EPISIOTOMY Extension to higher-order lacerations Small amount goes to the maturing lungs

Surgical incison of the perineal tissue performed in Infection Rest of blood is shunted away from lungs by ductous
order to facilitate delivery of the fetus. ateriosus back to aorta
Episiorrhaphy
Indications - suture repair of an episiotomy Blood travels back from aorta to the two umbilical
arteries to the placenta
Fetal distress Anatomy and Physiology
Fetal Circulation The placenta will re-supply the blood with oxygen
Maternal reason to expedite delivery
Umbilical cord Fetal circulation is a low-pressure system
Rigid perineum preventing delivery
2 umbilical arteries: return non-oxygenated blood, Low pressure system
Shoulder dystocia fecal waste, CO2 to placenta
Lungs are closed
Breech presentation 1umbilical vein: brings oxygenated blood and nutrients
to the fetus Most oxygenated blood flows between the atria of the
Lacerations heart through the foramen ovale
Anatomy and Physiology
LACERATIONS This oxygen rich blood flows to the brain through the
Fetus depends on placenta to meet O2 needs while ductus arteriosus
Tissues are unable to stretch any further and tear
organs continue formation
under pressure. Conversion of Fetal to Infant Circulation
Oxygenated blood flows from the placenta
1st degree At birth
- limited to fourchette, perineal skin, and vaginal To the fetus via the umbilical vein
mucous membrane. Clamping the cord shuts down low-pressure system
After reaching fetus the blood flows through the
2nd degree inferior vena cava Increased atmospheric pressure(increased systemic
- perineal skin, vaginal mucous membrane, underlying vascular resistance) causes lungs to inflate with
fascia and muscles of the perineum. Blood continues to travel from the inferior vena cava oxygen
to the ductus venosis
3rd degree Lungs now become a low-pressure system
- from perineum and involves the anal sphincter. Ductus Venosis
Pressure from increased blood flow
4th degree Small amount of blood routed to growing liver
- rectal wall into the lumen of the rectum. Conversion: Fetal to Infant Circulation
Increased blood flow leads to large liver in newborns
Equipment In the left side of the heart causes the foramen ovale
Blood continues to travel up the inferior vena cava to close
Sterile or tap water
Empties into the right atrium of the heart More heavily oxygenated blood passing by the ductus
1 x 10 mL syringe arteriosus causes it constrict
The blood then passes to the left atrium through the
1 x 22 gauge infiltration needle foramen ovale Functional closure of the foramen ovale and ductus
arteriosus occurs soon after birth
10 mL lidocaine 1% Foramen ovale
Overall anatomic changes are not complete for weeks
Mayo episiotomy scissors Small opening in the septum of the heart
Conversion (cont)
Types of Episiotomy Completely bypasses the non-functioning lungs
What happens to these special structures after birth?
Mediolateral - downward and outward from Blood continues journey to the left ventricle blood is
the midpoint of the fourchette about 2-5 cm then pumped into the aorta Umbilical arteries atrophy
from anus.
Blood is circulated to the upper extremities Umbilical vein becomes part of the fibrous support
Median center of fourchette about 2.5 cm ligament for the liver
posteriorly Blood then returns to the right atrium
The foramen ovale, ductus arteriosus, ductus venosus
Complications From the right atrium, the blood goes to the right atrophy and become fibrous ligaments
ventricle then to the pulmonary arteries
Bleeding Overview of Conversion
Pulmonary arteries
Umbilical cord is clamped Increased systemic resistance POWERS- necessary to push the fetus through the
passageway.
Loose placenta Summary
POSITION- mother may need frequent changes in
Closure of ductus venosus Reviewed anatomy and physiology of fetal circulation position as the labor progresses.

Blood is transported to liver and portal system Discussed conversion from fetal to infant circulation PSYCHE- refers to the mothers emotional status
during labor.
Loss of placenta also leads to

PASSENGER
Overview of Conversion
FETAL ATTITUDE relationship of fetal body parts to one
First breath SIGNS OF IMPENDING LABOR
another.
Lungs expand and fluid is expelled LIGHTENING FETAL LIE relationship of the long axis of the fetus to
the long axis of the mother.
Decreased pulmonary resistance The descent of the fetus into the pelvis relieves
pressure on the diaphgram, allowing the mother to
FETAL PRESENTATION body part of the fetus that is
Increased pressure in left atrium breathe more easily and "feel lighter."
closer to the pelvix, determined by fetal lie.
Closure of foramen ovale May occur as long as 2 to 4 weeks prior to the onset of FETAL POSITION refers to the relationship of the
labor.
presenting part to the four quadrants ogf the maternal
pelvis.
Overview of Conversion
SIZE OF THE FETUS
BRAXTON HICKS CONTRACTIONS
Loss of placenta
Largest part is the head.
Irregular painless contractions occur througout
Increased systemic resistance
pregnancy. Bones of the fetal skull are not fussed but instead
Pressure in right atrium decreased joined by fibrous connective tissue called sutures .
More noticeable during the last few weeks.
Change from right to left shunting to left to right blood Fontannels, large spaces that prevent undue presaure
CERVICAL CHANGES
flow on the fetal brain.
At about 35 weeks of gestation, the cervix begings to
Increased O2 levels in pulmonary circulation Molding shaping of the fetal head to the bones of the
mature or "ripen".
maternal pelvis.
Closure of the ductus arteriosus Effacement & dilatation may begin.
POWERS
Fetal vs. Infant Circulation
BLOODY SHOW
Primary power comes from thr involuntary muscle
Fetal Release of the mucus plug from thw cervix. contarctions of the myometrium. Begin in response ti
the posterior pituitary hormone, oxytocin.
Low pressure system
Often begins within 48 hours after bloody show.
CHARACTERISTICS:
Right to left shunting RUPTURED MEMBRANES
Frequency time from onset of one contraction to the
Lungs non-functional next contraction.
Tearing or perforation of the amniotic sac releasing
amniotic fluid.
Increased pulmonary resistance Duration time from onset of contraction to the end of
Usually occurs after labor begins. contraction.
Decreased systemic resistance
True Labor VS. False Labor Intensity strengthof the contraction at its peak.
Infant

High pressure system

VARIABLES AFFECTING LABOR Secondary power comes from the mother actively
Left to right blood flow
pushing the fetus to the birth canal. Spontaneous urge
PASSAGE- consists of maternal structures through to push, known as Ferguson's reflex, occurs when the
Lungs functional
which the fetus must travel. presenting part reaches the pelvic floor.
Decreased pulmonary resistance
PASSENGER- fetus.
STAGES OF LABOR
1st Stage: Dilatation and Effacement
Also known as dilatation stage
Begins with regular contractions and ends with
complete effacement and dilatation of the Cervix.
Usually the longest stage and is divided into three
phases: latent, active, transition.
LATENT PHASE
from the onset of contraction until the cervix is dilated
to 4cm.
contractions usually occur every 10-15mins. &
gradually increase to 5mins. apart.
each contractions lasts 30-40 secs. and is mild to
moderate intensity.
ACTIVE PHASE
4-8 cm of cervical dilatation
Contractions every 3-5 mins.
Lasts 60-90 secs. and are moderate to strong
intensity.
TRANSITION PHASE
cervix widens from 8-10cm
Contractions are strong, occurring every 2-3 mins Expulsion is the birth of tje reat of the fetus after
lasting 90 secs. restituition.
2nd Stage: Birth 3rd Stage: Complete Placenta Expulsion
Begins when the cervix is completely dilated. Begins with birth of the fetus
Ends with the birth of the baby. Ends with expulsion of the placenta
Contractions continue every 2-3mins lasting 60 - 90 Placenta should be delivered within 30 mins of birth.
secs.
Signs of placental separation:
When the largest part of the fetal head appears with
the vulva and remains visible between contractions, Sudden gush of blood from the vagina
crowning has occurred.
Lengthening of the umbilical cord
MECHANISMS OF LABOR
Globular shape of the uterus
Engagement the presenting part enters the true pelvis.
Descent begins with engagement and continues as the
4th Stage: Recovery
contractions push the fetus through the pelvis.
Flexion deacribes the attitude fetus assumes. First hour after birth.
Mother's body begins to return to a nonpregnant state.
Internal rotation most commonly ocxirs during the
first or second stage of labor.
BP has moderate decline, pulse increases and then
Extension occurs when the fetus extends its head, gradually slows.
pushing its occiput against the maternal symphysis
Normal blood loss is between 250 to 500 ml.
pubis
Restituition turning of the fetal head to be in normal
alignment with the shoulders.
 CHARACTERISTIC TRUE LABOR FALSE LABOR

Contractions Occur regularly, Occur

becoming stronger, irregularly, or
lasting longer, become regular
occuring closer only
together. temporarily.

Increase in intensity Often stop with

with walking. walking or
position change.
Felt in lower back,
radiating to lower Are felt in back
portion of abdomen. or abdomen
above the
Continue despite umbilicus.
use of comfort
measures. Often can be
stopped with
use of comfort
measures.

CHARACTERISTIC TRUE LABOR FALSE LABOR

Cervix Shows progressive May be soft, but has no

change, softening,
effacement, dilatation,
passage of bloody
show.
Moves in an increasing
anterior position.
Requires vaginal exam
to detect changes.
significant change in
effacement, dilatation,
and no bloody show.
Is often in a posterior
position.
Requures vaginal exam
to determine
characteristics.

Fetus Presenting part Presenting part is not

becomes engaged in often engaged in the
the pelvis. pelvis.