MODULE 2 INTRAPARTUM PROCESSES OF LABOR AND BIRTH

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MODULE 2 INTRAPARTUMPROCESSES OF LABOR AND BIRTH
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• KEY FACTORS RELATED TO PROGRESS OF LABOR
• FORCES OF LABOR
• INTRAPARTAL ASSESSMENT AND CARE OF MOTHER AND
  FETUS
• CARE OF MOTHER AND INFANT IN LABOR, DELIVERY, AND
  IMMEDIATE POST PARTUM
• BIRTH RELATED PROCEDURES

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MODULE 2 PART 1KEY FACTORS RELATED TO PROGRESS
OF LABOR
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KEY FACTORS RELATED TO PROGRESS OF LABOR

• PASSAGEWAY (BIRTH CANAL)
• PASSENGER (FETUS)
• POSITION OF THE MOTHER AND FETUS
• PHYSIOLOGICAL FORCES OF LABOR
• PSYCHOSOCIAL CONSIDERATIONS

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BIRTH PASSAGE

• SIZE OF PELVIS
• TYPE OF PELVIS
• CERVICAL DILATATION, EFFACEMENT
• ABILITY OF VAGINA AND INTROITUS TO EXPAND

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BIRTH PASSAGE

• FOUR CLASSIC PELVIC TYPES
• GYNECOID
• ANDROID
• ANTHROPOID
• PLATYPELLOID

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BIRTH PASSAGE

• CERVICAL DILATATION AND EFFACEMENT
• DILATATIONMEASURED IN CENTIMETERS FROM 0 TO 10
• 0 CMCERIVX CLOSED
• 10 CMFULL DILATATION
• EFFACEMENTMEASURED IN PERCENTAGE 0 TO 100

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Figure 1511a Effacement of the cervix in the
primigravida. Beginning of labor. There is no
cervical effacement or dilatation. The fetal head
is cushioned by amniotic fluid.
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Figure 1511b Beginning cervical effacement. As
the cervix begins to efface, more amniotic fluid
collects below the fetal head.
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Figure 1511c Cervix about one-half effaced and
slightly dilated. The increasing amount of
amniotic fluid exerts hydrostatic pressure.
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Figure 1511d Complete effacement and
dilatation.
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UTERINE AND CERVICAL CHANGES

• UPPER UTERINE SEGMENT THICKENS AND PULLS UP
• LOWER SEGMENT EXPANDS AND THINS OUT
• EFFACEMENT
• CAUSES OF UTERINE CHANGES
• ESTROGEN STIMULATES MUSCLE CONTRACTIONS
• COLLAGEN IN CERVIX BROKEN DOWN
• INCREASED WATER CONTENT OF THE CERVIX

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MODULE 2 PART 2THE PASSENGER (FETUS)
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• FETUS (PASSENGER)
• SIZE OF FETAL HEAD
• FETAL ATTITUDE
• FETAL LIE
• FETAL PRESENTATION
• IMPLANTATION SITE OF PLACENTA

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PASSENGER

• FETAL HEAD
• SUTURES
• FRONTAL
• SAGITTAL
• CORONAL
• LAMBOIDAL
• MOLDING
• FONTANELLES

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Figure 152 Superior view of the fetal skull.
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PASSENGER

• LANDMARKS OF FETAL SKULL
• MENTUM
• SINCIPUT
• ANTERIOR FONTANELLE (BREGMA)
• VERTEX
• POSTERIOR FONTANELLE
• OCCIPUT

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Figure 154a Typical anteroposterior diameters
of the fetal skull. When the vertex of the fetus
presents and the fetal head is flexed with the
chin on the chest, the smallest anteroposterior
diameter (suboccipitobregmatic) enters the birth
canal.
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Figure 156a Cephalic presentation. Vertex
presentation. Complete flexion of the head allows
the suboccipitobregmatic diameter to present to
the pelvis.
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Figure 156c Brow presentation. The fetal head
is in partial (halfway) extension. The
occipitomental diameter, which is the largest
diameter of the fetal head, presents to the
pelvis.
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PASSENGER

• FETAL LIE AND PRESENTATION
• FETAL LIE-- Relation of long axis of fetus to
  long axis of the mother
• Longitudinal
• Transverse
• FETAL PRESENTATIONthe body part of the fetus
  that first enters the pelvis

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PASSENGER (PRESENTATION)

• CEPHALIC PRESENTATION (95)
• VERTEXSUBOCCIPTOBREGMATIC
• MILITARY--OCCIPITOFRONTAL
• BROW--OCCIPITOMENTAL
• FACE--SUBMENTOBREGMATIC

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PASSENGER (PRESENTATION)

• BREECH PRESENTATION (3)
• COMPLETEHIPS FLEXED, KNEES FLEXED
• FRANKHIPS FLEXED, KNEES EXTENDED
• FOOTLINGHIPS FEET EXTENDED, FEET,FOOT PRESENT
  TO MATERNAL PELVIS
• KNEELINGHIPS EXTENDED, KNEES FLEXED

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PASSENGER (PRESENTATION)

• SHOULDER (TRANSVERSE) PRESENTATION (2)
• TRANSVERSE LIESHOULDER IS USUAL PRESENTING PART
• COMPOUNDUSUALLY ARM OR HAND PRESENTING ALONG
  PRESENTING PART

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MODULE 2 PART 3POSITION OF MOTHER AND FETUS
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POSITION OF FETUS IN RELATION TO MOTHERS PELVIS

• ENGAGEMENT
• WHEN THE WIDEST DIAMETER OF THE PRESENTING PART
  HAS REACHED OR PASSED THE PELVIC INLET
• ENGAGEMENT USUALLY CORRESPONDS TO O STATION
• FLOATINGWHEN PRESENTING PART IS ENTIRELY OUT OF
  THE PELVIS AND FREELY MOVABLE IN THE INLET

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Figure 158 Measuring the station of the fetal
head while it is descending. In this view the
station is 22/23.
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POSITION

• STATION
• RELATIONSHIP OF FETAL PRESENTING PART TO THE
  LEVEL OF THE ISCHIAL SPINES
• THE ISCHIAL SPINES ARE O STATION
• ABOVE THE SPINES IS A NEGATIVE VALUE
• BELOW THE SPINES IS A POSITIVE VALUE

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MODULE 2 PART 4A PHYSIOLOGICAL FORCES OF LABOR
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PHYSIOLOGIC FORCES OF LABOR

• CONTRACTION PHASES---INCREMENT, ACME, DECREMENT
• DESCRIBED WITH FREQUENCY, DURATION, AND INTENSITY
• PRIMARY AND SECONDARY FORCES OF LABOR
• EFFECTIVENESS OF PUSHING
• DURATION OF LABOR

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Figure 1510 Characteristics of uterine
contractions.
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SIGNS OF LABOR

• LIGHTENING
• BRAXTON HICKS CONTRACTIONS
• CERVIAL CHANGES
• BLOODY SHOW
• RUPTURE OF MEMBRANES
• SUDDEN BURST OF ENERGY
• WEIGHT LOSS
• NV, DIARRHEA, BACKACHE

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TRUE LABOR/FALSE LABOR

• TRUE
• CONTRACTIONS REGULAR, INCREASE IN DURATION
  STRENGTH
• INTERVAL SHORTENS
• DILATATION EFFACEMENT PROGRESS
• INTENSITY INCREASES WITH WALKING

• FALSE
• CONTRACTIONS IRREGULAR, NO CHANGE IN DURATION,
  STRENGTH
• INTERVAL IRREGULAR OR NO CHANGE
• NO DILATATION OR EFFACEMENT
• WALKING LESSENS OR HAS NO EFFECT ON CONTRACTIONS

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MODULE 2 PART 4BSTAGES OF LABOR
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• FIRST STAGE OF LABOR
• STARTS WITH BEGINNING OF REGULAR CONTRACTIONS TO
  FULL DILATATION
• FIRST STAGE IS DIVIDED INTO THREE PHASES LATENT,
  ACTIVE, AND TRANSITION

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PHASES OF LABORFIRST STAGE

• LATENT---0--3 CENTIMETERS, CONTINUING EFFACEMENT
• ACTIVE---4--7 CENTIMETERS, COMPLETE EFFACEMENT
• TRANSITION 8--10 CENTIMTERS ENGAGEMENT

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CONTRACTION CHARACTERISTICS

• LATENT PHASE
• MILD10-30MIN. LASTING 20-40 SECONDS
• MODERATE5-7MIN. LASTING 30-40 SECONDS
• ACTIVE PHASE
• MODERATE TO STRONG2-3 MIN. LASTING 40-60 SECONDS
• TRANSITION
• STRONG1-1/2-2 MIN. LASTING 60-90 SECONDS

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PSYCHOLOGIC ADAPTIONSTO LABOR LATENT PHASE

• FEELS ABLE TO COPE WITH DISCOMFORT
• MAY BE RELIEVED THAT LABOR HAS FINALLY STARTED
• USUALLY ABLE TO TALK THROUGH CONTRACTION
• IS ABLE TO RECOGNIZE AND EXPRESS FEELING OF
  ANXIETY

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PSYCHOLOGIC ADAPTIONSTO LABOR ACTIVE PHASE

• ANXIETY INCREASES
• FEARS LOSS OF CONTROL
• MAY HAVE DECREASED ABILITY TO COPE
• LESS TALKATIVE

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PSYCHOLOGIC ADAPTIONS TO LABOR TRANSITION PHASE

• WITHDRAWS INTO HERSELF
• DOUBTS ABILITY TO COPE
• APPREHENSIVE AND IRRITABLE
• TERRIFIED OF BEING ALONE
• DOES NOT WANT ANYONE TO TALK TO HER OR TOUCH HER
• DIFFICULT TO CONCENTRATE ON TASK

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SECOND STAGE OF LABOR

• BEGINS WITH COMPLETE CERVICAL DILATATION AND ENDS
  WITH THE BIRTH OF THE INFANT

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THIRD STAGE OF LABOR

• BEGINS WITH BIRTH OF INFANT AND ENDS WITH THE
  DELIVERY OF THE PLACENTA

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FOURTH STAGE OF LABOR

• BEGINS WITH DELIVERY OF PLACENTA TO 4 HOURS AFTER

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LABOR REVIEW

• DESCRIBE THE FIVE CRITICAL FACTORS THAT INFLUENCE
  LABOR IN THE ASSESSMENT OF A MOTHERS AND FETUS
  PROGRESS IN LABOR AND BIRTH, GIVING TWO EXAMPLES
  OF EACH

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MODULE 2 PART 5MATERNAL PHYSIOLOGIC ADAPTION TO
LABOR
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• RENAL -- gtIN RENIN, PLASMA RENIN ACTIVITY,
  ANGIOTENSIN
• VOIDING CAN BE AFFECTED BY EDEMA,DISPLACEMENT
• GIDECREASED MOTILITY, DELAYED STOMACH EMPTYING

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• CARDIAC OUTPUT INCREASES
• WBC CAN INCREASE TO 25,000mm
• BP INCREASES
• ACID/BASE BALANCEMAY SEE gt Ph EARLY IN LABOR

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INTRAPARTAL NURSING ASSESSMENT

• HISTORY
• PERSONAL DATA
• HX PREVIOUS ILLNESS
• PROBLEMS IN PRENATAL PERIOD
• PREGNANCY DATA
• INFANT FEEDING METHOD CHOSEN
• ANY PRENATAL EDUCATION ?
• BIRTH PLAN

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MATERNAL PSYCHOSOCIAL HISTORY

• POVERTY
• NUTRITION
• PRENATAL CARE
• CULTURAL BELIEFS
• ENVIRONMENT
• USE OF DRUGS/ALCOHOL
• DOMESTIC VIOLENCE

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MATERNAL PSYCHOSOCIAL ISSUES

• EMOTIONAL STATUS
• SOCIOCULTURAL BELIEFS
• PREVIOUS CHILDBIRTH EXPERIENCE
• SUPPORT
• MENTAL AND PHYSICAL PREPARATION

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INTRAPARTAL ASSESSMENT-- STAGE ONE

• VITAL SIGNS
• WEIGHT
• LUNGS
• FUNDUS
• EDEMA
• HYDRATION
• PERINEUM

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INTRPARTAL ASSESSMENT STAGE ONE

• LABOR STATUS
• FETAL STATUS
• LAB VALUES
• CULTURAL INFLUENCES
• RESPONSE TO LABOR
• CHILDBIRTH PREPARATION
• ANXIETY
• SUPPPORT

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LABOR EVALUATION METHODS

• CERVICAL ASSESSMENT
• VAGINAL EXAM
• DILATATION
• EFFACEMENT
• STATION

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Figure 162 To gauge cervical dilatation, the
nurse place the index and middle fingers against
the cervix and determines the size of the
opening. Before labor begins, the cervix is long
(approximately 2.5 cm), the sides feel thick, and
the cervical canal is closed, so an examining
finger cannot be inserted. During labor, the
cervix begins to dilate, and the size of the
opening progresses from 1 cm to 10 cm in
diameter.
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FETAL ASSESSMENT

• FETAL POSITION
• PALPATIONLEOPOLDS MANEUVER
• INSPECT SIZE AND SHAPE OF WOMANS ABDOMEN
• VAGINAL EXAM TO DETERMINE PRESENTING PART
• FETAL HEART RATE
• ULTRASOUND

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Figure 164 Top The fetal head progressing
through the pelvis. Bottom The changes that the
nurse will detect on palpation of the occiput
through the cervix while doing a vaginal
examination. Source Myles, M. F. (1975).
Textbook for midwives (p. 246). Edinburgh,
Scotland Churchill-Livingstone.
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Figure 165d Fourth maneuver Facing the
womans feet, place both hands on the lower
abdomen and move hands gently down the sides of
the uterus toward the pubis. Note the cephalic
prominence or brow.
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• GROUP EXERCISE
• LIST THREE POTENTIAL PROBLEMS RELATED TO
• PASSENGER
• POSTION
• PASSAGEWAY
• PHYSIOLOGICAL FORCES OF LABOR
• PSYCHOSOCIAL ISSUES

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MODULE 2 PART 7AFETAL HEART RATE (FHR) MONITORING
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• ELECTRONIC FETAL HEART RATE MONITOR--DOPPLER
• BASELINE RATE120-160BPM
• WHAT CAUSES
• FETAL TACHYCARDIA
• FETAL BRADYCARDIA

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• ELECTRONIC MONITORING OF CONTRACTIONS
• TOCOEXTERNATION ASSESSMENT OF CONTRACTIONS
• IUPCINTERNAL ASSESSMENT OF CONTRACTIONS

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EXTERNAL MONITORING

• EXTERNALULTRASONIC TRANSDUCER (DOPPLER)
• HIGH FREQUENCY SOUND WAVES REFLECT MECHANICAL
  ACTION OF FETAL HEART
• DIFFICULT TO OBTAIN CONTINUOUS, ACCURATE RECORD
  AT TIMES

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Figure 168 Electronic fetal monitoring by
external technique. The tocodynamometer (toco)
is placed over the uterine fundus. The toco
provides information that can be used to monitor
uterine contractions. The ultrasound device is
placed over the area of the fetal back. This
device transmits information about the fetal
heart rate. Information from both the toco and
the ultrasound device is transmitted to the
electronic fetal monitor. The fetal heart rate is
displayed in a digital display (as a blinking
light), on the special monitor paper, and audibly
(by adjusting a button on the monitor). The
uterine contractions are displayed on the special
monitor paper as well.
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INTERNAL FHR MONITORING

• MEMBRANES MUST BE RUPTURED
• CERVIX SUFFCIENTLY DILATED
• PRESENTING PART LOW ENOUGH FOR PLACEMENT
• SMALL ELECTRODE ATTACHED TO PRESENTING PART
• MOST ACCURATE APPRAISAL OF FETAL WELL-BEING IN
  LABOR

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Figure 169a Technique for internal, direct
fetal monitoring. Spiral electrode.
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Figure 169b Attaching the spiral electrode to
the scalp.
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FHR MONITORING

• VARIABILITY
• BEAT TO BEAT CHANGES IN FETAL HEART RATE
• INDICATION OF AN INTACT CNS
• ABSENT
• MODERATE
• MARKED

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Figure 1610 Normal fetal heart rate pattern
obtained by internal monitoring. Note normal FHR,
140 to 158 beats/min, presence of long- and
short-term variability, and absence of
deceleration with adequate contractions. Arrows
on bottom of tracing indicate beginnings of
uterine contractions.
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Figure 1611a Short- and long-term variability.
Increased LTV STV present.
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Figure 1611b Average LTV STV absent.
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Figure 1611c Absent LTV STV present.
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Figure 1611d Absent LTV STV absent.
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FHR MONITORING

• ACCELERATIONS
• DECELERATIONS
• EARLY
• LATE
• VARIABLE

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Figure 1612 Types and characteristics of
early, late, and variable decelerations. Source
Hon, E. (1976). An introduction to fetal heart
rate monitoring (2nd ed., p. 29). Los Angeles
University of Southern California School of
Medicine.
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• V C
• E H
• A O
• L P

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FETAL ASSESSMENT

• SCALP STIMULATION
• FETAL BLOOD SAMPLING (FBS)
• NORMAL SCALP pH gt 7.25, 7.20-7.25 BORDERLINE,
  lt7.20 NONREASSURING
• MEMBRANES MUST BE RUPTURED
• CERVIX DILATED 2-3CM
• PRESENTING PART -2 STATION OR LOWER

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MODULE 2 PART 8NURSING INTERVENTIONSIN FIRST
AND SECOND STAGES OF LABOR
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FIRST STAGE-- LATENT PHASE

• DILATATION, EFFACEMENT, STATION
• MEMBRANE ASSESSMENT
• COMFORT LEVEL
• VS, FHR
• UTERINE CONTRACTIONS EVERY 30-60 MIN.
• TEACHING

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LATENT PHASE

• ENCOURAGE AMBULATION
• ENCOURAGE VOIDING Q2H
• COMFORT MEASURES
• NUTRITION OFFER FLUIDS
• PAIN ASSESSMENT
• EPIDURAL MONITORING
• IDENTIFY AND OBSERVE SUPPORT PERSON(S)

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FIRST STAGE-- ACTIVE PHASE

• ENCOURAGE TO VOID Q1-2 HOURS
• AUSCULTATE FHR Q15-30 MIN.
• PALPATE CONTRACTIONS Q15 MIN.
• VAGINAL EXAMS TO ACESS PROGRESS
• EPIDURAL MONITORING, VS Q15-30 MIN.
• START IV INFUSION IF UNABLE TO TOLERATE FLUIDS
• ACCESS COLOR AND ODOR OF AMNIOTIC FLUID

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FIRST STAGE-- TRANSITION

• PALPATE CONTRACTIONS Q15 MIN.
• STERILE VAGINAL EXAMS TO ACCESS LABOR PROGRESS
• ASSESS FHR EVERY 15-30 MIN., DEPENDING ON RISK
  FACTORS
• ASSIST WITH BREATHING
• KEEP WOMAN FROM PUSHING UNTIL 10 CM.
• STAY WITH PATIENT!

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INTRAPARTAL NURSING INTERVENTIONS SECOND AND
THIRD STAGE OF LABOR

• SECOND AND THIRD STAGE OF LABOR
• ENCOURAGMENT, ASSIST WITH PUSHING,DO NOT LEAVE
  PATIENT
• ASSIST WITH DELIVERY
• DELIVERY OF PLACENTA
• APGAR SCORE, IMMEDIATE CARE OF NEWBORN
• PITOCIN INFUSION

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MODULE 2 PART 9INTRAPARTUM NURSING
INTERVENTIONSTHE DELIVERY
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• THE DELIVERY
• PUSHING
• BIRTHING POSITIONS
• LABOR SUPPORT

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Figure 1513 Mechanisms of labor. A, B,
Descent. C, Internal rotation. D, Extension.
E, External rotation.
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INTRAPARTAL NURSING CARE THE THIRD STAGE

• DELIVERY OF THE PLACENTA
• SCHULTZ MANUEVER
• DUNCAN MANUEVER
• PLACENTA ACCRETA
• RETAINED PLACENTA

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INTRAPARTAL NURSING CARE THE FOURTH STAGE

• VS
• FUNDUS
• LOCHIA
• PERINEUM/ABDOMINAL INCISION
• BLADDER
• COMFORT LEVEL
• COMFORT MEASURESWHAT ARE THEY?

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INTRAPARTAL NURSING CARE THE FOURTH STAGE

• CONTINUE PITOCIN ADMINISTRATION---WHY?
• PAIN MEDICATION
• DIET
• HEMODYNAMIC CHANGES
• CULTURAL CONSIDERATIONS

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ADAPTION TO EXTRAUTERINE LIFE

• IMMEDIATE CARE OF THE NEWBORN
• RESPIRATORY ASSESSMENT
• CIRCULATORY ASSESSMENT
• THERMOREGULATIONHOW WOULD YOU ACHIEVE THIS?

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IMMEDIATE CARE OF THE NEWBORN

• APGAR SCORE
• MAINTAIN RESPIRATIONS
• PROVIDE AND MAINTAIN WARMTH
• UMBILICAL CORD CARE
• CORD BLOOD COLLECTION
• HANDS OFF ASSESSMENT
• NEWBORN IDENTIFICATION
• FACILITATE ATTACHMENT

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IMMEDIATE POSTPARTUM CARE OF MOTHER

• VS
• HEMODYNAMIC CHANGES
• FUNDUS, LOCHIA
• VOIDING STATUS
• EPISIOTOMY/LACERATION ASSESSMENT
• PAIN

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MODULE 2 PART 10MATERNAL ANALGESIA AND ANESTHESIA
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MATERNAL ANALGESIA ANESTHESIA

• PAIN PERCEPTION AFFECTED BY
• PREVIOUS EXPERIENCE
• CULTURAL EXPECTATIONS, BELIEFS
• FATIGUE, FEAR, ANXIETY
• ENVIRONMENT
• SUPPORT SYSTEM

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MATERNAL ANALGESIA

• STADOL
• DEMEROL
• MORPHINE
• OPIATE ANTAGONISTNARCAN
• REGIONAL ANALGESIA

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MATERNAL ANESTHESIA

• REGIONAL ANESTHESIA
• EPIDURAL
• CONTINUOUS EPIDURAL
• SPINAL

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A
B
C
D
Figure 183c Tip of needle in epidural space.
Source Bonica, J. J. (1972). Principles and
practice of obstetric analgesia and anesthesia
(p. 631). Philadelphia Davis.
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Figure 184 Levels of anesthesia for vaginal
and cesarean births. Source Reprinted with
permission of Ross Laboratories, Columbus, OH.
From Clinical Education Aid No. 17.
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MATERNAL ANESTHESIA

• LOCAL INFILTRATION
• PUDENDAL
• GENERAL

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ANALGESIA AFTER DELIVERY

• EPIDURAL NARCOTIC ANALGESIA (DUROMORPH)
• CONTRAINDICATIONS
• SIDE EFFECTS
• DOSAGE

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MODULE 2 PART 11ABIRTH RELATED PROCEDURES
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BIRTH RELATED PROCEDURES

• AMNIOTOMY
• ARTIFICIAL RUPTURE OF MEMBRANES (AROM
• SPONTANEOUS RUPTURE (SROM)

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AMNIOTOMY

• AFTER 3CM MAY SHORTEN LABOR (AROM) CAN BE A
  STIMULATION OF LABOR
• FHR ASSESSED BEFORE AND AFTER AROMWHY?

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BIRTH RELATED PROCEDURES

• LABOR INDUCTIONSTIMULATION OF UTERINE
  CONTRACTIONS
• INDICATED INDUCTIONWHAT CONDITIONS WOULD WARRANT
  AN INDICATED INDUCTION?
• ELECTIVE INDUCTION

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BIRTH RELATED PROCEDURES

• ELECTIVE INDUCTIONS
• INCREASE IN LAST 10 YEARS
• CONTROVERSY, CONTROVERSY!!!!!!!
• RISKS
• EVIDENCE BASED PRACTICELATE PRETERM NEWBORNS--
  34-37 WEEKS

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BIRTH RELATED PROCEDURES

• LABOR INDUCTION STRIPPING OF MEMBRANES
• ADVANTAGES
• LABOR USUALLY OCCURS WITHIN 24HOURS
• DISADVANTAGES
• CAN BE PAINFUL
• UTERINE CONTRACTIONS
• BLOODY DISCHARGE

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BIRTH RELATED PROCEDURES

• LABOR INDUCTION/AUGMENTATION
• RISKS
• HYPERSTIMULATION OF THE UTERUS
• UTERINE RUPTURE
• WATER INTOXICATION
• NONREASSURING FETAL HEART RATE PATTERNS

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BIRTH RELATED PROCEDURES

• CERVICAL RIPENINGPROSTAGLANDIN E2
• RISKS
• UTERINE HYPERSTIMULATION
• NONREASSURING FETAL STAUS
• HIGHER INCIDENCE OF POSTPARTUM HEMORRHAGE
• UTERINE RUPTURE

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BIRTH RELATED PROCEDURES

• CERVICAL RIPENING
• ADVANTAGES
• SHORTER LABOR
• LOWER REQUIREMENTS FOR OXYTOCIN IN LABOR
• VAGINAL BIRTH IS USUALLY ACHIEVED WITHIN 24 HOURS
• INCIDENCE OF CESAREAN BIRTH IS REDUCED

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• VERSION
• EXTERNAL
• EXTERNAL MANIPULATION
• INTERNAL
• USED TO DELIVER SECOND TWIN DURING VAGINAL BIRTH
  IF NOT DESCENDING OR IN DISTRESS--RARE

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MODULE 2 PART 11BBIRTH PROCEDURES
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BIRTH RELATED PROCEDURES

• VACUUM EXTRACTION
• SUCTION CUP PLACED ON FETAL OCCIPUT
• PUMP IS USED TO CREATE SUCTION
• TRACTION IS APPLIED
• FETAL HEAD SHOULD DESCEND WITH EACH CONTRACTION

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• INDICATIONS FOR VACUUM EXTRACTION
• PROLONGED SECOND STAGE OF LABOR
• NONREASSURING FETAL HEART RATE PATTERN
• USED TO RELIEVE PUSHING EFFORT (MATERNAL FATIGUE)
• WHEN ANALGESIA INTERFERES WITH ABILITY TO PUSH
  EFFECTIVELY
• BORDERLINE CPD (CEPHALO-PELVIC DISPROPORTION)

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BIRTH RELATED PROCEDURES

• VACCUM EXTRACTION
• MATERNAL RISKS
• NEONATAL RISKS

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EPISIOTOMY

• SURGICAL INCISION OF PERINEUM TO ENLARGE OUTLET
• RESEARCHEVIDENCE BASED PRACTICE
• PREVENTATIVE MEASURES
• TWO TYPES
• MEDIAN
• MEDIOLATERAL

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BIRTH RELATED PROCEDURES

• INDICATIONS FOR CESAREAN BIRTH
• CPD
• PLACENTAL ABRUPTION
• ACTIVE GENITAL HERPES
• UMBILICAL CORD PROLAPSE
• FAILURE TO PROGRESS IN LABOR
• PROVEN NONREASSURING FHR PATTERN
• COMPLETE PLACENTA PREVIA

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BIRTH RELATED PROCEDURES

• INDICATIONS FOR CESAREAN BIRTH
• BREECH PRESENTATION
• PREVIOUS CESAREAN BIRTH
• MAJOR CONGENITAL ANOMALIES
• CERVICAL CERCLAGE
• NON-REASSURING FHR PATTERNS

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BIRTH RELATED PROCEDURES

• CESAREAN BIRTH
• SKIN INCISIONS
• TRANSVERSE (PFANNENSTIEL)
• VERTICAL
• UTERINE INCISIONS
• TRANSVERSE
• SELHEIM (LOWER UTERINE SEGMENT)
• CLASSIC (UPPER SEGMENT OF CORPUS)

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BIRTH RELATED PROCEDURES

• PREPARATION FOR C-BIRTH
• MAJOR SURGERY
• SPINAL ANESTHESIA
• MANY TIMES PARENTS HAVE LITTLE TIME TO PREPARE
  PSYCHOLOGICALLY

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BIRTH RELATED PROCEDURES

• AMNIOINFUSION
• INCREASES FLUID VOLUME IN UTERUS BY INSTILLATION
  OF NORMAL SALINE INTO THE UTERUS
• DECREASES PRESSURE ON THE CORDVARIABLE
  DECELERATIONS
• PROMOTES INCREASED PERFUSION TO FETUS
• CAN DILUTE HEAVY MECONIUM FLUID
• USED IN PRETERM LABOR WITH PPROM

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BIRTH RELATED PROCEDURES

• VBAC (VAGINAL BIRTH AFTER CESAREAN)
• CRITERIA
• PREVIOUS C-BIRTH, LOW TRANSVERSE UTERINE INCISION
• AN ADEQUATE PELVIS
• NO OTHER UTERINE SCARS OR PREVIOUS UTERINE
  RUPTURE
• AN IN HOUSE PHYSICIAN AND ANESTHESIOLOGIST