DEFINITION: RELATED DIAGNOSTIC TESTS:

The relationship between the measurements of the fetal head and the diameters Ultrasound of fetus to determine presentation and lie.
of the maternal pelvis. Manual exam before labor
CT scan with estimated weight of fetus.

ETIOLOGY: MEDICAL MANAGEMENT:

The birth passage includes the maternal bony pelvis, beginning at the
pelvic inlet and ending at the pelvic outlet. A narrowed diameter in
these areas can result in CPD if the fetus is larger than the pelvic
diameters.
The adequacy of the maternal pelvis for a vaginal birth should be assessed both
during and before labor. During the intrapartal assessment, the size of the fetus
and its presentation, position, and lie must also be considered.
Frequent assessments of cervical dilation and fetal descent are made.
If progress ceases, the decision for a cesarean birth is made.

PATHOPHYSIOLOGY: NURSING MANAGEMENT:

Labor is prolonged in the presence of CPD. Membrane rupture can result from
the force of the unequally distributed contractions being exerted on the fetal
membranes.
In obstructed labor, in which the fetus cannot descend, uterine rupture can
occur. With delayed descent, necrosis of maternal soft tissues can result form
pressure exerted by the fetal head. Eventually, necrosis can cause fistulas from
the vagina to other nearby structures. Difficult, forceps-assisted births can also
result in damage to maternal soft tissue.
Vitals q4hrs or as ordered by doctor.
Monitor both contractions and fetus continuously.
Any signs of fetal distress are reported to the CNM or MD immediately
Position mother in ways to increase the pelvic diameters.
Sitting or squatting increases the outlet diameters and may aid in fetal descent.
Monitor fetus for signs of hypoxia take appropriate actions if necessary.
Monitor mother and fetus for any signs of distress.
Monitor contractions and EFM or IFM, report any unusual findings.

SIGNS & SYMPTOMS: HEALTH DEVIATION SELF-CARE REQUISITES:

*Prolonged labor
*Cervical dilation and effacement are slow
*Engagement of the presenting part is delayed
*Adequacy of the maternal pelvis small for size of fetus
Encourage pt to assume a position that will add in the descent of fetus.
Provide support to client and family members in coping with the stress of a
complicated labor.
Encourage pt to drink clear fluids to maintain hydration.
Encourage pt to take cleansing breaths in-between contractions to promote
adequate oxygen exchange for her and baby.

REFERENCE PAGES:
Contemporary Maternal-Newborn Nursing Care, Ladewig, London, Moberly,
Olds
Pgs 488, 489

Tabors Medical Dictionary, Davis, pg 37

Causes of Cephalopelvic Disproportion (CPD):

Increased Fetal Weight:

Very large baby due to hereditary reasons - a baby whose weight is estimated to be above 5 Kgs or 10 pounds .
Postmature baby - when the pregnancy goes above 42 weeks.
Babies of women with diabetes usually tend to be big.
Babies of mothers who have had a number of children - each succeeding baby tends to be larger and heavier.
Fetal Position:
Occipito-posterior position - In this position the fetus faces the mothers abdomen instead of her back.
Brow presentation
Face presentation.
Problems with the Pelvis:
Small pelvis.
Abnormal shape of the pelvis due to diseases like rickets, osteomalacia or tuberculosis.
Abnormal shape due to previous accidents.
Tumors of the bones.
Childhood poliomyelitis affecting the shape of the hips.
Congenital dislocation of the hips.
Congenital deformity of the sacrum or coccyx.
Problems with the Genital tract:
Tumors like fibroids obstructing the birth passage.
Congenital rigidity of the cervix.
Scarring of the cervix due to previous operations like conisation.
Congenital vaginal septum.

Summary
A preoccupation with cephalopelvic disproportion is the main reason for a reluctance to abandon the conservative attitude towards labour which prevails in the
United Kingdom and Ireland. In a series of 1000 consecutive primigravidae, in which an active approach to labour was adopted, the incidence of disproportion was
less than 1 per cent and there was notable absence of trauma, especially to the child.

Oxytocin stimulation is recommended as an essential instrument to define disproportion when the natural forces are not adequate. Excessive caution is criticized
because a diagnosis of disproportion cannot be made unless uterine action is adequate. It is concluded that the possibility of cephalopelvic disproportion does not
justify a passive attitude towards labour in a modern maternity unit.

First Stage of Labor

 Begins at the onset of labor and ends when the cervix is 100 percent effaced and completely dilated to 10 centimeters.

 Average length ranges for a first-time mother is from ten-to-fourteen hours and shorter for subsequent births.

 Read more in our Health Libarary

  The first stage of labor
 Cerival Effacement and Dilation
 Illustration of Cervical Effacement

Second Stage of Labor

 Begins when the cervix is completely effaced and dilated and ends with the birth of the baby.

 Average length for a first time mother ranges from 1 to-2 hours and shorter for subsequent births.

 Read more in our Health Library

 The second stage of labor

Third Stage of Labor

 Begins with the birth of the baby and ends with the delivery of the placenta.

 Average length for all vaginal deliveries ranges from five-to-fifteen minutes.

Fourth Stage of Labor

 Begins with delivery of the placenta and ends one-to-two hours after delivery.

Amniotomy
surgical rupture of the fetal membranes.
PATIENT CARE. Amniotomy results in drainage of the amniotic fluid and thus hastens labor by allowing the head to fit more
snugly into the dilating cervix. There is little or no discomfort accompanying the procedure; the patient will require only an
explanation of what is to be done, and proper draping and cleansing of the perineum. After amniotomy the expelled fluid is
carefully observed for color. A yellow or green color indicates fetal distress. The fetal heart rate is monitored for signs of fetal
distress because amniotomy increases the risk of a prolapsed cord.

What is Amniotomy?

Amniotomy is the official term for artificially breaking the bag of waters during labor. It is believed that breaking the bag
of waters will help to speed up an otherwise slow labor. Amniotomy is part of the Active Management of Labor practiced
in some hospitals.
Amniotomy is performed by a midwife or doctor. A long, thin instrument with a hook on the end is inserted into the
vagina and through the cervix so it can catch and rip the bag of waters. To perform an amniotomy, the cervix must be
dilated enough to allow the instrument through the cervix, generally at least a two.

Why choose Amniotomy?

Unlike other medical methods of starting labor, amniotomy does not add synthetic hormones to your labor. Instead it
seems to stimulate your body's own labor process.

Amniotomy allows the use of an internal electronic fetal monitor.

How effective is Amniotomy?

Amniotomy alone is unpredictable, it may take hours for labor to start with amniotomy. Because amniotomy increases the
risk for infection, most caregivers use amniotomy in combination with synthetic oxytocin. Birth does happen faster when
amniotomy is combined with synthetic oxytocin than when amniotomy is used alone.

Risks of Amniotomy

Risks for Mother

 Increases the risk for infection. This risk is increased with length of time the waters are broken and with vaginal
exams.

 Because of the infection risk, a time limit is given by which the mother must give birth. As the time limit approaches
attempts to progress labor will become more aggressive.

 The fore waters equalize pressure on the cervix so it will open uniformly. When they are broken, the mother
increases her chances of having uneven dilation.

Risks for Baby

  Increases the risk of umbilical cord compression.

 The fore waters equalize pressure on the baby's head as it presses against the cervix. When they are broken, the
pressure on the baby's head may be uneven causing swelling in some parts.

Enema Recipe:

8 oz.Vegetable Glycerin
32 oz. of warm filtered water
mix together in a container
Or you can use an 8 oz. bulb syringe with the glycerin in it and inject contents into the rectum.  Then take a warm water enema as per
below

Temperature 103° Fahrenheit

Directions:

Add solution to enema bag, mixing with warm filtered water to achieve the required amount of solution.
Hang enema bag about 18 in. to 3 ft. above rectum. A good tool for this is the IV Stand for Enemas
If you need good flow control for the enema solution.  A ramp clamp is a good option.

The Knee-chest position with chest against floor and rectum higher than head this is a best position to receive an enema.
Insert nozzle/rectal tube tip into anus, using a good lubricant (Super Salve  Surgilube  Vaseline 13oz.   Astroglide 
 KY Warming Liquid Lubricant) as needed. using a good lubricant will help prevent injury to the delicate anal tissues.

Inject solution into rectum slowly, approximately one cup per minute (8oz.) and take as much as possible , you can refill bag if
needed. 
Try to slightly distend the colon or until it becomes very uncomfortable to take any more solution.

  Massaging abdomen in counter-clockwise direction during the injection will distribute the solution throughout the colon.
When the enema bag is empty or no more fluid can be taken remove nozzle/rectal tube.  
For those that have trouble retaining the nozzle and or the solution.
  You might want to try a retention nozzle  during the administration of the enema.

 Some people use a retention plug after they received their enema solution and removed the nozzle to retain their enema for the desired
amount of time. You can also fold a washcloth and press it tightly against the anus.

Retain the solution for several minutes as, this will allow the enema to do its job.

Then you can move to the toilet and release the enema.

When having a normal bowel movement or releasing an enema:

When expelling the enema:
Massage abdomen in a clockwise direction .
From the cecum up towards the transverse colon across to the descending colon and down towards the anus.

Massaging the abdomen while expelling the enema helps move the enema solution , gas and feces toward the rectum and out the anus.
The best position for expelling your enema is squatting over the toilet not sitting on it. The squatting position puts pressure on your
abdomen from your thighs.

In many countries, toilets are made so that people squat when they move their bowels. The Welles Step positions your body so that you
are squatting when you sit on the toilet. Squatting,  supports the abdominal wall and the bowel as we bear down, brings about an easier
bowel evacuation in this way.
People who use the Welles Step tend to have fewer hemorrhoids, hernias, anal fissures, varicose veins and almost never have to use
laxatives. 
It slides under the toilet when not in use.

Demerol
Meperidine hydrochloride is a narcotic analgesic with multiple actions qualitatively similar to those of morphine; the most
prominent of these involve the central nervous system and organs composed of smooth muscle. The principal actions of
therapeutic value are analgesia and sedation.

CLASSIFICATION

Cephalosporin antibiotic

ALTERNATE NAME

ZINACEF

 INDICATIONS

 prevention or treatment of systemic infections caused by susceptible strains of micro-organisms

 RECONSTITUTION AND STABILITY

 powder stable at room temperature

 IM
o reconstitute 750 mg vial with 3.0 mL sterile water for injection to yield a 220 mg/mL solution
 IV
o reconstitute 750 mg vial with 8.0 mL sterile water for injection to yield a 90 mg/mL solution
o reconstitute 1500 mg vial with 16 mL sterile water for injection to yield a 90 mg/mL solution
  reconstituted solutions should be stored in the refrigerator; discard after 24 hours

 COMPATIBILITY

 compatible with most commonly used IV solutions

 compatible via Y-site with acyclovir, ceftazidime, clindamycin, cyclosporine, furosemide, gentamicin, heparin, meperidine, metronidazole, morphine, multivitamins,
ondansetron, potassium chloride
 do not mix with other drugs in the same container

prophylaxis - the prevention of disease

What is epidural anesthesia?

Epidural anesthesia is regional anesthesia that blocks pain in a particular region of the body. The goal of an epidural is to
provide analgesia, or pain relief, rather than complete anesthesia, which is total lack of feeling. Epidurals block the nerve
impulses from the lower spinal segments resulting in decreased sensation in the lower half of the body. Epidural medications
fall into a class of drugs called local anesthetics, such as bupivacaine, chloroprocaine, or lidocaine. They are often delivered
in combination with opioids or narcotics, such asfentanyl and sufentanil, to decrease the required dose of local anesthetic.
This way pain relief is achieved with minimal effects. These medications may be used in combination with epinephrine,
fentanyl, morphine, or clonidine to prolong the epidural’s effect or stabilize the mother’s blood pressure.

Low Transverse C-Section 

In a low transverse C-section (LTCS), the doctor cuts through the lower uterine segment of the uterus, which typically doesn't involve the
same tissue as a classical C-section. This region of the uterus has less muscular fiber, and is less easy to tear or rupture with future
labors.

There are still risks with a LTCS, but they seem to be fewer in nature. The uterine scar will tear less easily, as we already suggested. However, even
though many women can deliver subsequent babies vaginally after this procedure, many doctors still advise going the C-section route with subsequent
babies, just to be on the safe side.