

• }Vital signs per policy (cardiac output change)
• }Monitor amount of vaginal flow
• }Assess for bladder distension, cath prn
• }Clean her up, clean peri-pad & gown
• }Let her get some sleep