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OB Nursing
Intrapartum
01/28/09
1 time mom need to come to the hospital when contractions are
st

regular and 5 minutes apart.

2nd time mom and thereafter needs to come to the hospital when
contractions are regular and 10 minutes apart. (Because the road has
already been paved)
OR
If they start to bleed.
Losing the mucous plug & have the bloody show. (pink tinged
discharge, can be brown (textbook def.)) (Truth: red) Mucous plug falls
out when cervix starts to dilate (@ 2cm)

***Toco-monitor- leads on fundus- measures contraction.

Pg. 121 fig. 6-4

I= Increment
A= Acme
D= Decrement

Frequency- Time between the beginning of one contraction to the

beginning of the next contraction. * Must be longer than two
minutes!!*
Duration- beginning of a contraction to the end of that contraction. *
should last no more than 90 seconds!!*
Interval- time between contractions (uterine relaxation). * Should be
at least 60 seconds. No sooner!!*
Intensity- strength of contraction. The higher the peak the stronger
the contraction.

-If any of these #s are off, it increases the risk of uterine

rupture.
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Pg. 135
1. Early Deceleration: drop in baby’s Heart rate, in the early part of a
contraction, This is a reassuring pattern (by the end of the contraction,
the heart rate returns back to baseline). Normal finding- due to fetal
head compression (stimulates vagal response)
2. Late Deceleration: drop in baby’s HR, in the late part of a
contraction, (@ the peak or 30 seconds into contraction) After the
uterus is relaxed, baby’s HR stays low. Will not go back up to baseline.
Non-reassuring pattern.
Could be caused by:
Uteroplacental insufficiency (UPI): reduced blood flow (supply)
from the placenta. (fetal hypoxia/acidosis)
3. Variable Deceleration: Drop in baby’s HR, occurring anytime
during a contraction ( HR will be seen @ 60-70 bpm) W, V, and U
shaped patterns. (Bad, Worst, Non-reassuring pattern)
Could be caused by:
Cord Compression
Nuchal Cord (cord @ baby’s neck)

Nursing Intervention for Deceleration:

*Early: Nothing
*Late: (L) side, administer O2 (10-12L/min. face
mask),Discontinue pitocin drip, Call Dr.
*Variable: Trendelenburg position or any position where
the hips are higher than the head. (Knee-Chest
position)-> Helps to relieve the pressure placed on
the cord. (L) side, administer O2 (10-12L/min. face
mask),Discontinue pitocin drip, Call Dr.

Intensity can be measured by feeling the fundus. Walk fingers from

side until you reach the center-> Feels like a rock.

Types of intensity upon palpation:

1. Mild: Firm but some indention (nose)
2. Moderate: (chin)
3. Firm: (forehead)

Contractions during the 1st stage of labor causes cervical dilation. Pain
caused by cervical dilation.
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OB Nursing
4 Stages of Labor
1/28/09

Stage 1:
Dilation: From the beginning of true onset of labor and
contractions until the cervix is 10cm dilated (100% effaced (thin &
short)). Can last up to 24 hours.
*First Stage of labor is divided into 3 phases:
1. Latent (prodromal) Phase:
Ÿ 0-3 cm cervical dilation
Ÿ Contractions 5-10 min. apart
Ÿ Lasting @ 15-40 seconds in duration
Ÿ No epidurals or pain meds at this point (slows & stops labor)
Ÿ V/S q 1-2 hours
Ÿ Good time to teach pt.
Ÿ Pain is caused by cervical dilation
2. Active Phase:
Ÿ 4-7 cm cervical dilation
Ÿ Contractions 2-3 min. apart
Ÿ Lasting 40-60 sec. in duration
Ÿ Give pain meds in this phase; may have an epidural (@
5cm.)
Ÿ Pt. normally is concentrating on contractions
3. Transition Phase: (shortest phase and hardest phase)
Ÿ 8-10 cm cervical dilation
Ÿ Contractions every 2-3 min.
Ÿ Lasting 60-90 sec. in duration *should not last more than 90
sec.!!*
Ÿ Women lose control-- may act out
Ÿ No pain meds (Demerol IV) B/c delivery is within a few hours.
Meds could depress infant’s respiration.
Ÿ V/s q 10-30 min. Take B/P between contractions.

Check for FHT over baby’s back (using Leopold’s Maneuver)

Normal rate is 120-160 bpm (toco-monitor)
Location of the heart rate:
Breech Presentation: Above umbilicus
Cephalic Presentation: Below umbilicus

Accelerations: Increase in FHR from the baseline (ANS)

Variability- Changes in FHR beat-to-beat.
1. Short term: Measured by internal monitor; most reliable
measure of fetal well being. (Variations beat-to-beat;
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minimal 3-5 beats)

2. Long term: (over 10 min time)
0-2 bpm and loss of variability-- L side, O2, Notify MD/charge nurse

*Amniotomy- Manual ROM (rupture of membranes);complication is cord

compression (Alice clamp/Amniohook)
*Amniotic fluid should be 800 mL; clear to straw color with white flex
(vernix). Characteristic odor; Nitrazine paper (yellow paper that
measures pH) is inserted into vagina and turns blue when it comes in
contact with amniotic fluid. *Nurse should note time membranes
ruptured, color, odor of the fluid. *Always check FHT when membranes
rupture. Any time the water breaks, your 1st priority is to assess
the FHT!! (in case baby compresses the cord)

Ÿ Green amniotic fluid: indicates meconium is present (sign of fetal

distress) common in breech presentation or post
term babies.
Ÿ Wine colored Fluid: ? Abruptio placenta or blood
Ÿ Foul odor: infection

Friedman’s chart: chart the progress of labor. Deals with how fast the
cervix is dilating.

During labor pt. may become dehydrated (mouth breathing); fluids are
allowed in early labor (ice chips, etc.) ?NPO--? C-section

Full bladder interferes with uterine contractions and cervical

dilation, Decreases the progression of labor and creates
ineffective uterine contractions.
*make sure to have patient keep their bladder empty; check pt. q 2
hours to void. If foley catheter-> it must be removed when pushing.

Walking increases true labor--as long as membranes (bag of waters)

are intact and the head is engaged. *with Braxton Hicks- walking will
lessen contractions-> means false labor. Lie in Left lateral position
while in labor.

Effleurage: slight stroking movement by the fingertips over the

abdomen can cause distraction during contractions (tennis balls- for
back pain) Gate closing mechanism. Posterior presentations cause
BACK PAIN! (LOP/ROP). Pelvic Rock/Pelvic Tilt to help with back pain.
Baby can still be born w/ posterior presentation- extremely painful.
Squatting and hands-knees position to turn baby to anterior position.

If pt. complains of wanting to have a BM, the nurse should

check cervical dilation. This is a complaint that indicates the
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baby is coming. (*Delivery is imminent) other S/s: Bulging perineum,

increased bloody show.

Pushing during 1st stage is a no-no!! can cause maternal exhaustion,

fetal hypoxia, and can tear the cervix.

Second Stage of Labor: From 10 cm dilated to delivery of baby (lasts

an avg. of 1h 30min for muligravidas) (2h total)
Delivery
Ÿ V/S q 15 min
Ÿ Contractions may last up to 90 seconds (but no longer)
Ÿ Contractions every 4-5 min. or 1-2 min.
Ÿ Pushing Phase--(breathing) no pushing in the 1st stage of labor
Ÿ Push should resemble urination -> not BM
Ÿ The act of pushing expedites the delivery process, it
doesn’t prevent it.
Ÿ Pt. should not hold breath when pushing- use “open-glottis
breathing”; Holding breath when pushing can cause vagal
stimulation.

Episiotomies (lacerations of the perineum) are given to prevent tissue

trauma. Episiotomies are measured in degrees 1-4 with 4 being
most severe.

Crowning occurs when the whole circumference of the head can be

seen in the vagina with contractions.

After delivery, the fundus can be palpated @ or slightly below the

umbilicus at the midline.

Third Stage of Labor: From delivery of the baby to delivery of the

placenta.
Delivery of the Placenta
Ÿ Normally takes less than 20 min.
Ÿ Don’t pull on cord to hasten delivery- can cause an inverted
uterus
S/S of placenta separation:
Ÿ Uterus rises above umbilicus, forms round global shape, small
gushes of blood
Ÿ Lengthening of the cord
Causes of Placenta Separation:
Ÿ Strong contractions after baby comes out-> breaks off the uteran
wall.

Shiny Schultz: Fetal side; Shiny; Most commonly seen

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Dirty Duncan: Maternal side; rough; red; has incidence of retained

placenta fragments (some cotalydones stay in uterus-> inhibits
uterine contractions

Umbilical Cord always checked 3 vessels (1 vein, 2 arteries) Notify MD

if not.

If fundus is above or to the left or right of the umbilicus- Bladder is full.

** Check uterus to make sure it is firm (should feel like a grapefruit).

Immediately after delivery the uterus is located 1-2 cm below or at
the umbilicus in midline. If “boggy” (relaxed) support the uterus
with one hand, and massage the fundus. Estimate blood loss.
(Overstimulation of uterus can cause relaxation. **

Shaking and chills are a normal physiological response after delivery--

Provide blankets.
Mother/infant bonding time.

EES ointment to eyes prevent blindness caused by gonorrhea/chlym.

(ophthalmia neonatorium).

Blood loss for 3rd stage is 500 mL at time of delivery

Blood loss for C-sections is less than 1 L.

Airway #1 for the infant after delivery; identification band placed in the
delivery room before transport to the nursery.
Cord clamped in 2 places after delivery.

APGAR scoring: Done at 1 and 5 min.

Respiratory Rate, HR, Color, Muscle tone,
Reflexes, and irritability. (Max score is 10.
7+ is normal)
*Most infants receive no more than 9 due to acrocyanosis (bluish
discolorations of the hands and feet) Acrocyanosis is a normal finding.
*

Stage 4 of Labor: 1-4h postpartum

Recovery
Ÿ **Major risk in this stage is hemorrhage!!**
Ÿ Monitor for S/S of hypovolemic shock
Ÿ V/S--Bradycardia is normal. May be 40 bpm (transient pulse) DO
NOT WANT TO SEE TACHYCARDIA (SIGN OF HEMORRHAGE) V/S q
15 min till stable
Ÿ Check fundus, should be in mid-line and firm (grapefruit) If not
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firm, support and massage the fundus.

Ÿ Have pt. void frequently (full bladder prevents effective
contraction of uterus to prevent bleeding) (4-6h to void) Table 10-
13 Fundal massage
Ÿ Encourage breastfeeding (Stimulates production of Oxytocin-
uterine contraction- prevents hemorrhage)
Ÿ Inspect perineum after delivery- lateral position preferred.
Icepacks to perineal area for comfort.

Pitocin (Oxytocin) is given to stimulate labor contractions.

Side effects: Hypertension, fluid retention, and uterine rupture
(monitor BP/sustained uterine contraction)

Prostaglandin ‘E-2’: softens the cervix (causes cervical changes) for the
induction of labor.

Lochia: is the vaginal discharge after delivery.

Vitamin K: is given in the nursery in the Vastus lateralis to prevent

hemorrhage because the small intestines are sterile. (Vitamin K is
produced in the intestines)

C-Section: general anesthesia for emergency; lack of bonding.

If cut up and down: cannot have a VBAC. Increases the chances
of uterine rupture.
Classical Vertical through skin and uterus.
*Skin cut does not mean uterus is cut the same direction.*

*Pfannenstiel’s incision- made along the pubic hairline.*

(may be done due to position of baby, herpes lesions, cephalo-
pelvic disproportion (CPD), abruptio or placenta previa.)
CPD- baby’s head cannot fit through the pelvis.

Same nursing care- just a surgery pt. with dressing/staples. Keep

uterus firm/check if boggy/ fundal massage while supporting the
fundus.

*The pt. goes from a delivery pt. to a surgical pt.*

Mechanisms of Labor:
Effacement: Thinning and shortening of the cervix (%)
Dilation: Enlargement for the cervical opening (1-10)

Stations:
Presenting part of the fetus to the Ischial spines
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0- Part is at the Ischial spines (exact spines)

Negatives- Baby is floating; not engaged in the pelvis
Positives- Past Ischial spines (+5 visible on the pelvic floor)
*Engagement occurs when at zero station*
Example:

Cardinal Movements:
Exact order through vagina
1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External Rotation
7. Expulsion
Cardinal Movements: In Depth

1. Engagement:
Presenting part passes through Ischial spines. 1st
indication of pelvic adequacy (head is too large to
fit in the pelvis)
2. Descent:
Baby descends into toward the pelvis.
3. Flexion:
Allows narrowest portion of the head to enter the
pelvic outlet (flexion of head caused by
pressure against the pelvis)
4. Internal Rotation:
Turning of the head to the side in order for the head
to pass through the Ischial spines.
5. Extension:
Allows head to pass under syphilis pubis; presenting
part is visible at the vaginal opening; apply
gentle pressure against the head of the fetus to
prevent too fast of an expulsion (traumatize
maternal tissues).
6. External Rotation (restitution):
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Head rotates to align with shoulders (internal rotation

of the shoulders occur at the same time).
7. Expulsion:
Delivery; anterior shoulder first under syphilis pubis;
then head is supported and lifted, to allow delivery
of posterior shoulder; rest of body slips out of
the birth canal.

Baby is normally born face down.

OB Nursing
All about the fetus!
2/2/09
Ischial Spines
Table 6-2 P. 131

False v. True labor- know difference!

False labor is prodromal
Precipitant delivery (< 3h) not good- Could cause cervical tear.

False True
Contractions are irregular Contractions are regular
Walking lessens contractions, makes Walking increases contractions, when
them go away engaged
Abdominal Pain Back pain radiating to the abdomen
No Bloody Show Bloody Show
No change in effacement/dilation of Effacement/Dilation of Cervix
cervix

Dilation is measured in cm
Effacement is measured in % (thinning and shortening of the cervix)

The Passenger P. 122

Size of fetal head: 13-14 in
Anterior fontanel: diamond shaped- closes 12-18 mo.- pulsates
Posterior fontanel: Triangle shaped- closes 2-3 mo.
Molding: cranial bones overlap to come through the pelvis.
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Lie
Position of the baby in relation to the mother’s spine.
1. Longitudinal: fetus parallel with mother’s spine
2. Transverse: (Shoulder presentation) fetus perpendicular to
mother’s spine.
Attitude
Flexion and extension related to position of fetal extremities
(including the head) to itself. Flexion is most common and best. (all
balled up in flexion)

Presentation
Part of the baby that enters the pelvis 1st.
1. Cephalic: Head 1st.
2. Vertex: Head is flexed entering pelvis 1st
3. Military: Head is neither flexed nor extended
4. Brow: Head is partially extended
5. Face: Head is fully extended
Breech
1. Frank Breech: Butt down; legs in the air. Legs flexed @ hips
and extending towards shoulders. Most common
breech presentation.
2. Full/Complete Breech: Butt 1st legs flexed (Indian style).
3. Footling Breech: One or both feet present 1st in the cervix.

Position
Location of presenting part in mother’s pelvis
3 letters: 1st letter: Right or Left
2nd letter: Reference points (type of presentation)
O= Occiput
M= Mentum (chin)
S=Sacral
3rd letter: Reference points
A=Anterior
P=Posterior
T=Transverse
Box 6-1 pg. 126
Vertex
LOA: Left, Occiput, anterior- L side facing mommy’s spine.
ROA: Right, Occiput, Anterior- R side facing mommy’s spine.
ROP: Right, Occiput, Posterior- R side pelvis, head down, face up
LOP: Left, Occiput, Posterior- L side pelvis, head down, face up
* Prolonged, harder labor!!*
ROT: Right, Occiput, Transverse- R side pelvis, head 1st, ear forward
LOT: Left, Occiput, Transverse- L side pelvis, head 1st , ear forward
LSA: Left, Sacral, Anterior- L side pelvis, butt 1st, ear forward
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LMA: Left, Mentum, Anterior- L side pelvis, face 1st, facing forward

Signs of Impending Labor

Ÿ Braxton Hicks contraction
Ÿ Increased vaginal discharge
Ÿ Bloody show
Ÿ Rupture of membranes
Ÿ Energy spurt (nesting)
Ÿ Weight loss

The initiation of labor is unknown!!

Epidural= Hypotension

Tears: Perineal tears and lacerations

Tears- jagged
1st degree: Superficial tear
2nd degree: Involves SQ tissue
3rd degree: slices/tears to the anal sphincter
4th degree: slices/tears THROUGH the anal sphincter

D/t CPD- cephalo-pelvis disproportion.

Anxiety and Fear can slow or stop labor.

Tocolytics: relaxes the uterus. Ex. Magnesium Sulfate (drug of choice to

stop pre term labor. Monitor for fluid overload, tachycardia,
hypotension)

Beta-adrenergic Drugs stop labor

8. Ritadrine (yutopar): Hypotension, Fluid retention, increased blood
sugar and K+ levels. Causes maternal and fetal tachycardia.
9. Indomethocin: S/E- causes ductus arteriosus to close. Can give but
runs the risk of early closure of shunt. Epigastric pain.
10.Nifedipine (procardia): lowers BP
11.Brethine (terbutaline): commonly used (given SQ) relaxes smooth
muscle. Opens bronchioles. Decreases BP; tachycardia

Steroids
12.Corticosteroids Betamethazone (Dexamethazone) Given IM to
mother during labor- 2 injections, 24h apart to help build surfactant
in fetal lungs. Used for the Premature baby so it will have less
chance of Respiratory complications. Used for pre-term labor (@ 34-
35 wks.) if anticipating a few days before delivery. Also relaxes
smooth muscle around vessels.
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Shoulder dystocia Occurs when fetal shoulder gets caught

on pubic bone.
13.Can break clavicle
14.McRobert’s Procedure: Flex mommy’s hips to abdomen, butt comes
off the bed, shoulder dislodges, baby comes out.
15.Suprapubic pressure

Oxytocin Challenge Test=Contraction Stress Test

Premature Rupture of Membranes (PROM)

BOW breaks without contraction of uterus- only have 24h after
membranes rupture to get the baby out otherwise infection can occur.
Can also cause chorioanmioitis: inflammation of the uterus.

Hypotonic uterine contractions: slow, ineffective- Failure to progress (C

section)
Hypertonic Uterine contractions: excessive, hard contractions.
Decreased O2 to the fetus.

Cervix dilates 1.2 cm/hr with 1st baby.

Fractured pelvis is the most common reason of shoulder dystotia.

Fibronectin: protein found in amniotic fluid. If found in vagina, means

the BOW has ruptured.

Bishop’s score- determines if induction is feasible for woman. If they

qualify for induction.

Manual version: Dr. turns the fetus externally from abdomen.

For posterior position: Back pain: Pelvic rock, Squats, Hands/Knees

position.

Prolapsed cord: push up on baby to relieve pressure on cord.

Trendelenburg, Hands/knees position.

Pitocin causes Fluid retention.

Brandell’s Retraction Ring (Ring found where uterus and cervix meet)
Indicates uterine rupture. Indention of the ring can be palpated. (C/o
shoulder pain)
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Know C-section incisions: P. 181

Low vertical
Low transverse- most common
Classic- used for emergencies and placenta previa- Once you’ve had a
classical you can never have a VBAC! Increases the risk of uterine
rupture.

Blood patch: used for women who has an epidural. 5-10 mL of blood is
injected into epidural site to seal it off so no fluids drain out. Also
reduces Spinal Headache.

**After 40 weeks gestation, the placenta starts to decrease in

functioning ability!!**

Hydroamnios: Increased amniotic Fluid. Commonly caused by:

Diabetes, GI obstruction in the fetus (not swallowing enough amniotic
fluid).

Oligeoamnios: Decreased amniotic fluid. Risk of prolapsed cord due to

renal problems in fetus (can’t excrete what they’re swallowing).

**Massage 1st, Pee 2nd!**

Forceps Delivery
Complications:
Intracranial Hemorrhage
Facial Nerve Paralysis

Vacuum
Complications:
Increased intracranial pressure (ICP)
Bleeding in the brain

Counter traction is placed on baby’s head as it is being born. If it

comes out too quick, it can cause head injury (brain) and tear the
woman.

Monial infection= yeast infection

Baby comes out: Immediately Clamp the cord and cut.

Clamps in two places: @ umbilicus and @ 4 in in front of it- cut

between the clamps.

IUGR: Intrauterine Growth Retardation: fetus doesn’t grow as expected.

Due to PIH; Decreased adequate blood flow.
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If mommy gets mag, NO AMINOGLYCCOSIDES for baby!!!

Ch. 6,7,8 test no earlier than Thursday!!