6-28-2009

Labor & Delivery

~ Clinical Rotation Quiz ~

1. Discuss the four stages of labor and what happens in each

stage. Define primigravida and multigravida and state how
the stages are different for each.

Labor occurs in four stages, and may occur quicker in multigravida than in the
woman who is primigravida. Primigravida women have only been pregnant
one time; Multigravida women have been pregnant more than one time. The
first stage of labor is the longest stage for both the multi and primigravida
woman averaging 8 - 10 hours. This stage of labor begins with the onset of
true labor and ends with the complete effacement and dilation of the cervix.
The first stage is divided into 3 phases; latent, active and transitioning
phases. The latent phase of labor is the first 3 cm of dilation of the cervix. This
phase can be quite long, and may also be painless resulting in the woman not
even realizing much of this phase. Changes thatthat occur during this phase
include: fetal positioning changes, cervical effacement, dilation of up to 3 cm,
and contractions that gradually increase in intensity, duration, and frequency,
the contractions become about 5 minutes apart. Woman may have mild
discomfort or pain during this phase, most often felt as low back-ache, or
moderate intensity menstrual-like cramps. The laboring woman during this
phase is usually quite excited, sociable, and cooperative, she is also anxious
about the birth of her baby. The second phase of labor known as the Active
phase is where the cervix dilates at a more rapid rate from 4 cm to 7 cm. This
phase usually lasts on average 4.6 hours for the nullipara woman, and 2.4
hours for the multipara woman. The cervix becomes completely effaced, and
the fetus has begun to descend into the pelvis. Contractions have become
stronger, and are about 40 - 60 seconds in duration, they are also much more
painful for the laboring woman during this phase. If she has chosen to receive
an epidural or another type of pain medication this is the time she will be
given it. The behavior of the woman changes also from excitement, to feeling
of helplessness, anxiety, and she also becomes much more quiet, she is
concentrating on the task at hand. The third phase or Transitional stage is
usually very intense, but is also short in length, average time is 3.6 hours in
the nullipara. The cervix is dilating from 8 cm to 10 cm, the fetus is
descending further into the pelvis, contractions have become very strong and
last from 60 - 90 seconds each. Contractions are usually 1.5 - 2 minutes apart
in this phase. This phase is the most difficult phase, the woman may have
nausea, vomiting, leg tremors, as well as being irritable. Women may also lose
control of their behaviors during this phase if the pain is intense.
Second stage of labor begins with the complete effacement and dilation of the
cervix, and ends with the birth of the baby. This stage lasts 30 minutes to 3
hours in the nulliparous woman, and 5 - 30 minutes in the multipara woman.
Contractions are still strong and are about 2 - 3 minutes apart, lasting 40 - 60
 seconds each. The pressure on the pelvic floor caused by the decent of the
fetus causes the mother to feel the urge to push. She may feel she needs to
have a bowel movement at this time. As crowning begins the woman may feel
stretching or tearing even if no trauma is occurring. Behavior of the laboring
woman in this phase goes from uncontrolled to feeling more in control of the
situation. She is sometimes not even aware of what is going on around her,
she is solely focused on pushing the baby out. This stage demands intense
physical exertion, and energy demands.
Third stage of labor or the placental stage begins with the birth of the baby
and ends with the placenta being expelled from the uterus. This is the
shortest stage of labor, averaging 5 - 10 minutes, but up to 30 minutes. The
uterus still contracts firmly but with minimal pain at this time, the woman is
usually so excited at what she has just done and anxious to see her baby. The
placenta separates from the uterine wall after birth due to the decrease in the
size of the uterus, which also decreases the size of the placental site. After the
expulsion of the placenta the uterus must contract firmly and remain
contracted for the compression of open vessels to occur at the implantation
site, otherwise the birth may result in hemorrhage and/or maternal demise.
Fourth stage of labor occurs during the first 1 - 4 hours after birth. This stage
includes the physical recovery of the mother and infant. Bonding between the
mother and infant occurs, uterine contractions are still occurring to help
control bleeding, some pain due to the mild contractions or traumas due to
the birth may also be present. The woman is usually exhausted but finds it
hard to sleep with all of the excitement, and eagerness to get acquainted with
her new baby.

2. Describe the 3 phases of a contraction. Define frequency,

duration and intensity as it relates to the contraction.

The normal characteristics of contractions are coordinated, involuntary and

intermittent. Contractions occur in three phases; increment, which occurs as
the contraction begins in the fundus and spreads to the rest of the uterus;
peak, where the contraction is the strongest or most intense; and decrement,
which is the period of the contractions decrease in intensity, the uterus has
begun to relax again. The contraction cycle is also described in terms of
frequency, duration and intensity. Frequency is the time in between the start
of 2 contractions, it is measured in minutes. Duration refers to the length of
the contraction from the beginning to end. It is expressed in seconds. The
intensity refers to the strength of the contraction(s), terms used to describe
the strength are mild, moderate and intense.

3. What is an epidural? State the nursing care for the client that
has received an epidural.

An epidural is a regional analgesia and anesthesia that provides adequate

pain relief without sedating the woman during labor and birth. The epidural
block is best when started in women who are in active labor, as giving it prior
to has been shown to slow the progress of labor. Epidural blocks are usually
performed by an anesthesiologist or nurse anesthetist. A local anesthetic is
injected into the small epidural space and is usually combined with opiod
analgesics to provide substantial pain relief. The epidural is given via an
epidural catheter that is inserted into the woman's L3 or L4 interspace, the
catheter allows a continuous infusion of medication so that pain relief can be
maintained during labor and birth. The epidural can also be individualized
 depending on the level of pain relief the woman is wanting to achieve, the
medication can also be given intermittently or by PCA. Nursing care of the
woman who has received an epidural includes: recording maternal vital signs
and FHR to use as a baseline to compare with vitals taken after the epidural is
given, assessment of the woman's bladder must be done frequently as a full,
distended bladder can inhibit the descent of the fetus, urinary catheterizations
are performed as ordered, observing for signs and symptoms related to any
adverse effects or catheter migration, and to ensure adequate intravenous
access is in place with the proper fluids running at the correct rate.

4. What are the two types of electronic fetal monitoring? Hint:

External and Internal! When is each used? What conditions
have to be present for internal monitoring?

The two types of electronic fetal monitoring are external and internal fetal
monitoring. The external fetal monitor is commonly used during labor to
assess the fetal heart rate and uterine activity. The external monitor is applied
to the woman's belly and secured in place with an elastic belt, it usually needs
to be readjusted to the correct position when the mother or fetus is active. No
special conditions have to be present to use the external monitor, the woman
just has to be pregnant. There are some factors that can affect the apparent
intensity of a contraction: fetal size(small), abdominal fat thickness, position
of the mother, and location of the transducer.
Internal fetal monitoring is used for a more accurate assessment of the fetal
heart rate and uterine activity. This monitor is an invasive device, and requires
the membranes to be ruptured as well as at least 2 cm of cervical dilation.
This type of monitor since it is invasive increases the risk of infections.
Internal monitoring uses an electrode that is attached under the skin about 1
mm on the scalp of the fetus, but in a breech presentation it may be applied
to the buttocks. The electrode only records the fetal heart rate, another device
called an intrauterine pressure catheter is used to measure the uterine
activity. This pressure catheter senses the changes in the intrauterine
pressure, it is also sensitive enough to pick up intra-abdominal pressure
changes as seen with coughing and/or vomiting.

5. Give the normal ranges for the fetal heart rate. What is
bradycardia and a possible cause? What is tachycardia and a
possible cause?

The normal range of the fetal heart rate is from 110 - 160 bpm, and the rate is
variable by the age of the fetus, premature fetuses of 26 - 28 weeks are at the
higher end of the range due to the immature parasympathetic nervous
system.
Bradycardia is a fetal heart rate less than 110 bpm, that lasts for 10 minutes
or longer. Possible causes of fetal bradycardia include: fetal head
compression, fetal hypoxia, fetal heart block, fetal acidosis, compression of
the umbilical cord, and/or late second-stage labor with maternal pushing.
Tachycardia is a fetal heart rate more than 160 bpm for at least 10 minutes.
Possible causes of fetal tachycardia: maternal dehydration, maternal fever,
maternal or fetal hypoxia, maternal or fetal hypovolemia, maternal
hyperthyroidism, fetal cardiac arrhythmias, severe maternal anemia, fetal
 acidosis, or drugs that were given to the mother (decongestants,
bronchodilators, or stimulant drugs).

6. Define variability and baseline as they are related to the fetal

heart rate. Why is variability important?

The fetal heart rate baseline is the average heart rate in two minutes, and
then rounded to the nearest 5 bpm. The uterus must be at rest, between
contractions, and there must not be any significant fluctuations in the rate
with in the time it is being measured.
Variability denotes the fluctuations in the baseline fetal heart rate that cause
the printed paper to have an irregular rather than smooth appearance.
Variability occurs because of the multiple factors that affect the fetal heart
rate. Evaluating variability is important to help in determining how tolerant
the fetus is of labor. Variability is used during electronic fetal monitoring
because with adequate oxygenation the normal function of the autonomic
nervous system is promoted which helps the fetus tolerate and adapt to the
stresses of labor.

7. Define decelerations. State the three major types of

decelerations, possible causes and treatments for each.

The three types of decelerations are; early decelerations which are not
associated with fetal compromise, and have a gradual decrease from the
baseline FHR. These decelerations are thought to be caused by fetal head
compression that normally occurs during a contraction, the deceleration
should be no more than 30 - 40 bpm less than the baseline; late decelerations
indicate a deficient exchange of oxygen and waste products in the placenta,
these are non-reassuring patterns. If late decelerations are seen it indicates
the fetus is intolerant of contractions during labor. The cause may be maternal
hypotension, diabetes, or maternal hypertension. This type of deceleration
usually start after the peak of a contraction with the FHR returning to the
baseline after the contraction has ended; variable decelerations occur when
flow is reduced in the umbilical cord. This type of deceleration may or may not
occur during contractions, and rise and fall abruptly as the umbilical cord is
compressed and then relieved. Variable decelerations last up to 15 seconds
and decrease in the fetal heart rate is at least 15 bpm. Causes of variable
decelerations may include: nuchal cord, prolapsed cord, oligohydraminios or
other conditions causing insufficient blood flow in the umbilical cord.

8. If a pattern of late decelerations is detected, what nursing

actions should be initiated? If the deceleration does not
improve, what action will probably be taken?

If late decelerations are seen or other non reassuring fetal heart rate patterns,
the nurse should try to identify the cause, by evaluating the patterns,
monitoring maternal vital signs, and perform a vaginal exam for evidence of a
prolapsed cord. If oxytocin is being given via IV it needs to be stopped, fluids
need to be increased to increase the mothers blood volume, the mother
should be put in a non-supine position, give O2
by face mask at 8 - 10 L/min, start continuous electronic fetal monitoring if not
already begun, notify the physician or mid-wife as soon as possible. If the late
decelerations are severe the nurse and staff should prepare for immediate
 delivery via cesarean section, the staff should include persons to resuscitate
the neonate if needed.

9. What is pitocin and when is it used in labor and delivery? How

is it given and what nursing actions are necessary during its
use? Why/how is it used after the delivery?

Pitocin also known as Oxytocin, is an identical synthetic compound to a

natural hormone produced by the posterior pituitary. It stimulates smooth,
uterine muscles, which results in increases in the strength, frequency, and
duration of a contraction. It is used to induce or augment labor contractions at
or near term. It is also used to help control and maintain postpartum bleeding,
by stimulating the uterus to contract, which helps in compressing blood
vessels. It can also be used to induce labor of an inevitable or incomplete
abortion. Nursing actions needed during pitocin administration include:
assessing fetal heart rate, maternal vital signs, observe for effective labor
patterns by watching contraction frequency, duration, and intensity, and
observe for hypo or hypertonic uterine contractions. The pitocin is usually
given IV piggypack or by intramuscular injections. When pitocin is continued
or given postpartum nursing actions should include: observing firmness of the
fundus, as well as the height and deviation, massaging the fundus if boggy,
watch for signs of hemorrhage, such as more than one peri-pad an hour
and/or large clots. Monitor vital signs, intake and output, signs of cramping,
breath sounds and for other signs of fluid retention.

10. Define effacement and tell how it is measured. Define dilation

and tell how it is measured. How do both of these indicate
progress in labor?

Effacement is the thinning and shortening of the cervix that occurs during
labor. It occurs because of the descending fetus which pushes down on the
cervix making it shorten and thin. The nulliparous woman completes
effacement earlier in the laboring process than the multiparous woman,
because the multiparous woman has a thicker cervix. Measurement of cervical
effacement is estimated as a percentage or the original cervical length, with a
fully thinned cervix being 100% effaced.
Dilation is the opening of the cervix that occurs during labor. 10 cm dilation is
considered complete cervical dilation. The 10 cm dilation is sufficient enough
to allow the passage of the full term fetus.

11. What are some of the different types of analgesia given to the
mother while she is in labor and how do these affect the fetus?

Labor and delivery includes a great deal of pain, and laboring women all deal
with the pain differently. However most will want some type of pain relief,
some of these analgesics include: Demerol, Fentanyl, and Nubain, these are
opiod analgesics. The opiod analgesic Demerol given for pain relief may cause
dysphoria rather than any significant effect on pain. This analgesic is also of
concern because its metabolite normeperidine has a half-life of 15 - 23 hours
in the newborn which can result in neonatal respiratory depression or low
Apgar score. The opiod analgesics are usually given in frequent, small doses
via IV, to ensure quick pain relief with a predictable duration of action, and it
also reduces the risk of neonate respiratory depression. Other medications
 such as, Phenergan are usually given with opiod analgesics to help relieve
nausea and vomiting that is common when opiates are given. Phenergan can
also add to the opiod's effect on respiratory depression. Sedatives such as
barbituates may be given in small doses to help a fatigued, laboring woman
rest, but these are not commonly given because of their prolonged depressant
effects on the newborn.

12. What is PIH and describe the treatments and care of the
mother in labor with PIH?

PIH is pregnancy induced hypertension also known as preeclampsia. It is

characterized by a systolic blood pressure of 140 mmHg and a diastolic of 90
mmHg that develops after 20 weeks gestation. It is also accompanied by
proteinuria of > 0.3g collected in a 24 hour period, and random testing done by
using a urine dipstick of ≥ 1+. Treatment and care of the intrapartum woman
with PIH includes: administration of oxytocin to induce labor if not
contraindicated, keeping the woman in a lateral position to promote placental
circulation, pain relief should be well managed to help prevent the woman
from getting agitated which can increase the blood pressure and thus
increasing the risk for seizures, the woman must also be on seizure
precautions (bed rails up, close monitoring of vitals, dim lights), Magnesium
sulfate is given with the oxytocin in a secondary infusion to offset seizures
from occurring, continuous electronic fetal monitoring should be initiated if not
already, and during the birth a pediatrician, neonatologist, or neonatal nurse
practitioner must be present to care for the newborn, a resuscitation team
must also be ready if needed.

13. What assessment and nursing care is given to the mother in

the immediate recovery period after her delivery?

Care during the immediate recovery period following birth focuses on

observing for hemorrhage and relief of any pain or discomfort. When
observing for hemorrhaging it is important to assess the woman's vital signs,
bladder for distention, amount and color of lochia, and uterine fundus.
Assessment of the fundus should include the fundal height, firmness, and
position, this should be assessed with each vital sign assessment. The fundus
is one of the most important aspects to assess when observing for signs of
hemorrhage, as it is the most common cause of excess bleeding in the post
partum woman. If the uterus does not continue to contract firmly it inhibits
the compression of blood vessels that are open at the placental separation
site. During this exam, the fundus should be firm, midline, positioned below
the umbilicus, and about the size of a large grapefruit depending on the
normal anatomy of the woman and also if she was pregnant with multiple
fetuses. Bladder distention can cause the uterine contractions to stop or slow,
which can also lead to hemorrhaging. If distention is felt the woman should be
given a bedpan so that she can empty her bladder, if she is unable to due to
swelling of the urinary meatus related to trauma caused by birth she may
need to be catheterized. The lochia should also be assessed each time vital
signs are taken. The lochia should not exceed one peri-pad an hour
immediately following birth, nor should it have any large clots. If either of
these are noticed the physician should be contacted immediately. The
perineum and labial areas should also be assessed for hematoma formation,
and can be inhibited by application of ice packs to the areas. Comfort of the
post partum woman is also important following birth. Ensure the woman has
clean bedding, if they were soiled, ice packs for her perineal areas (some peri-
 pads have ice packs in them which just need to be put in the freezer or
fridge), she may also need to be given analgesics for afterpains common after
birth. Nurses should instruct the woman to ask for pain medication prior to the
pain level getting uncomfortable. It is common for women to be chilly after
giving birth so ensuring they are warm by providing extra blankets and warm
drinks. The nurse also allows privacy for the family so that the mother and
father and if any siblings may start the bonding process. If the infant has a
normal Apgar score the infant may be allowed to stay with the mother for its
first assessment and bath (depending on the facilities policy). Mothers who
have chosen to breastfeed are allowed to do so at this time, the sucking of the
infant during breastfeeding stimulates oxytocin secretion which helps in
contracting the fundus as well as maintaining the firmness of the fundus.

14. What are the three main causes and treatments for
postpartum hemorrhage?

Postpartum hemorrhaging is a leading cause of maternal demise. Three main

causes include: Uterine atony which is responsible for about 80% of post
partum hemorrhage. This condition is caused by the lack of uterine muscle
tone resulting in the inability of the uterus to contract. Treatment for this
condition includes massaging the uterus and expressing any clots that have
accumulated, ensuring that the bladder is not full as this too may inhibit the
uterus from contracting properly, administration of oxytocin may be given
diluted in a rapid IV infusion to induce uterine contractions, if blood loss has
caused blood pressure to fall Methergine may be given to help increase the
blood pressure, if the oxytocin is not effective in controlling the uterine atony
a drug named Prostin or Hemabate may be given IM or injected right into the
uterine muscle. If bleeding is unable to be controlled arteries may have to be
cauterized or even complete and radical hysterectomy.
Trauma is the second common cause of post partum hemorrhage, and can
include trauma to the vagina, cervix, as well as perineal lacerations or
hematomas. Surgical repair is often needed for hemorrhaging caused by
trauma.
Subinvolution, which is the most dangerous due to the time period it happens,
occurs 7 - 14 days after birth and is due to the delayed return of the uterus to
its non-pregnant size, and fragments of the placenta that remained attached
to the myometrium. Excessive bleeding occurs when the clots start to slough
away several days after birth. This is the most dangerous post partum
hemorrhage because the woman is unaware and unsuspecting of any
complications this far after birth. Treatment is usually done immediately after
birth by ensuring the placenta is intact once expelled, if it is not the physician
or mid-wife may manually explore the uterus to locate the missing fragments,
and then remove them. If this condition does occur and able to be treated, the
treatment includes: controlling the bleeding by administering oxytocin,
methylergonovine, or prostaglandins. Placental fragments are usually expelled
with the bleeding, but a sonogram may be done to locate any placental
fragments. If bleeding continues a D&C may be necessary to remove the
fragments. Broad spectrum antibiotics are also given if infection is suspected.