Mod 2 Maternity and Peds Chapter 13

• uterine stretch
• progesterone withdrawal
• increased oxytocin sensitivity
• increased release of protaglandins

in last trimester, estrogen levels increase and progesterone levels decrease; this leads to increase in myometrium gap junctions; gap junctions are proteins that connect cell membranes and facilitate the coordiantion of uterine contractions and myometrial stretching

increase in estrogen

in the decidua and fetal membranes

• Cervical changes
• Lightening
• Increased Energy Level
• Bloody show
• Braxtion Hicks contractions
• Spontaneous Rupture of Membranes

1 month to 1 hour before labor begins

from an elongated structure to a shortened, thinned segment

when the fetal presenting part begins to descend into the maternal pelvis

• primiparas- 2 weeks or more before labor begins
• multiparas- may not occur until labor

increase energy level 24 to 48 hours before onset of labor and is a result of an increase in epinephrine release caused by a decrease in progesterone

the mucous plug that fills the cervical canal dureing pregnancy that is expelled as a result of cervical softening and increased pressure of the presenting part

• braxton hicks occur primarily in the abdomen and groin and gradually spread downward before relaxing; they are irregular and can be decreased by walking, voiding, eating, increasing fluid intake or changing position; they usualy last about 30 seconds and can last up to 2 mins
• Real contractions occur in the lower back and are regular and are not decreased by any activity.

late preterm

• barrier to infection is gone and an ascending infection possible
• danger of cord prolapse if engagement has not occured with sudden release of fluid and pressure with rupture.
• notify healthcare provider immediately

cervical dilation and effacement

• braxton hicks
• false labor
• prodromal labor

The five P's

• Passageway (birth canal)
• Passenger (fetus and placenta)
• Powers (contractions)
• Postion (maternal)
• Psychological Responses

The 5 additional P's

• Philosopy (low tech , high touch)
• Partners (support caregivers)
• Patience ( natural timing)
• Patient preparation (childbirth knowledge base)
• Pain Control ( comfort measures)

Hormones relaxin and estrogen cause the connective tissue to become more relaxed and elastic and cause the joints to become more flexible

the true pelvis

the inlet, the mid-pelvis, and the outlet

the fetus' chest is compressed causing lung fluid and mucus to be expelled and removes the space occupying fluid so that air can enter the lungs wth the newborn's first breath

Pelvic oulet

• gynecoid
• anthropoid
• android
• platypelloid

Gynecoid pelvis

anthropoid pelvis

android pelvic

Platypelloid or flat pelvis

• cervix
• pelvic floor muscles
• vagina

the cervix effaces (thins) and dilates (opens) to allow the presenting fetal part to descend into the vagina.

degree of body flexion

relationship of body parts

first body part

the elongated shape as a result of overlapping cranial bones; happens as the fetus passes through the pelvis

when fluid collects under the scalp

when blood collects beneath the scalp

anterior fontanelle

anterior fontanelle

Posterior fontanelle

• suboccipitobregmatic (approximately 9.5 cm at term)
• biparietal (approximately 9.25 cm at term )

flexed position in which the chin is resting on the chest

all joints flexed ---back rounded, chin on chest, thighs flexed on abdomen, legs flexed at knees

• longitudinal (which is the most common)
• transverse

when the spine of fetus is parallet to that of mother

• when spine of fetus is perpendicular to the spine of mother
• fetus cannot be delivered vaginally

• cephalic (head first)
• breech (pelvis first)
• shoulder (scapular first)

• vertex presentation
• military presentation
• brow presentations
• face presentation

• fetus skull becoming hung up as it passes through last
• the umbilical cord can become compressed between the fetal skull and the maternal pelvis after the fetal chest is born
• possible trauma to head as a result of the lack of opportunity for molding

• frank breech (buttocks present first with both legs extended up toward the face) (50-70%)
• full or complete breech (the fetus sits crossed-legged above the cervix) (5-10%)
• footling or incomplete breech (one or both legs are presenting) (10-30 %)

• prematurity
• placenta previa
• multiparity
• uterine abnormalities (fibroids)
• congenital anomalies such as hydocephaly

the relationship of a given point on the presenting part of the fetus to a designated point on the maternal pelvis

• occipital bone (O) (vertex presetation)
• chin (mentum {M}) (face presentation)
• buttocks (sacrum{S}) (breech presentation)
• scapula (acromion process {A}) (shoulder presentation)

• Right and left anterior
• right and left posterior

• first letter - R or L for whether tilted to right or left
• second letter- particular presenting part of fetus (O, S, M, A, or D)
• third letter- defines the location of the presenting part in relation to anterior (A) or posterior (P) or transverse(T)

• Left occipitoanterior
• Right occipitoanterior

station refers to relationship of the presenting part to level of the maternal pelvic ischial spines; it is measured in centimeters and is referred to as a minus or plus, depending on it location above or below the the ischial spine; minus is above and plus is below; plus being closer to birth

signifies the entrance of the largest diameter of the fetal presenting part ( usually the fetal head) into the smallest diamter of the maternal pelvis; fetus is said to be engaged when the presenting part reaches 0 station.

when engagement has not occurred because the presenting part is freely movable above the pelvic inlet

• Engagement ( presenting part passes through the pelvic inlet)
• descent (downward movement of the fetal head until it is within the pelvic inlet)
• flexion ( vertex meets resistance from the cervix, the walls of the pelvis, or the pelvic floor.)
• internal rotation ( resistance from one side of the pelvic floor causes head to rotate 45 degrees anteriorly to midline under the symphysis)
• extension (the nucha (the base of the occiput) becomes impinged under the symphysis and causes head to extend to pass under pubic arch)
• external rotation ( after head is born , it goes back to original position)
• expulsion ( passage of the rest of the body is easier)

• increment (build up of the contraction)
• acme (peak or highest intensity)
• decrement (descent or relaxation of the uterine muscle fibers)

• frequency ( how often occur and measured from the increment of one contraction to the increment of the next)
• duration ( how long it lasts and is measured from beginning of the increment to the end of decrement for same contraction)
• intensity (strength of contraction dtermined by manual palpation or measured by an internal intrauterine catheter (IUPC); measures pressure of amniotic fluid inside the iterus in millimeters of mercury)
• intensity

trained female support person for a woman during the birthing process

• reduce rate of cesarean births among low risk women having their fist child to 15% of live births, from a baseline of 18 %
• reduce rate of cesarean births among women who have had a prior cesarean birth to 63% of live births from a baseline of 72%

artificial rupture of the fetal membranes and can be done when the fetal head is at -2 station or lower with cervix dilated to at least 3 cm

oxytocin (Pitocin)

• spontaneous rupture of membranes and labor does not start
• pregnancy more than 42 weeks' gestation
• maternal hypertension
• diabetes
• lung disease
• uterine infection

• Heart rate increases by 10 to 20 bpm
• cardiac output increases by 10-15% in first stage and 30-50% in second stage of labor
• blood pressure increases by 10-30 mm Hg during contractions
• white blood cell count increases to 25,000 to 30,000 cells/mm3
• resp rate increases; more O2 consumed; increase in metabolism
• gastric motility and food absorption decrease ; increase risk of nausea and vomiting with aspiration
• temp rises slightly
• muscular aches/cramps
• basal metabolic rate increases and blood glucose levels decrease because of stress of labor

• periodic fetal heart rate accelerations and slight decellerations related to fetal movement, fundal pressure, and uterine contraction
• decrease in circulation and perfusion to fetus secondary to uterine contractions
• increase in arterial babon dioxide pressure (PCO2)
• decrease in fetal breathing movements throughout labor
• decrease in fetal O2 pressure with a decrease in the partial presure of O2

• dilation
• expulsive
• placental
• restorative

• latent or early phase
• active phase
• transition phase

• cervix dilates from 0 to 3 cm
• contractions occur every 5 to 10 min and last 30 to 45 seconds; described as mild by palpation
• effacement of cervix is from 0 to 40%
• for mulliparous women this phase lasts about 9 hours and for multiparous women it lasts about 6 hours

• cervix usually dilated from 4 to 7 cm
• 40-80% effacement takes place
• this phase can last up to 6 hours for nulliparous and 4.5 hours for multiparous women
• contractions every 2-5 minutes and last 45 to 60 seconds
• moderate to strong contractions by palpation
• dilation rate for nulliparous is 1.2 cm/hour and multiparous women is 1.5 cm/hour

• dilation slows moving from 8 to 10 cm
• effacement from 80 to 100%
• shortest and most difficult phase
• lasts about 1 hour in first birth and about 15 to 30 min in successive births
• contraction stronger, more painful, more frequent ( 1 to 2 min) lasting 60 to 90 seconds
• ave rate of fetal descent is 1 cm/hour in nulliparous and 2 cm/hour in multiparous women
• strong desire to push
• should not last longer than 3 hours for nulliparas and 1 hour for multiparas

• begins with cervical dialtion of 10 cm
• and effacement and ends with the birth of newborn
• contractions every 2-3 min lasting 60-90 seconds
• approx 1 hour for nullipara and half that for multipara

• pelvic phase - fetal head is negotiating the pelvis, rotating and advancing in descent
• perineal phase - fetal head is lower in the pelvis and is distending the perineum (this is when there is a strong urge to push)

begins with the birth of the newborn and ends with separation and birth of the placenta

Two phases

• placental separation
• placental expulsion

• the uterus rises upward
• the umbilibal cord lengthens
• sudden trickle of blood is released from the vaginal opening
• the uterus changes its shape to globular

• the fetal side first ( shiny gray side) (called Schult's mechanism or "shiny schultz's")
• maternal side (red raw side) (called Duncan's mechanism or "dirty Duncan")

to facilitate the firming of uterus so that uterine blood vessels constrict, which minimizes the possibility of hemorrhage.

• vaginal- 500 ml
• Cerarean - 1000 ml

• begins with completion of the expulsion of the placenta and membranes and ends with the initial physiologic adjustment and stabilization of the mother (1-4 hours after birth)
• initiates postpartum period

vaginal discharge that is red, mixed with small clots, and moderate flow

• to prevent hemorrhage
• bladder distention
• venous thrombosis

every 15 min for at least 1 hour