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Lecture 6
Introduction
Uterus: pear-shaped muscle made of 3 layers:
Endometrium inner lining - shed during menses.
Myometrium - muscle layer middle
Perimetrium - outer layer -extra support to whole
structure.
THEORIES of LABOR:
Combination of factors start labor:
Oxytocin & prostaglandin - most important
biochemical factors in stimulating uterine
contractions.
Estrogen uterus response & progesterone it.
THEORIES:
STAGES of LABOR
4 in All !
First Stage
Onset of true labor to complete dilation = 10 cm.
~ 6-18 hrs. primapara; 2-10 hrs. multipara.
Cervix becomes more anterior.
Third Stage
Delivery of placenta ~ 5 - 30 min.
Separation should be automatic [uterus contracts & mom
bears down]
Dont palpate non-contracted uterus possible eversion.
Maternal vessels still open.
Antibiotics
Fourth Stage
Placenta out; mother recovers in LDR
Labor, delivery, & recovery
Lasts ~ 1 hr. unless complications arise.
Then pt. transferred to PP unit.
Monitor/document maternal VS q 1 - 4 hr
Assess
Breathing Techniques
Slow chest: 6-12 easy breaths/min. Used in early labor.
Combination: quicker, lighter breaths
Used during active labor; one slow breath in beginning &
quicker breaths to follow.
Pant-Blow: 3 - 4 quick breaths, with forceful exhalation.
Used @ end of 1st stage when contx.s strongest.
Elimination
Monitor UO q 2-4 hr.
Pressure of fetal head reduces bladder tone.
Full bladder > inhibits labor.
Catheterize. Remove > delivery.
Hydration
IV to hydrate; pt. diaphoretic & NPO x ice chips.
Lactated ringers; good volume expander.
Passenger: [infant]
Fetal head: widest part of body; most difficult to pass
thru vaginal canal; passage depends on bones, sutures,
fontanelles.
Cranium - 8 bones meet @ suture lines
Cranial bones move & overlap, allows skull to pass thru
birth canal.
Fontanelles: soft spaces created by junctures of suture
lines - covered by membranes; compress during delivery
to aid in passage of fetus.
Molding of infant head.
Passenger cont.
Skull widest @ antero-posterior diameter [front
to back] than @ transverse diameter [across].
Antero-posterior diameter measures differently
@ different locations.
Friedmans Curve
Passageway:
Refers to fetus passing thru uterus, cervix, vaginal
canal. Single most important determinant to mechanism
of labor.
A. 4 Types of pelvis:
4.
PELVIC INLET:
Antero-posterior diameter - front to back ~ 12.5
cm. (diagonal conjugate)
Powers:
Uterine contxs: primary force moving fetus thru
maternal pelvis during 1st stage of labor.
Maternal Efforts: woman adds voluntary pushing
force to force of contx.s during 2nd stage of
labor to propel fetus thru pelvis.
Psyche:
Psychologic Response to birth process:
Prepared for childbirth - Childbirth classes-Prenatal care.
Previous childbirth experience - Complicated?
Support from significant other - Separated? Marital
strain? FOB involved? Abuse?
Emotional status - anxious/depressed, drug use, psych
hx
Culture - background may influence response to pain.
Some moan, some stoic, some verbally expressive.
Fear/anxiety exacerbate pain uterine dysfunction &
ineffectual labor & posttraumatic stress disorder
Maternal/Fetal Evaluation
During Labor
With Electronic
External/Internal
Monitoring
3 Phases of UC:
a. increment
b. acme [peak]
c. decrement
As contractions intensify, labor progresses.
Vaginal Exam - dilation, effacement, station, &
presentation.
Assessment:
Intermittent - 20 minute tracing standard.
Continuous - for active labor or with complications.
Duration: beg. of contx. to end of same contx.
Lasts ~ 30 sec. [early] to ~ 60 sec. [active].
Frequency: beg. of one contx. to beg. of next.
~ q 5 -30 min. early labor; q 2-3 min. active labor.
Resting Tone: period of uterine rest bet. contx.s.
Measure by palpation; internally measures ~10 mmHg.
Internal Monitoring
More Accurate !
Fetal scalp electrode: wire electrode attached to scalp of
fetus -monitors FHR accurately & continuously.
Advantages: precise assessment of FHR; not affected by
fetal movement.
Disadvantages: lacerations of fetal scalp, mom cant
ambulate.
Nursing Interventions:
* accoustic stimulation to wake fetus
* Narcan
* Amnioinfusion - decreases cord comp; dilutes mec.
* Left/right lateral position or knee-chest; notify MD;
fetal scalp pH, possible emergency C/S; IVF, O2
Flat tracing or minimal aka non-reactive tracing
[pencil mark pattern] indicates fetal distress; must be
corrected or delivered ASAP. Experienced RN usually able
to determine reason for non-reactive tracing.
Nursing Interventions:
-Left lateral position takes pressure
off aorta & vena cava; circulation to
uterus.
- IV flow rate Circulation
oxygen - face mask [5liters/min].
D/C pitocin & document
assist with fetal blood sampling
[measures acidosis in fetus which
signifies hypoxia]
Prepare for emergency C/S if decels.
persist
Nursing Interventions
emotional support
physical support touch, massage
reduce anxiety
bonding with newborn as a couple
Obstetrical Procedures
Types:
Contraindications:
Nursing Interventions:
IVF 10 units Pitocin in 1000 ml. RL
Start rate @ 1 milliunit/min - pump
Gradually to establish effective contx. pattern
Monitor UC for frequency, rate, intensity
Monitor FHR for signs of fetal distress
Maternal BP, pulse, temp
I&O
Notify MD of progress
Chart q 15 min on graph
Prepare for delivery: radiant warmer, O2, suctioning,
Hyper-stimulation of uterus; shut off pitocin as per MD.
1-2
40-50
-2
3-4
60-70
-1, 0
>5
>80
+1, +2
medium
mid
soft
anterior