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Midwifery Nursing

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Midwifery Nursing Labor and birth process Prepared by: Mrs. Raheegeh Awni * * Supportive care For women to be active participants in their labor care, preparation and ... – PowerPoint PPT presentation

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Title: Midwifery Nursing


1
Midwifery Nursing
  • Labor and birth process
  • Prepared by Mrs. Raheegeh Awni

2
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3
Outline
  • First stage of labor
  • True labor versus false labor
  • Admission to labor
  • Assessment during labor
  • Progress in labor
  • Partograph sheet
  • Nursing care
  • Fetal monitoring

4
introduction
  • During late pregnancy the woman and fetus prepare
    for the labor process.
  • The fetus has grown and developed in preparation
    for extrauterine life.
  • The woman has gone various physiolgic adaptations
    during pregnancy that prepare her for birth and
    motherhood.

5
  • Labor and birth represent the end of pregnancy,
    the beginning of extrauterine life for the
    newborn, and change in lives of families.
  • (lowdermilk Berry 2006)

6
labor
  • Is the process of moving the fetus, placenta and
    membranes out of the uterus and through the birth
    canal.

7
THE LABOR PROCESS
  • Midwife needs to emphasize that labor and
    delivery are normal physiologic processes.
  • The pregnant woman typically approaches the time
    of delivery with major concerns of her personal
    well-being, that of her unborn child, and fear of
    a difficult and painful labor. Addressing these
    concerns and minimizing her discomfort should be
    of paramount importance to all participants
    involved in the care of the mother and her fetus.

8
Onset of labor
  • Multiple theories have been proposed to explain
    biophysiologic factor that initiate labor, but
    the process is not fully understood.
  • Maternal, fetal factors influence labor onset.

9
  • As pregnancy advances, progesterone is less
    effective in controlling rhythmic uterine
    contractions that normally occur. In addition,
    there may also be an actual decrease in the
    amount of circulating progesterone.
  • There is increased production of prostaglandins
    by fetal membranes and uterine decidua as
    pregnancy advances.
  • In later pregnancy, the fetus produces increased
    levels of cortisol that inhibit progesterone
    production from the placenta.

10
Initiation of Labor
  • The exact mechanism that initiates labor is
    unknown. Theories include
  • Uterine stretch theory uterus becomes stretched
    and pressure increases, causing physiologic
    changes that initiate labor.
  • As pregnancy progresses, there is a gradual rise
    in the amount of circulating oxytocin.

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11
Maternal factor theories
  • 1.Uterine muscles are stretched cuseing release
    of prostaglandin.
  • 2.Pressure on cervix stimulate nerve plexus,
    causing release of oxytocin by maternal posterior
    pituitary gland (the Ferguson reflex).
  • 3.Oxytocin stimulation circulation blood
    increases slowly during pregnancy rises
    dramatically during labor and peaks during second
    stage ,oxytocin and prosoglandin work together to
    inhibit calcium binding in muscle cells, raising
    intracellular calcium and activating contractions.

12
Fetal factor theories
  • 1.Fetal crotisol cocentrationproduced by fetal
    adrenal gland, rises and act on the placenta to
    reduce progesterone formation and increase
    prostaglandin,( Anencephalic) fetuses no adrenal
    glands) tend to have prolonged gestation.
  • 2.prostaglandinproduced by fetal membranes
    amnion and chorion) and the decidua, stimulates
    contractions ,when archidonic acid stored in
    fetal membranes is released at term, it is
    converted to prostaglandin.

13
Sign preceding labor
  • 1-Lightening the fetus descends into the true
    pelvis the women breath more easily, but more
    bladder pressure result from this shifts and
    consequently are turn of urinary frequency.
  • 2.low persistent low backache and sacroiliac
    distress as result of relaxation of the pelvic
    joint.
  • 3.Strong frequent, but irregular uterine
    contraction (Braxton hicks)

14
  • 4. Brownish or bloody tinged cervical mucus may
    be passed bloody show.
  • 5.Cervix become soft partially effaced, the
    membrane may rupture.
  • 6.Loss of 0.2 to1.5Kg weight, result from water
    loss.
  • 7.Asurge of energy (women speak of having a burst
    of energy that they often use to clean the house.
  • 8.Less common diarrhea, nausea, vomiting and
    indigestion.

15
Stages of labor
  • Labor is completed within 18 hr the normal labor
    is consist of
  • 1.Regular progression of uterine contraction.
  • 2.Affacment and progressives dilation of the
    cervix
  • 3.Progress in decent of the presenting part

16
first stage
  • From onset of regular uterine contraction to
    full dilation of the cervix(1hr in multiparous to
    up to 20 hr in primipara.
  • Its divided 3 phases
  • 1.Latent phase more progress in effacement of
    the cervix, little increase in descent (0-3cm),
    6-8 hr, mild to moderate contractions, every 5-30
    min, station zero in nulliparous and 0-2 in
    multiparous.
  • 2.Active phase (4-7cm) 3-6 hr, conraction
    moderate to strong, every 3-5min, station
    varies1 to 2
  • 3.Transition phase (8-10cm) 20-40 min,
    contraction strong, regular, every 2-3 min,
    station 2 to 3

17
second stage
  • Begins when the cervix is fully dilated to the
    birth of the fetus (20minut in multiporous,50minut
    es in nuliporours.
  • Sinkin and Acheta (2000)described the latent and
    active phase of second stage labor.
  • Latent begins about the time of complete
    dilation of the uterus, when the contractions are
    weak, women not feel the urge to push (small
    bearing down efforts)
  • Active when contraction resume the women is
    making strong bearing down effort, and the fetal
    station is advancing.

18
third stage
  • Begins from the birth of the fetus until the
    placenta is delivered, placenta separates with
    the third or forth strong uterine contraction .
  • Duration (3-5minut) or up to 1hr.
  • The risk of hemorrhage increase as the length of
    the third stage increase
  • Fourth stage of labor 2 hr after delivery of

19
First Stage of Labor
  • Begins at the onset of regular uterine
    contraction and ends with full cervical dilation.

20
Cont, First Stage of Labor
  • Consists of the following three phases
  • Latent phases up to 3cm.
  • Active phase 4-7cm.
  • Transition phase 8-10.
  • Nuliparous attend care in latent phase.
  • Multiparous attend in active phase.

21
  • True labor versus false labor

22
True labor
  • Contractions become regular, stronger and lasting
    longer and closer together.
  • Becomes more intense with walking.
  • Felt in lower back radiating to lower abdomen.
  • Cervical effacement.
  • Cx moves to anterior position.
  • Presentation engaged and urinary frequency

23
False ( spurious) labor
  • Irregular or temporarily regular.
  • Stop with walking and or position change.
  • Relieved by comfort measures.
  • Cx. posterior, soft, no change in effacement or
    dilation.
  • No engagement.

24
Physiology of the first stage
  • DURATION or Length of labor varies according to
  • Parity
  • Birth interval
  • Psycholo0gical state
  • Presentation
  • Position of the fetus
  • Pelvic shape and size

25
  • Uterine contractions increase in intensity,
    frequency, and duration as labor progresses due
    to stretching of the cervix.
  • During uterine contractions, the active upper
    portion of the uterus becomes thicker, whereas
    the lower uterine segment stretches and becomes
    thinner (referred to as fundal dominance

26
  • At the completion of a contraction, the upper
    uterine segment retains its shortened, thickened
    cell size and, with each succeeding contraction,
    becomes thicker and shorter. As a result, the
    upper uterine segment never totally relaxes
    during labor.
  • Cells of the lower uterine segment become
    thinner and longer with each contraction. This
    mechanism is greatly responsible for the progress
    of the fetus through the birth canal.

27
Uterine action
  • Fundal dominance
  • Contx.starts near one of the cornua and spreads
    across and down ward.
  • Contx.lasts longest in the fundus and is more
    intense there.
  • This pattern permits the cervix to dilate and the
    strongly contracting fundus to expel the fetus.

28
polarity
  • Is the term used to describe the neuromuscular
    harmoney that prevails between the two poles or
    setgments of the uterus throughout labor.
  • The upper pole contracts strongly and retracts to
    expel the fetus, the lower pole contracts
    slightly to and dilates to allow expulsion.
  • If polarity i9s disorganized, then the progress
    of labor is inhibited.

29
Contraction and retraction
  • During labor, the contractions doesnt pass off
    entirely, but muscle fibers remain some of the
    shortening of contraction instead of becoming
    completely relaxed.
  • This is termed retraction.
  • It assists in progressive expulsion of the fetus.
  • The upper segment becomes shorter and thicker and
    its cavity diminish.

30
  • Contx. occurs with rhythmic regularity and
    interval between them gradually lessens.
  • By the end of the first stage, they occur at 2-3
    minute intervals, last for 50-60 sec. and are
    very powerful.

31
Formation of upper and lower uterine segments
  • The body of the uterus is divided into two parts
    by the end of preg.
  • Upper uterine segment thick and muscular.
    Concerned with cont. and retraction.
  • Lower uterine segment formed of isthmus and
    cervix, about 8-10 cm in length. concerned with
    distension and dilation.
  • In labor, the retracted longitudinal fiber of the
    upper segment pull on the lower causing it to
    stretch aided by the force of the presenting
    part.

32
The retracting ring
  • A ridge between the thinned lower uterine segment
    and the thick retracted upper uterine segment
    caused by obstructed labor.
  • Also called Bandl's ring.
  • The lower segment is abnormally distended and
    thin, and the upper segment is abnormally thick.
  • Visible above the symphysis pubis in mechanically
    obstructed labor

33
  • Factors affecting labor experience

34
1.passenger
the fetus moves through the birth canal is
determined by several interacting factors
1.the size of fetal
head.2.fetal presentation. 3.fetal lie.
4.fetal attitude.
5.fetal position.
35
Fetal size
  • Excessive size and fetal skull bones may not be
    able to override enough to be accommodated in the
    bony pelvic cavity.
  • Fetal posture Flexed head allows smallest
    diameter of fetal head (occiput) to present and
    pass through the birth canal.

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36
Fetal lie
The fetal head is flexed, back is rounded, and
extremities are flexed. Flexed head allows
smallest diameter of fetal head (occiput) to
present and pass through the birth canal (see
Figure 37-1).
through the birth canal (see Figure 37-1).
  • Is the relationship of the fetal long axis to the
    long axis of the woman) that is either
  • transverse, longitudinal, or oblique.
  • In a longitudinal lie (99 of all births), the
    fetal head will present (cephalic presentation)
    or the buttocks or feet will present (breech
    presentation).

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37
fetal attitude.
  • The fetal attitude describes the relationship of
    the fetus' body parts to one another.
  • The normal fetal attitude is commonly referred to
    as the fetal position the head is tucked down to
    the chest, with arms and legs drawn in towards
    the center of the chest.

38
  • Abnormal fetal attitudes may include a head that
    is extended back or other body parts extended or
    positioned behind the back.
  • Abnormal fetal attitudes can increase the
    diameter of the presenting part as it passes
    through the pelvis, increasing the difficulty of
    birth.

39
Fetal position
  • Is the relation of the presenting part to the
    four quadrants of the mother pelvis.
  • Position is donated by three letter
    abbreviation-
  • 1-first letter donate the location of the
    presenting part in the right or left side of the
    mother pelvis-L).
  • 2-middle letter donate for the specific
    presenting part of the fetus O (occiput)
  • S(sacrum)
  • M (mentum) (chin)
  • Sc(scapula)shoulder .
  • 3-third letter -for the location of the
    presenting part in relation to the
    anterior(A),posterior(P),or transverse (T)
    portion of the maternal pelvis
  • E.g. ROA, LSP

40
Example of fatal vertex in relation to front,
back or side of maternal pelvis
41
fontanels and sutures help in1.make the skull
flexible to accommodate the infant brain which
continue to grow for sometime after birth.
2.bones overlabing,or sliding over one anther
permits adaptation to the various diameters of
the maternal pelvis.
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Certain critical diameter of the fetal head are-
  • 1-biparietal diameter-(9.25)cm is the largest
    transverse diameter well flexed cephalic
    presentation .
  • 2-the anteroposterior diameters-
    suboccipitobregmatic diameter-9.5 cm at term the
    head is in complete flexion, this the smallest
    diameter allow the fetal head to pass easily
    through the pelvis.
  • As the head is more extended, the anteroposterior
    diameter widens, the head may not be able to
    enter the pelvis.

45
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Critical diameter of the fetal head
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48
2.Fetal presentationrefers to part of fetus
that enters the pelvic inlet first and leads
through the birth canal during labor at term
three type 1.cephalic head96 of birth
.2.breech presentation (buttocks or
feet)3.3.shoulder presentation 1of birth.
49
Presenting part refers to that part of the fetal
body first felt by the examining finger during
vaginal examination.
  • Presentation
  • Cephalic( vertex)
  • Breech
  • Shoulder
  • Presenting part
  • Occipital
  • Sacrum
  • scapula

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2-Passage way
  • Birth canal composed of
  • 1-mothers rigid bony pelvis .
  • 2-soft tissue of the cervix, pelvic floor,vagina,
    introitus(the external opening to the vagina

52
  • Pelvic Dimensions
  • Adequate pelvic inlet (anteroposterior diameter
    normal shape).
  • Adequacy of pelvic dimensions determined by
    pelvic examination during pregnancy and again
    with the onset of labor.

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Soft tissues
  • Include the distensible lower uterine segment,
    cervix, pelvic floor muscles, vagina and
    introitus.
  • The cervix effaces and dilates to allow the first
    fetal portion to descend in to vagina.
  • The pelvic floor is a muscular layer that help
    the fetus rotate anteriorly as it passes through
    the birth canal.

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3-power
  • -Involuntary power involuntary uterine
    contraction (primary power),
  • -Voluntary power bearing down effort by the
    women (secondary power)
  • -Primary power is responsible for the
    effacement and dilation of the cervix.
  • -secondary power have importance in the
    expulsion of the infant from the uterus and
    vagina after full dilatation.
  • The pushing in the second stage is more
    effective.
  • (robers, 2002).

57
4- postion of laboring women
  • Frequent changes in position relieve fatigue,
    increase comfort and improve circulation
  • -An upright position- (walking, sitting,
    kneeling, or squating) has the advantage to
    promote the descent of the fetus, uterine
    contraction stronger and more efficient, also
    increases the women cardiac output.
  • -The all four position (hand and knee) used to
    relive backache, and if the fetus is in an
    occipitoposterior position assist in anterior
    rotation of the fetus.

58
squatting
59
psychology
  • 1.External forces including place of birth.
  • 2.Prepration.
  • 3.Type of provider. 4. Procedure.
  • 5.Physiology (sensation) as an interval
    force.

60
Mechanism of labor
  • For vaginal birth to occur, the fetus must adapt
    to the birth canal during the descent.
  • Seven cardinal movement that occur in a vertex
    presentation-
  • 1-engagment
  • 1-descent
  • 3-flexion
  • 4-internal rotation
  • 5-extention
  • 6-external rotation
  • 7- birth of expulsion

61
1- engagement
  • Is used to indicate that the largest transverse
    diameter of the presenting part has passed
    through the maternal pelvic brim or inlet into
    the true pelvis and usually corresponds to
    station.
  • When the biparietal diameter of the head pass
    into the pelvic inlet.

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2- descent
  • Is the progress of presenting part through the
    pelvic canal.

63
Descend
  • Station of presenting part
  • Nuliparous0st. in early phases
  • 1cm to 2cm in active phase
  • Transition phase 2 to 3cm

64
Descend
  • Multiparous -2 to zero in latent phase
  • Active phase 1 to 2cm
  • Transition phase 2 to 3 cm

65
Station
  • refers to the relationship between the fetal
    presenting part and pelvic landmarks.
  • When the presenting part is at zero station, it
    is at the level of the ischial spines, which are
    the landmarks for the midpelvis. This is
    important in the vertex presentation because it
    implies that the largest dimension of the fetal
    head, the biparietal diameter, has passed through
    the smallest dimension of the pelvis, the pelvic
    inlet.
  • In 1988, the American College of Obstetricians
    and Gynecologist introduced a classification
    dividing the pelvis into 5-cm segments above and
    below the spines

66
  • If the presenting part is 1 cm above the spines,
    it is described as -1 station.
  • If it is 2 cm below the spines, the station is
    2.
  • At -5 station, the presenting part is described
    as floating.
  • At 5 station, the presenting part is on the
    perineum, and it may distend the vulva with a
    contraction and be visible to an observer.

67
Show
  • Latent phase brown discharge, mucous plug, pale
    pink mucous, scanty.
  • Active phase pink bloody mucous, mild to
    moderate in amount.
  • Transition phase bloody, copious mucous.

68
Assessment of uterine contractions
  • Uterine contractions are the primary powers that
    act involuntarily to expel fetus and placenta.
  • Assessed by
  • Womans subjective description of pain
  • Palpation and timing of contraction
  • Electronic monitoring

69
Uterine contractions
  • Parts of contraction
  • Slow increment the building up of a contraction
    from its beginning.
  • Acme intrauterine pressure less than 80 mmHg.
  • Decrement letting down of the contraction.

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Uterine contraction
  • Is described in terms of the following
  • Frequency how often it occurs the time elapses
    from the beginning of one contraction to the
    beginning of the second contraction.
  • Intensity strength of a contraction at its
    peak.
  • Duration the time that elapses between the onset
    and the end of a contraction.
  • Resting tone the tension in the uterine muscle
    between contractions.

72
Palpation of uterine contraction
  • Mild- slightly tense fundus feels like touching
    finger to tip of nose.
  • Moderate- firm fundus feels like touching finger
    to chin.
  • Strong- rigid, broad like fundus, feels like
    touching finger to forehead.

73
Cervix
  • Uterine activity must be assessed in relation
    to
  • their effect on the degree of cervical dilation,
    effacement, and descend.
  • Effect on the fetus.

74
Effacement ( taking up of the cervix)
  • Here the cx. Is drawn up and gradually merges
    into the lower uterine segment.
  • In primparous this results in complete effacement
    in internal and external os.
  • Oestrogen stimulate placenta to release PGsthat
    induce production of enzymesthat will
    digestcollagen in the cervix.

75
Vaginal Examination
  • Reveals whether woman is in true labor.
  • Determine whether membranes have ruptured.

76
Vaginal Examination
  • Indications
  • On admission
  • When significant change occur in uterine
    activity.
  • Urge to pear down
  • ROM
  • Variable deceleration

77
Assessment of amniotic membranes and fluid
  • SROM occurs in approximately 25 with onset of
    labor.
  • Can occur at any time of labor.
  • Occurs most commonly in transition phase.

78
Assessment of amniotic membranes and fluid
  • Amniotomy ( AROM ) may be done to
  • Augment labor
  • Induce labor
  • Insertion of fetal scalp electrode
  • Intrauterine pressure catheter

79
Characteristics of amniotic fluid
  • Color pale, straw colored, contain white flecks
    of vernix caseosa, lanugo and scalp hair.
  • Viscosity and odor watery, no strong odor.
  • Amount varies with GA. 1000 ml/36-38 weeks.

80
EVIDENCE
  • Membrane sweeping at initiation of labor
    increased the spontaneous vaginal delivery rate,
    reduced oxytocic drug use, shortened induction to
    delivery interval, and improved patient
    satisfaction.
  • (Membrane Sweeping at Initiation of Formallabor
    induction Obstet Gynecol 2006)

81
Medwifery Diagnosis
  • Anxiety related to
  • Negative experience with child birth.
  • Cultural differences

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Midwife Diagnosis
  • Impaired urinary elimination
  • Impaired fetal gas exchange
  • Low self esteem
  • Acute pain

83
  • MATERNAL ASSESSMENT

84
Admission to labor
  • Interview techniques
  • Physical assessment
  • Laboratory investigations
  • Fetal assessment.
  • Family centered is the trend in maternity today.

85
Admission to labor
  • Birth plan
  • Choice if infant feeding
  • Pain management
  • Name of health care provider
  • Family members desired during labor and birth
  • Ethnic or cultural expectation

86
  • HISTORY
  • Obtain a brief oral history when the woman is
    admitted to the birthing area.
  • Each agency has its own admission forms, but they
    usually include the following
  • information
  • Womans name and age
  • (LMP) and estimated date of birth (EDB)
  • Attending physician or certified nurse-midwife
    (CNM)

87
  • Personal data blood type Rh factor results of
    serology testing
  • prepregnant and present weight allergies to
    medications, foods, or other substances
    prescribed and over-the-counter medications
    taken.
  • History of drug and alcohol use and smoking
    during the pregnancy.

88
  • History of previous illness, such as
    tuberculosis, heart disease,
  • diabetes, and so forth.
  • Problems in the prenatal period, such as
    elevated blood pressure, Seizure history
  • bleeding problems, recurrent urinary tract
    infections, other infections.
  • A history of genital herpes, bleeding, abnormal
    placentation, hepatitis B/C, HIV, carriage of
    group B streptococcus
  • Pregnancy data gravida, para, abortions, and
    perinatal deaths
  • The method chosen for infant feeding
  • Type of prenatal education classes (childbirth
    education classes)
  • (Williams Wilkins. Manual of Obstetrics 2007,
    7th Edition, Lippincott)

89
  • Womans preferences about labor and birth, such
    as no episiotomy, no analgesics or anesthetics,
    or the presence of the father or others at the
    birth.
  • Pediatrician or family practice physician
  • Additional data history of special tests such
    as nonstress test (NST),
  • biophysical profile (BPP), or ultrasound history
    of any preterm labor
  • onset of labor amniotic fluid membrane status
    and brief description of previous labor and
    birth.

90
  • Status of amniotic membranes.
  • If ruptured, time of rupture, color of fluid, and
    odor.)
  • Ultrasound is used to evaluate amniotic fluid
    volume if the status of the membranes is still
    uncertain after physical and laboratory testing.
  • The psychosocial history is a critical component
    of intrapartal assessment.

91
Psychological factors
  • Because of the prevalence of domestic violence in
    society, the midwife needs to consider the
    possibility that the woman may have experienced
    abuse at some time in her life.
  • Women with history of sexual have intense
    sensation in uterus and vaginal area.
  • Triggered by intrusive procedures as vaginal
    examination, restrains by Iv lines and epidurals
    and being watched by students.

92
  • The following screening questions should be asked
  • universally when the woman is alone so that she
    can answer freely (ACOG, 1999)
  • 1. Has anyone close to you ever threatened to
    harm you?
  • 2. Have you ever been hit, slapped, kicked,
    choked, or otherwise
  • physically hurt by someone? If yes, by whom?
    Total number of times?
  • Has anyone, including your partner, ever forced
    you to have sex?
  • Are you afraid of your partner or anyone you
    mentioned.

93
CULTURAL ASSESSMENT
  • Cultural influences determine customs and
    practices
  • regarding intrapartal care.
  • Who would she like to remain with her during
    your labor and birth.
  • What would she like to wear during labor.
  • What activity would she like during labor.
  • What position would she like for the birth.
  • Is there anything special yoshe would like.
  • Observe the womans response when privacy is
  • difficult to maintain and her body is exposed.
  • If the woman is to breastfeed, ask if she would
    like
  • to feed her baby immediately after birth.

94
Physical examination
  • General systems assessment
  • Leopold maneuver
  • Assessment of uterine contractions
  • Vaginal examinations

95
PHYSICAL ASSESSMENT/ NORMAL FINDINGS
  • Blood pressure (BP) 130 systolic and 85
  • diastolic in adult 18 years of age or older or no
  • more than 1520 mm Hg rise in systolic pressure
  • over baseline BP during early pregnancy
  • Pulse 6090 beats per minute (bpm)
  • Respirations 1422/minute (or pulse rate
  • divided by 4)
  • Pulse oximeter (if used) 95 or greater
  • Temperature 36.237.6C (9899.6F)

96
  • Weight
  • 2535 lb greater than prepregnant weight
  • Lungs
  • Normal breath sounds, clear and equal
  • Fundus
  • At 40 weeks gestation located just below xiphoid
  • process
  • Edema
  • Slight amount of dependent edema
  • Hydration
  • Normal skin turgor, elastic
  • Perineum
  • Tissues smooth, pink color

97
head
  • Examination of the head should include fundoscopy
    to rule out vascular abnormalities, hemorrhages,
    or exudates that may suggest such diseases as
    diabetes or hypertension.
  • Pale conjunctivae (or nail beds) may suggest
    anemia.
  • Facial as well as hand and ankle edema are common
    in preeclampsia.
  • The thyroid gland should be palpated to rule out
    goiter or other masses.

98
Chest
  • Examination of the chest may reveal the presence
    of a pneumonic process or significant cardiac
    murmurs (other than the physiologic systolic
    ejection murmur common in pregnancy) and provides
    a baseline in case complications such as
    pulmonary edema develop.

99
  • Distended neck veins suggest congestive heart
    failure, which, although rare, is a serious
    complication of labor and should be recognized
    early so that proper therapy may be initiated.
  • Auscultation of the lungs for rales, crackles,
    and wheezes is especially important in patients
    with asthma or hypertension, or at risk for
    pulmonary edema.

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Abdomen
  • An attempt should be made to palpate major
    abdominal viscera for pain or masses, although
    this is difficult with a term-sized uterus.
  • Epigastric tenderness may suggest preeclampsia or
    HELLP (hemolysis, elevated liver enzyme levels,
    and a low platelet count) syndrome.

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Extremities
  • Examination of extremities should include an
    assessment of peripheral edema.
  • Although mild ankle edema commonly is found near
    term in normal pregnancies, severe lower
    extremity or hand edema may suggest preeclampsia.
  • A brief neurologic examination should be
    performed because the presence of deep-tendon
    hyperreflexia and clonus may suggest impending
    seizure activity.

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Obstetric Abdominal Examination
  • It is essential to determine the position of the
    fetus within the uterus for labor management with
    the four maneuvers described by Leopold for
    examination of
  • Fetal Lie
  • Presentation
  • Fetal Heart Tones

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  • Uterine contractions regular pattern
  • FHR 110160 bpm
  • Presentation Cephalic, 97
  • Breech, 3
  • Position left occiput anterior (LOA) most common
  • Activity fetal moveme

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  • Membranes may rupture before or during labor
  • Amniotic fluid clear, with earthy or human odor,
  • no foul-smelling odor
  • Fetal Status

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Pelvic Examination
  • Inspection
  • The perineum should be inspected for herpetic
    lesions, large vulvar varicosities, large
    condylomas, and evidence of poorly healed
    perineal lacerations
  • Diagnosis of ruptured membranes may sometimes be
    visually confirmed

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Palpation of the Cervix
  • Palpation of the cervix should be done when the
    patient is between contractions to ensure
    accuracy and to minimize the patient's
    discomfort.
  • Dilation of the cervix describes the degree of
    opening of the cervical os.
  • Effacement of the cervix describes the process of
    thinning that the cervix undergoes before or
    during labor

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Palpation of the Fetal Presenting Part
  • Identification of fetal presentation should be
    confirmed by digitally palpating the fetal
    presenting part.
  • Vertex presentation can be confirmed by palpating
    the suture lines of the fetal skull. If the
    suture lines cannot be identified with certainty,
    other presentations must be considered.
  • Inability to positively identify the presenting
    part demands an ultrasound examination.
  • Station
  • position

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Laboratory Tests
  • prenatal laboratory tests should be drawn at
    admission.
  • Hematocrit or hemoglobin
  • Urinalysis, including microscopic examination and
    urine testing to detect asymptomatic bacteriuria
  • Blood group and Rh status
  • Antibody screen
  • Rubella immunity status
  • Serologic test for syphilis
  • Cervical cytology
  • Hepatitis B virus surface antigen (HbsAg)
  • HIV testing (recommended for all pregnant women,
    with their consent).
  • Additional laboratory evaluations, such as
    (STDs),

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Assessment of Progress in Labor
  • Assessment requires periodic digital examination
    of the cervix to assess changes in effacement,
    cervical dilation, and descent of the presenting
    part. Vaginal examinations should be timed often
    enough to determine the progress of labor, while
    still being limited for the sake of patient
    comfort and to minimize the risk of infection.
  • The latent phase of labor is variable in length
    and may range between 14 and 20 hours without
    being pathologic.
  • As long as fetal well-being is assured, and
    absent maternal compromise, an operative
    intervention for a protracted labor is not
    indicated.

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The partogram (partograph)
  • Is considered a valuable tool in the improvement
    of maternity care by allowing midwives and
    obstetricians to record intrapartum details
    belief that its use was applicable in developed
    and developing settings led to its introduction
    worldwide.
  • ( Effect of Different Partogram Action Lines on
    Birth Outcome VOL. 108, NO. 2, AUGUST 2006).

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Amniotomy
  • Or artificial rupture of the membranes (AROM), is
    usually accomplished by fracturing the membranes
    with a sterile plastic instrument that is guided
    between two gloved fingers.
  • Is the only definitive way to visualize the
    amniotic fluid.

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Indications for amniotomy
  • Visualizing the amniotic fluid for quantity and
    evidence of meconium or blood.
  • Gaining direct access to the fetus for placement
    of internal fetal monitors.
  • To induce labor or restore progress in labor.
  • Impending second stage of labor where the
    provider wants to minimize the risk of exposure
    to body fluids during the birth.
  • To gain direct access to the fetal scalp.

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  • The effect of amniotomy on the duration of labor
    is controversial
  • Most studies suggest that amniotomy performed in
    the active phase of labor significantly shortens
    labor.
  • At the National Maternity Hospital in Dublin,
    amniotomy is performed by protocol once the
    diagnosis of active labor has been confirmed.
  • Amniotomy performed during or before the latent
    phase of labor has been shown not to be
    beneficial to the course of labor.

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Risks of amniotomy
  • Rupture of a fetal vessel traversing the fetal
    membranes (vasa previa) at the site of amniotomy.
  • Prolapse of the umbilical cord
  • The risk of cord prolapse can be minimized by not
    performing amniotomy until the head is engaged in
    the pelvis and is exerting significant pressure
    against the cervix.
  • Cord prolapse can also occur with spontaneous
    rupture of membranes.
  • Fetal acidosis
  • variable fetal heart rate decelerations

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Plan of care and interventions
  • Implement fetal monitoring per protocol.
  • Provide labor care as hospital procedures manual.
  • Inform health care provider if any problem
    occurs.
  • Provide care of vaginal birth as hospital
    procedures manual.
  • Provide immediate care of new born.

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Physical midwifery care in during labor
  • General hygiene ( showers and warm water baths ).
  • Nutrient and fluid intake.
  • Elimination voiding and bowel elimination (
    routine use of enema to empty rectum is
    considered to be harmful and useless ).

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Ambulation and positioning
  • Advantages
  • Enhance uterine activity.
  • Distraction from labors discomfort.
  • Enhances maternal control.

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Ambulation and positioning
  • Encourage ambulation if
  • Membranes are intact.
  • Fetal presenting part is engaged.
  • After ROM
  • Woman hasnt received medications for pain

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Ambulation and positioning
  • Woman should change her position every 30- 60
    minutes.
  • Side lying or lateral position because it
    promotes uteroplacental and renal blood flow.
  • It increases fetal oxygen saturation.

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Ambulation and positioning
  • If the fetus is OP position, encourage woman to
    squat during contraction.
  • This position increases pelvic diameter, allowing
    the head to rotate to more AP position.

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Ambulation and positioning
  • Hand and knee position during contractions is
    recommended to facilitate rotation of fetal
    occiput from posterior to anterior position.

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Ambulation and positioning
  • Gymnastic ball or birth ball is used in physical
    therapy to support womans body as she assumes
    various labor and birth positions.
  • It encourages pelvic mobility pelvic and
    perineal relaxation when woman moves in rhythmic
    movements.

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Supportive caring
  • Involves
  • emotional support
  • physical care
  • Comfort measures

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Supportive caring
  • Effective support during labor results in
  • Shorter labors
  • Reduced rates of complications and surgical or
    obstetrical interventions

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Evidence
  • Supportive caring
  • Fathers support in birth helped mothers to have
    more positive experiences in all aspects of
    childbirth.
  • There was no relationship between fathers
    support and length of labor, use of
    pain-relieving drugs, or obstetric interventions
    in birth.
  • When mother and father were supported during
    labor and delivery, the rate of the fathers who
    adopted an active role was high.
  • ( Effects of Fathers Attendance to Labor and
    Delivery on the Experience of Childbirth in
    Turkey.2007)

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Comfort measures
  • Maintaining a comfortable , supportive
    atmosphere.
  • Using touch therapeutically like heat or ice
    applied to back during contraction.
  • Non pharmacological measures to relieve
    discomfort like massage and hydrotherapy.

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Supportive care
  • For women to be active participants in their
    labor care, preparation and labor support are
    crucial.
  • A supportive atmosphere during labor and birth
    can make all the difference in creating an
    optimal experience for normal birth.
  • The benefits of childbirth education, a prepared
    spouse or partner, and continuous labor support
    of a doula, competent nurse, and a patient
    physician who endorse natural childbirth are
    credited with providing a satisfying normal-birth
    experience.
  • (Marry A. Advanced Preparation and Positive Labor
    Support Create an Optimal Experience for Normal
    Birth. 2006)

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