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critical factors in labor (5 p's)
- passage
- passenger
- presenting part
- physiologic forces of labor
- psychosocial considerations
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three sections of the pelvis
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four types of pelvis
- gynecoid
- android
- anthropoid
- platypelloid
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anthropoid pelvis
oval, long A-P of inlet, shortened transverse, favorable for vaginal birth
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android pelvis
male; heart shaped, all med-pelvic diameters reduced, reduced outlet
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platypelloid pelvis
flat, short A-P and transverse diameters; mid-pelvic transverse diameter only normal one
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gynecoid pelvis
normal female; round; favorable for vaginal birth
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factors affection the passenger
- fetal head
- fetal attitude
- fetal lie
- fetal presentation (presenting part)
- fetal position
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types of fetal head sutures (passenger)
- frontal
- sagittal
- coronal
- lambdoidal
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frontal suture
between the two frontal bones
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sagittal suture
between the two parietal bones
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coronal suture
between the frontal and parietal bones
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lambdoidal suture
between the two parietal and occipital bones
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fetal attitude
- def
- normal
- deviations cause?
- relationship of fetal parts to each other
- flexion of the head
- difficulties to labor and delivery process
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fetal lie
- def
- normal is?
- transverse is?
relationship of the cepalocaudal axis (spine: head to toe) of fetus to that of the mother
longitudinal
fetal spine at right angles to mother's (results in a shoulder presentation)
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presentation
- def
- types
- cephalic (head, vertex, brow, face)
- breech (complete, footling or incomplete)
- shoulder (transverse lie)
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relationship of maternal pelvis and presenting part (2)
-
egagement
- def
- floating
- dipping
occurs when the largest diameter of presenting part reaches or passes through pelvic inlet
balottable: freely moveable above pelvic inlet
begins descent into pelvis
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station
presenting part in relationship to ischial spines; at spines = zero
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position
- def
- charting notations used
refers to the relationship of the landmark on the presenting part to the anterior/posterior (rt. or lft. sides) of maternal pelvis
right, left, landmark and anterior and posterior (Ex. ROA - right, occiput, anterior)
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physiologic forces of labor
- primary
- secondary
involuntary: uterine muscle contractions that cause cervial change during first stage of labor
voluntary: use of abdominal muscles to push during second stage of labor
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normal FHT baseline
110-160 bpm
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FHT variability
- def.
- important in?
fluctuations of 2 cycles per minute or greater in the FHR and it is classified by the visually quantified amplitued of peak-to-trough in beast per minute
indicator of fetal well-being
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when assessing the FHT determine
- baseline (FHR during a 10 min pd round to 5bpm)
- variability
- if there are peridoic changes (associated with uterine ctx's) or episodic changes (not associated with ctx's)
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phases of contractions
- increment - building up
- acme - peak
- decrement - letting up
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contractions:
frequency -
duration -
intensity -
- beginning of one ctx to the beginning of the next ctx
- beginning to end of one ctx
- mild, moderate, strong
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theories of labor
- uterine overdistension
- placental aging - declining estrogen/progesterone levels
- increased production and senstivity to prostaglandins and oxytocin
- increase in corticotropin - releasing hormone
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two portions of uterus in labor
upper segment - fundus (contracticle portion becomes thicker and shorter)
lower segment - lower part of uterus and the cervix (non-contractile, passive, expands and thins)
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cervial labor changes
- effacement
- dilation
- bloody show
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effacement
thinning, drawing up of internal os and cervial canal into the uterine walls
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dilation
widening of os; caused by fetal axis and hydrostatic pressure as uterine longitudinal fibers are pulled over by the presenting part
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S&S of labor (premonitory signs)
- braxton hicks contractions
- lightening
- cervical changes
- energy burst/nesting behaviors
- joint/back aches and pain; wt loss; GI upset
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signs of true labor
- reg CTX; increasing frequency, duration and intensity shortening intervals
- discomfort, usually from back to abdomen; increases with ambulation
- progressive dilation and effacement
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false signs of labor
- irreg CTX; usually no change in intesity; lower abdominal pain
- discomfort usually no change with walking
- no change in dilation and effacement
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stages of labor
- first
- second
- third
- fourth
- beginning of true labor until full dilation
- begins with full dilation until delivery of baby
- after delivery of baby until expulsion of baby
- 1-4 hrs after expulsion of placenta
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first stage of labor
- work to be accomplished
- forces
- phases (3)
- effacement and dilation of cervix
- uterine ctx
- latent - 0-4cm; active - 4-8cm; transition - 8-10cm
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latent phase
- duration
- ctx
- show
- behavior
- avg is 5.3-8.6 hrs not to exceed 14-20 hrs
- irreg; mild-mod; 3-30 min apart lasting 20-40 secs and 25-50mm Hg
- clear plug to brownish/pink
- excitement signpost; alert, follows directions, talkative, apprehensive
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active phase
- duration
- ctx
- show
- behavior
- varies; should dilate 1.2-1.5cm/hr (2.4-4.6 hrs)
- reg; mod-strong; 2-5 min apart; lasting40-60sec and 50-70mmHg
- pink to bloody mucus
- serious signpost; inner-focused; experiences pain/fatigue; desires companionship/support
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transition phase
- duration
- ctx
- show
- behavior
- 1-2 hrs (3hrs if epidural in place
- strong-very strong; 1.5-2 min apart, lasting 60-90 sec and 70-100mmHg
- increase in bloody mucus
- self-doubt signpost; chaotic, difficulty focusing, irritable, N&V
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second stage of labor
- work
- forces
- duration
- ctx
- station
- show
- discomfort
- behaviors
- expulsion of fetus
- CTX + bearing down efforts
- 15 min-2hrs
- strong; may be decreased intesity and frequency
- crowning
- same or increase in amt
- strong urge to push if no regional anesthesia; may feel "tearing/ripping apart" sensation
- intense concentration: may doze between CTX; may express relief that end is near; if prolonged; increase fatige and anxiety; decreased coping
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bearing down methods
- valsalva
- open-glottis
- hold breath and push as long and hard as possible during the ctx
- exhale gently while pushing with ctx
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pushing positions
in order to restrain pushing
- side
- squatting
- lithotomy
- standing
- side-lying
- pant-blow breathing
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positional changes of fetus (cardinal movements)
- descent
- flexion
- internal rotation
- extension
- restitution
- external rotation
- expulsion
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descent
head engages and proceeds down birth canal
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flexion
head flexed to the chest as it meets resistance from soft tissues of pelvis
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internal rotation
- occiput of fetal head
- occipant
meets resistance from levator ani muscles
rotates to bring the back of neck under symphysis
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extension
back of neck pivots under symphysis
to negotiate pelvic curve; head must change from flexion to extension and ehad is born
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restitution
head returns to normal alignment with the shoulders, presents smallest diameter of shoulders to outlet
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external rotation
shoulders rotate to the anteroposterior position in the pelvis, head is turned farther to one side
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expulsion
after shoulders born; rest of the body delivers quickly
birth of neonate is complete
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third stage of labor
- work
- forces
- duration
- discomfort
- behaviors
- expulsion of placenta (separation and expulsion)
- uterine CTX and pushing
- 5-30 min
- slight cramping
- excited; relieved; may cry; usually very tired
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signs of placental separation
- globular-shaped uterus
- rise of fundus in abdomen
- sudden gush or trickle of blood
- lengthening of umbilical cord
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placental expulsion
- shiny shultz
- dirty duncan
- retained placenta
fetal side presents; separates from inside to outer margins
maternal side presents; separates from outer margins inward
if third stage is >30 min
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maternal cardiovascular adaptations
- cardiac output
- CV system stressed by many factors:
increases steadily throughout labor (31% increase in CO)
- contractions - bearing down (pushing)
- pain - apprehension, fear
- position - side-lying, supine
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During bearing-down efforts using valsalva maneuver:
- intrathoracic pressure _________?
- venous return is ________; venous pressure is _______
- transient rise in ____ and decrease in _____
- continued diminished venous return causes decreases in ____ and ____
- rises
- reduced; increased
- CO; pulse
- BP and CO
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what reverses effects of valsava maneuver?
when breath is taken
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repeated valslva may result in?
inadequate O2 exchange and fetal hypoxia
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BP __________ and HR _________ during CTX; HR may _________ by second stage
increases; decreases; increase
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Maternal pulmonary adaptations:
- first stage
- second stage
- significant changes can?
- changes reversed in ________ stage
- hyperventilation (res alkalosis)
- breath-holding (resp acidosis)
- be harmful to fetus
- fourth
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Maternal Renal adaptations:
- renin and angiotensinogen _________
- slight ___________
- polyuria d/t increased ____ and ____
- bladder pushed forward and up becomes _________
- increase
- protenuria not uncommon
- CO and GFR
- edematous
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Other Maternal adaptations
- GI - gastric motility and food absorption _________; prolonged __________
- Hematologic - WBC's and clotting factors ___________
- Glucose - levels ________ which lead to _______ in insulin requirements
- decrease; emptying time
- increase
- decrease; decrease
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Fetal Oxygenation depends on
- normal maternal blood flow and O2 sat
- adequate gas exchange in the placenta
- open circulatory pathway in umbilical cord
- normal fetal cirulatory and O2 carrying functions
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Fetal oxygenation may be compromised by
- maternal cardio-pulmonary alterations
- uterine activity
- placental alterations
- interruptions in cord blood flow
- fetal alterations
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psychological factors to stages of labor
- motivation for pregnancy
- attitudes and expectations
- self-esteem
- response to pain and stress
- usual coping mechanisms
- support systems
- trust in care-providers
- psychological prep for birth
- cultural influences
- negative attitudes
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