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Mechanical theory of labor
Organ becomes filled and distended, empties itself.
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Hormonal theory of labor
- Maternal progesterone and estrogen levels change.
- Maternal production of oxytocin and prostaglandin
- Increase in fetal cortisol
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Signs of labor
- Lightening
- Braxton Hicks
- Cervical changes
- Bloody show
- Rupture of Membranes
- GI disturbance
- Sudden burst of energy.
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Lightening is
Descent of fetus into the pelvis. Can occur two weeks before labor in primagravida (first pregnancy)
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Braxton Hicks is
Irregular intermittent contractions that do not dilate cervix
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Cervical changes during labor
Around 34 weeks the cervix begins to soften and become spongy. Effacement may begin
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Bloody show during labor is
Cervical secretion,blood tinged mucus, and the mucus plug. Labor often begins 24-48 hours after bloody show
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False labor is
- Irregular short contractions (1-2 hrs)
- Intervals between contractions stay the same
- stops when pt ambulates or changes positions
- Will stop with breathing, relaxing, comfort or hydration.
- Cervix May soften but doesn’t effect or dilate
- Contractions felt above navel.
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True labor is
- Contractions at regular intervals and will gradually shorten
- Will increase in intensity and duration
- Will continue and often worsen with ambulation
- Usually isn’t stopped with breathing etc
- Cervix softens, effaces, and dilates.
- Felt in lower back and radiates to abd.
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Responses to labor
- Increased CO and BP during contractions
- Increased RR and o2 consumption
- Bladder pushed forward and upward-encourage pt to void. Distention May impede fetal descent
- Peristalsis and absorption decrease- NPO
- Body temp increases and starts sweating
- WBC increases
- Small tears in vagina and perineum May occur from
- stretching
- Relaxation of pelvic joints resulting in back age and leg cramps
- Endorphins increase pain tolerance and pressure at perineum produces physiologic anesthesia
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Pain during labor is
- Individual
- Subjective
- Personal
- Expressed differently
- May be affected by culture
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5 p’s of labor
- Passageway
- Passenger
- Position
- Powers
- Psychological response
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Passageway
- Maternal passage is of primary concern when patient is planning a vaginal birth.
- True pelvis- must be big enough for baby
- Uterus- fundus thickens while lower uterus forms thinner tube.
- Cervix- contractions put pressure on fetus cause cervix pressure and dilation and effacing
- Vagina - has to stretch
- Perineum- pressure caused stretching and thinning
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Passenger
- Fetal size- head is largest part. Bones aren’t fused and can move and overlap through moms pelvis.
- Fetal attitude- relationship of fetal body parts. Ideal is flexion with head flexed on chest, arms over chest, and hips and knees over abdomen. Extension of limbs causes difficulty in labor.
- Lie- relationship of the cephalocaudal axis of fetus with cephalocaudal axis of mom
- Fetal presentation-determined by the fetal lie snd part of the fetus that enters the pelvis first. Most common is cephalic (head)
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Cephalic presentation
Head out first
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Breech presentation
Buttocks our first
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Frank breed presentation
Hips flexed, knees extended
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Vertex presentation
Head well flexed on chest, occiput is presenting part
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Brow presentation
Sinciput (forehead) is presenting part
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Face presentation
Face is presenting part
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Position
- Engagement- fixation of the fetal presenting part in the maternal true pelvis in which the widest diameter of the presenting part is at or below the level of the ischial spines.
- *** immediate concern when a pts membranes rupture prior to engagement is a prolapsed cord***
- ***take fetal HR for full minute in that situation ****
Station - relationship of the fetal presenting part to the isnial spines, it is measured in cm above (-) or below (+) the isnial spines.
Fetal position- relationship of the identified landmark on the presenting part of the four quadrants of the mother’s pelvis.
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Powers
- Primarily involuntary contractions of uterus with phases of relaxation.
- Rest restores oxygenation.
- Contractions have three phases.
- Secondarily voluntary use of abd muscles by mother to push.
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Increments
Increasing intensity of contraction
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Decrement
Decreasing intensity of contractions
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Frequency
- Time from the beginning of one contraction to the next. Includes rest period.
- Persistent contractions at intervals shorter than 60 seconds will reduce oxygenation
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Interval
The amount of time the uterus relaxes.
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Duration
Is the length of one contraction of the increment to the conclusion of the decrement.
- Duration of a contraction SHOULD NOT BE LONGER THAN 90 SECONDS or interval LESS THAN 60 SECONDS.
- REDUCES FETAL 02
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Intensity
Strength of the contraction at acme
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Ferguson’s reflex
- Spontaneous, involuntary urge to bear down
- Triggered when presenting parts reach pelvic floor where receptors trigger release of oxytocin
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Psychological response
- Anxiety reduces blood flow
- Responses influenced by culture
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First sign of labor:
Dilation and effacement
- Starts with Regular contractions ends with cervical dilation
- Longest stage of labor
- Divided into three phases: latent, active, and transition
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Latent phase of labor
- Ends with 3cm of dilation
- Longest phase
- Contractions 10-20 minutes lasting 15-30 seconds
- Contractions become more moderate
- Mom alert and talkative
- Educate on breathing
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Active phase
- Begins with 4 cm dilation
- Ends at 8 cm
- Contractions 3-5 minutes lasting 40-60 sec
- Have pt void q2h to prevent impeding fetal descent
- Intensity is stronger
- Focus on breathing.
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Transitioning
- Begins at 8 cm
- Ends at 10 cm
- Contractions 2-3min lasting 60-90 sec
- Strong contractions
- Focus on breathing, relaxing( pant- blow breathing)
- No narcotics- reduce fetal oxygenation.
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Characteristics during transition
- Restless
- Hyperventilating
- Anger
- Focused on self
- Not following directions
- Irritability
- N/v
- Very warm
- Sweating
- Increasing recital pressure
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Birthing
- Begins with complete cervical effacement and dilation of 10 cm
- End with birth of baby
- When cervix is 10 cm mom can push
- Pushing beforehand will cause cervical lacerations
Crowning- head seem at bulbs between contractions
Episiotomy- incision in perineum
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Mechanism of labor
- Engagement- occurs when presenting part of the fetus is in the pelvis. At station 0
- Descent- begins with engagement and continued with each contraction
- Flexion- fetal head is bent forward and meets resistance during descent causing chin to rest in sternum. Allows narrowest part of head to enter the pelvic outlet.
- Internal rotation- takes place during second phase. Head rotated so the occipital is next to the symphysis pubis
- Extension- the occipital pivots under the symphysis pubis and the fetal head becomes extended and pushes upward out of the vagina. Head born during this.
- External rotation and restitution: head rotated back into normal alignment with shoulders
- Expulsion: rest of body is born with gentle downward pressure on baby’s head.
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Third stage
- Begins with birth of baby
- Ends with delivery of placenta
- Takes 5-30 minutes
- Most places dispose of placenta, occasionally clients ask for it back.
- MD will examine the placenta and membranes for intactness.
- Retained fragments can cause hemorrhage.
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Fourth stage
- First 4 hours after birth
- Assess for hemorrhage****
- Blood loss usually 250-500ml ***
- Uterus should remain contracted to control bleeding.
- *keep check in firmness and position of the fundus.
- *positioned in midline of abd level with umbilicus
- * regular voiding to prevent uterine hemorrhage.
- Mother may experience shaking and chills
- Bonding is important
- May us ice pack for 12 hours
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Women having first child should enter facility when
Contractions are regular and every 5 minutes for an hour
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Women having 2nd or later child should enter facility when
Contractions are 10 min apart for 1 hr
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Leopoldo maneuver
Determine fetal line and presentation.
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A 15 beat fetal heart rate increase that lasts 15-20 seconds indicates
Good oxygenation to fetus
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Mild fundus contractions.
Feels like tip of nose
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Moderate fundus contractions
Feels like a chin
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Strong fundus contraction
Feels like forehead
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S/s of hyperventilating
Blurred vision, numbness, and tingling of hands and mouth.
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Normal fetal heart rate
110-160
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Disadvantage of epidural
Maternal Hypotension, bladder distention, epidural migration, n/v, pruritus, delayed resp depression.
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Epidural contraindicated with
Low platelet count
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Naloxone (narcan)
Reverses narcotic- induced resp depression.
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To prevent side effects of intrathecal block
Have client lie flat on back for hours.
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Preterm birth
Birth before 37 weeks
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Tocolytic agents
Terbutaline (breathine) (causes maternal tachycardia) and magnesium sulfate (causes warm flushing) given to inhibit contractions.
*keep calcium gluconate beside for magnesium sulfate side effects
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Chorioamnioitis
Intrauterine infection
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Dystocia
Long, difficult or abnormal labor caused by any of the 5 ps
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General anesthesia
NPO 6 hours prior to prevent aspiration.
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Hypertonic uterine contractions
Frequent uncoordinated contractions with increased resting time usually during latent phase of labor
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Hypotonic uterine contractions
Also called uterine inertia, usually occurs during active stage. Contractions become weak and ineffective and may cease
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Macrosomic
Large baby size weighing more than 8.8 lbs.
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Cephalopelvic disproportion
When fetal head will not fit through mother’s pelvis
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Secretion of catecholamines inhibit
Uterine contractions
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Prolonged labor
When the active phase of first stage of labor lasts longer than 15 hours, the risk for fetal death increases.
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Precipitate labor
- Too late for pain meds
- Labor lasting less than 3 hrs from onset of contractions to the birth.
- Complications: loss of coping ability, increased risk for uterine rupture, lacerations to cervical, vagina, and perineum.
- Fetal complications: hypoxia, distress, cerebral trauma
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Precipitate labor tips
Breath with pt! No time to teach breathing. Walk them through it during contractions
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Precipitate birth
- Birth occurs suddenly and unexpectedly with md to help.
- Stay with pt and call for help
Crowning May occur.
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Prolapsed coed
- Umbilical cord lies below the presenting part of fetus.
- May occur at any time and may not be visible
- Pressure on cord needs to be relieved
- Position mother on her back with her head lower than the rest of the body. Left modified sims with pillows under hips or knee chest position.
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Amniotomy
- Artificial rupture of membranes.
- Uses hook
- Assess fhr for a full minute
- Assess amniotic fluids for color, odor, consistency and quantity.
- Fluid should be clear with mild odor.
- Report watery green or discolored amniotic fluids
- Meconium stained fluids =fetal distress
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Induction of labor
- Iv oxytocin at slow rate then increase slowly at regular intervals.
- Assess fhr and contractions, bp and pulse.
Augmentation- stimulations of uterine contractions after they start on their own
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C section
- Incision in abd and uterus
- Scheduled or unscheduled
- May be able to have vagina birth next time.
- Assess fundus post op. Firm and at umbilicus
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Assisted birth: forceps
- Used on fetal head
- Cervix must be dilates, membranes ruptured, position and station of fetal head must be known.
- Assess infant for facial asymmetry
- Newborn may have bruising or edema
- Mom may have lacerations or hematoma
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Assists birth: vaccum
- Risk: vaginal and recital lacerations
- Fetal risk: cephalobematoma, brachial plexus palsy, retinal and intracranial hemorrhage snd hyperbilirubinemia.
- Can cause an elevated dome over posterior fontanelle.
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Care of infant
- Airway suctioned
- Apgar score assessed at 1 and 5 minutes after birth
- Apgar score of less than 6/10= fetal distress
- Warmth- skin to skin w/parent. Stockinette cap. Radiant warmer.
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Care of mother
BP before and after oxytocic meds
Fundus= firm, grape fruit sized, around umbilicus
Clean and dry episiotomy
Vaginal pads
Mom and baby allow to bond.
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