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PINES CITY COLLEGES

College of Nursing
Magsaysay Avenue, Baguio City

DR Write Up
Submitted to: Mrs. Deanna Botengan R.N Clinical Instructor Submitted by: Abella, Christian H. Amansec, Lovely F. Cerbito, may-Jean Bayating, Andrew Winston Q. Delos Reyes, Jorick P. Eugenio, Dianne O. Galapon, Roel T. Laguisma, John I. Madarang, Monica F. Raguindin, Roselie Uy, Mary Princess D. BSN IV-5 Group 4

A. PATIENTS PROFILE Name Age Occupation Address Case Number Diagnosis Surgeon : BANDOS, JOCELYN D. : 21 : NONE : 003 Trinville Subdivision Tomay LTB : 033406 : PU 37-38 weeks AOG, G1P0, Liking BOW x3 hours : Dra. Fianza

B. ANATOMY & PHYSIOLOGY OF THE SYSTEM INVOLVE

The uterus has thick, muscular walls and is very small. In a nulliparous woman, the uterus is only about 7 cm long by 4 to 5 cm wide, but it can expand to hold a 4 kg baby. The lining of the uterus is called the endometrium, and has a rich capillary supply to bring food to any embryo that might implant there. The bottom end of the uterus is called the cervix. The cervix secretes mucus, the consistency of which varies with the stages in her menstrual cycle. At ovulation, this cervical mucus is clear, runny, and conducive to sperm. Post-ovulation, the mucus gets thick and pasty to block sperm. Enough of this mucus is produced that it is possible for a woman to touch a finger to the opening of her vagina and obtain some of it. If she does this on a daily basis, she can use the information thus gained, along with daily temperature records, to tell where in her cycle she is. If a woman becomes pregnant, the cervical mucus forms a plug to seal off the uterus and protect the developing baby, and any medical procedure which involves removal of that plug carries the risk of introducing pathogens into the nearly-sterile uterine environment. The vagina is a relatively-thin-walled chamber. It servs as a repository for sperm (it is where the penis is inserted), and also serves as the birth canal. Note that, unlike the male, the female has separate opening for the urinary tract and reproductive system. These openings are covered externally by two sets of skin folds. The thinner, inner folds are the labia minora and the thicker, outer ones are the labia majora. The labia minora contain erectile tissue like that in the penis, thus change shape when the woman is sexually aroused. The opening around the genital area is called the vestibule. There is a membrane called the hymen that partially covers the opening of the vagina. This is torn by the womans first sexual intercourse (or sometimes other causes like injury or some kinds of vigorous physical activity). In women, the openings of the vagina and urethra are susceptible to bacterial infections if fecal bacteria are wiped towards them. Thus, while parents who are toilet-training a toddler usually wipe her from back to front, thus imprinting that sensation as feeling right to her, it is important, rather, that that little girls be taught to wipe themselves from the front to the back to help prevent vaginal and bladder infections. Older girls and women who were taught the wrong way need to make a conscious effort to change their habits.

At the anterior end of the labia, under the pubic bone, is the clitoris, the female equivalent of the penis. This small structure contains erectile tissue and many nerve endings in a sensitive glans within a prepuce which totally encloses the glans. This is the most sensitive point for female sexual stimulation, so sensitive that vigorous, direct stimulation does not feel good. It is better for the man to gently stimulate near the clitoris rather than right on it. Some cultures do a procedure, similar to circumcision, as a puberty rite in teenage girls in which the prepuce is cut, exposing the extremelysensitive clitoris. There are some interesting speculations on the cultural significance of this because the sensitivity of the exposed clitoris would probably make having sexual intercourse a much less pleasant experience for these women.

C. OPERATION/ SURGERY PERFORMED


A normal vaginal delivery (NVD) is a term for a vaginal delivery, whether or not assisted or induced, usually used in statistics or studies to contrast with a delivery by cesarean section. Childbirth (also called labor, birth, partus or parturition) is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus. The process of normal human childbirth is categorized in three stages of labor: the shortening and dilation of the cervix, descent and birth of the infant, and birth of the placenta.[1] In many cases, with increasing frequency, childbirth is achieved through caesarean section, the removal of the neonate through a surgical incision in the abdomen, rather than through vaginal birth. In the US and Canada it represents nearly 1 in 3 (31.8%) and 1 in 4 (22.5%) of all childbirths, respectively. Childbirth is routinely treated as a medically-centered hospital event in Western society, although prior to the 20th century it was a woman-centered event that occurred at home.

Signs and symptoms

Labor is accompanied by intense and prolonged pain. Pain levels reported by laboring women vary widely. Pain levels appear to be influenced by fear and anxiety levels, experience with prior childbirth, faction with the experience of childbirth than are other factors such as age, socioeconomic status, ethnicity, preparation, physical environment, immobility, or medical intervention from screaming but recommend moaning and grunting to relieve some pain. Crowning feels like an intense stretching and burning sensation. Even women who show little reaction to labor pains often display a reaction to crowning.

Psychological
Childbirth can be an intense event and strong emotions, both positive and negative, can be brought to the surface. While many women experience joy, relief, and elation upon the birth of their child, some women report symptoms compatible with post-traumatic stress disorder (PTSD) after birth. Between 70 and 80% of mothers in the United States report some feelings of sadness or "baby blues" after childbirth. Postpartum depression may develop in some women; about 10% of mothers in the United States are diagnosed with this condition. Abnormal and persistent fear of childbirth is known as tokophobia. Preventive group therapy has proven effective as a prophylactic treatment for postpartum depression. Childbirth is stressful for the infant. In addition to the normal stress of leaving the protected uterine environment, additional stresses associated with breech birth, such as asphyxiation, may affect the infant's brain.

2. Discussion of the procedure Normal human birth Mechanism of vaginal birth


Because humans are bipedal with an erect stance and have, in relation to the size of the pelvis, the biggest head of any mammalian species, human fetuses and human female pelvises are adapted to make birth possible. The erect posture causes the weight of the abdominal contents to thrust on the pelvic floor, a complex structure which must not only support this weight but allow three channels to pass through it: the urethra, the vagina and the rectum. The relatively large head and shoulders require a specific sequence of maneuvers to occur for the bony head and shoulders to pass through the bony ring of the pelvis. A failure of these maneuvers results in a longer and more painful labor and can even arrest labor entirely. All changes in the soft tissues of the cervix and the birth canal depend on the successful completion of these six phases: 1. Engagement of the fetal head in the transverse position. The baby's head is facing across the pelvis at one or other of the mother's hips. 2. Descent and flexion of the fetal head. 3. Internal rotation. The fetal head rotates 90 degrees to the occipito-anterior position so that the baby's face is towards the mother's rectum.

4. Delivery by extension. The fetal head passes out of the birth canal. Its head is tilted backwards so that its forehead leads the way through the vagina. 5. Restitution. The fetal head turns through 45 degrees to restore its normal relationship with the shoulders, which are still at an angle. 6. External rotation. The shoulders repeat the corkscrew movements of the head, which can be seen in the final movements of the fetal head. The fetal head may temporarily change shape substantially (becoming more elongated) as it moves through the birth canal. This change in the shape of the fetal head is called molding and is much more prominent in women having their first vaginal delivery.

Latent phase
The latent phase of labor, also called prodromal labor, may last many days and the contractions are an intensification of the Braxton Hicks contractions that may start around 26 weeks gestation. Cervical effacement occurs during the closing weeks of pregnancy and is usually complete or near complete, by the end of latent phase. Cervical effacement or Cervical dilation is the thinning and stretching of the cervix. The degree of cervical effacement may be felt during a vaginal examination. A 'long' cervix implies that not much has been taken into the lower segment, and vice versa for a 'short' cervix. Latent phase ends with the onset of active first stage; when the cervix is about 3 cm dilated.

First stage: dilation


There are several factors that midwives and clinicians use to assess the laboring mother's progress, and these are defined by the Bishop Score. The Bishop score is also used as a means to predict whether the mother is likely to spontaneously progress into second stage (delivery). The first stage of labor starts classically when the effaced (thinned) cervix is 3 cm dilated. There is variation in this point as some women may have active contractions prior to reaching this point, or they may reach this point without regular contractions. The onset of actual labor is defined when the cervix begins to progressively dilate. Rupture of the membranes, or a blood stained 'show' may or may not occur at or around this stage Uterine muscles form opposing spirals from the top of the upper segment of the uterus to its junction with the lower segment. During effacement, the cervix becomes incorporated into the lower segment of the uterus. During a contraction, these muscles contract causing shortening of the upper segment and drawing upwards of the lower segment, in a gradual expulsive motion. This draws the cervix up over the baby's head. Full dilatation is reached when the cervix has widened enough to allow passage of the baby's head, around 10 cm dilation for a term baby.

The duration of labor varies widely, but active phase averages some 8 hours for women giving birth to their first child ("primipara") and 4 hours for women who have already given birth ("multipara"). Active phase arrest is defined as in a primigravida woman as the failure of the cervix to dilate at a rate of 1.2 cm/hr over a period of at least two hours. This definition is based on Friedman's Curve, the gold standard for rates of cervical dilation and fetal descent during active labor. The Friedman curve likely represents an ideal, rather than an average, curve. This study does have limitations (e.g., assessment of cervical dilation is somewhat subjective), and as a result practitioners should use the Friedman Curve as a guideline rather than an absolute indicator of protraction and arrest. Women who do not progress at this rate are in no way "abnormal," as every birth is unique. Some practitioners misdiagnose "Failure to Progress," either out of impatience or inexperience, and perform an unnecessary Cesarean. However, as is the case with any misdiagnosis, doing so is severely discouraged due to the extra expense and healing time involved with Cesarean operations.

Sequence of cervix dilation during labor

Cervical Dilatation and Effacement


Using sterile gloves and lubricant perform a vaginal exam and determine the dilatation and effacement of the cervix. A small amount of bleeding during the days or hours leading up to the onset of labor is common and called "bloody show." Dilatation is expressed in centimeters. I have relatively large fingers, and for my hands, I make the following generalizations:
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1.5 cm: One finger fits tightly through the cervix and touches the fetal head.

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2.0 cm: One finger fits loosely inside the cervix, but I can't fit two fingers in. 3.0 cm: Two fingers fit tightly inside the cervix. 4.0 cm: Two fingers fit loosely inside the cervix. 6.0 cm: There is still 2 cm of cervix still palpable on both sides of the cervix. 8.0 cm: There is only 1 cm of cervix still palpable on both sides of the cervix. 9.0 cm: Not even 1 cm of cervix is left laterally, or there is only an anterior lip of cervix. 10.0 cm: I can't feel any cervix anywhere around the fetal head.

Effacement is easiest to measure in terms of centimeters of thickness, ie., 1 cm thick, 1.5 cm thick, etc. Alternatively, you may express the thickness in percent of an uneffaced cervix...ie, 50%, 90%, etc. This expression presumes a good knowledge of what an uneffaced cervix should feel like.

Fetal Orientation
By abdominal and pelvic examination, determine the orientation of the fetus. There are basically 3 alternatives:
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Cephalic (head first, or vertex) Breech (butt or feet coming first) Transverse lie (side-to-side orientation, with the fetal head on one side and the butt on the other)

Most of the time, the fetus will be head first (vertex). The easiest way for a relatively inexperienced examiner to determine this presentation is by pelvic exam. The fetal head is hard and bony, while the fetal butt is soft everywhere except right over the fetal pelvic bones. When the baby is presenting butt first, the presenting part is very soft, but with hard areas within it (sacrum and ischial tuberosities). If one or both feet are presenting first, you will feel them. If you don't feel any presenting part (head or butt) on pelvic exam, there is a good chance the baby is in transverse lie (or oblique lie). Then things get a little more complicated. Transverse lie or oblique lie can be suspected if the fundal height

measurement is less than expected and if on abdominal exam, the basic orientation of the fetus is side-to-side. More experienced examiners can tell much from an abdominal exam. Making a "V" with their thumb and index finger and pressing down just above the pubic bone, they can usually feel the hard fetal head at the pelvic inlet.

Leopold's Maneuvers
Leopolds' maneuvers are used to determine the orientation of the fetus through abdominal palpation. 1. Using two hands and compressing the maternal abdomen, a sense of fetal direction is obtained (vertical or transverse). 2. The sides of the uterus are palpated to determine the position of the fetal back and small parts. 3. The presenting part (head or butt) is palpated above the symphysis and degree of engagement determined

4. The fetal occipital prominence is determined. Status of Fetal Membranes


With a pelvic examination, determine the status of the fetal membranes (intact or ruptured). A history of a sudden gush of fluid is suggestive, but not convincing evidence of ruptured membranes. Sudden, involuntary loss of urine is a common event in late pregnancy. Usually, ruptured membranes are confirmed by a continuing, steady leakage of amniotic fluid, pooling of clear, Nitrazine positive fluid in the vagina on speculum exam. Vaginal secretions are normally slightly acid, turning Nitrazine paper yellow. Amniotic fluid, in contrast, is a weak base, and will turn the Nitrazine paper a dark blue. Dried amniotic fluid forms crystals (ferning) on a microscope slide. Vaginal secretions do not.

Blood Count
Following admission, the hemoglobin or hematocrit may be useful. Women with significant anemia are more likely to have problems sustaining adequate uterine perfusion during labor. They also have less tolerance for hemorrhage than those with normal blood counts. Women with no prenatal care should, in addition, have a blood type, Rh factor, and atypical antibody screen performed. Other tests may be indicated, based on individual histories.

Management of Early Labor


If the patient is in early labor, with a normal pregnancy, and intact membranes, she may feel like ambulating and this is very acceptable. Not all women in early labor feel like walking and she need not be forced out of bed. Some patients, particularly those with ruptured membranes and those with certain risk factors are probably better off staying in bed, even during early labor. While in bed, it is preferable, in women without continuous electronic fetal monitoring, to have them lie on one side or the other, but to avoid being on their back. Such lateral positioning maximizes uterine blood flow and provides a greater margin of safety for the baby. Women with continuous electronic fetal monitoring may choose whatever position is most comfortable. If there is a problem with uterine blood flow, it will be demonstrated on the fetal monitoring strip and appropriate position changes can be undertaken. Recheck the maternal vital signs every 4 hours. Elevation of blood pressure may indicate the onset of pre-eclampsia. Elevation of temperature >100.4 may indicate the development of infection. Because of the risk of vomiting and aspirating later in labor, it is best to avoid oral intake other than small sips of clear liquids or ice chips. If labor is lengthy or dehydration becomes an issue, IV fluids are administered. Lactated Ringer's or Lactated Ringer's with 5% Dextrose at 125 cc/hour (6-hours for 1 L) are good choices. Periodic pelvic exams are performed using sterile gloves and a water-soluble lubricant. The frequency of such exams is determined by individual circumstances, but for a normal patient in active labor, an exam every 2-4 hours is common. In active labor,

progress of at least 1 cm per hour is the expected pattern. If the patient feels rectal pressure, an exam is appropriate to see if she is completely dilated. Some women experience difficulty emptying their bladder during labor. Avoiding overdistension of the bladder during labor will help prevent postpartum urinary retention. If the patient is uncomfortable with bladder pressure and unable to void spontaneously, catheterization will be welcomed.

Monitor the Fetal Heart


Prior to active labor, the fetal heart rate for low risk patients is usually evaluated every hour or two. Once active labor begins for these women (4 cm dilated, with regular, frequent contractions), the fetal heart rate is evaluated every 30 minutes. This can be done by looking at the electronic fetal monitor (if used), or by measuring the fetal heart rate following a contraction. Fetal jeopardy is likely if the auscultated fetal heart rate is less than 100 BPM, even if it later rises back to the normal range of 120-160. Persistent fetal tachycardia (greater than 160 BPM) is also of concern. For women with significantly increased risks, it is better to evaluate the fetal heart rate every 15 minutes during the active phase of labor. Women in the second stage of labor (completely dilated but not yet delivered) usually have their fetal heart rate evaluated every 5 minutes until delivery.

Electronic Fetal Monitors


Electronic fetal monitors continuously record the instantaneous fetal heart rate on the upper channel and uterine contractions on the lower channel. They do this by attaching, either externally (and non-invasively) or internally, to detect the fetal heart and each uterine contraction. A normal contraction pattern in active labor shows contractions occurring about every 2-3 minutes and lasting about 60 seconds.

Short Term Variability

The normal fetal heart rate baseline is 120-160 BPM and has both short and long-term "variability." Short term variability means that from one moment to the next, the fetal heart speeds up slightly and then slows down slightly, usually with a range of 3-5 BPM from the baseline. Reduced variability occurs normally during fetal sleep and Long Term usually returns after 20 to 40 minutes. It also may be present Variability with fetal anomalies or injury. Persistent or progressively reduced variability is not, by itself, a sign of fetal jeopardy. But in combination with other abnormalities (see below), it may indicate fetal intolerance of labor. Long-term variability represents broad-based swings in fetal heart rate, or "waviness," occurring up to several times a minute. One form of long-term variability of particular significance is a fetal heart "acceleration." These usually occur in response to fetal movement, and are 15 BPM above the baseline or more, lasting 1020 seconds or longer. They can often be provoked by stimulating the fetal scalp during a pelvic examination, or by acoustically stimulating the fetus with a loud, obnoxious noise. The presence of fetal accelerations is reassuring that the fetus is healthy and tolerating the intrauterine environment well. During labor, no significance is attached to the absence of fetal accelerations. Tachycardia is the sustained elevation of fetal heart rate baseline above a 160 BPM. Most tachycardias are not indicative of fetal jeopardy. Causes include:

Tachycardia

Bradycardia

Early Deceleration

Variable Deceleration

Mild and Severe Variable Deceleration

Late Deceleration

Prolonged Deceleration

Bradycardia is the sustained depression of fetal heart rate baseline below 120 BPM. Most of these are caused by increased vagal tone, although congenital cardiac abnormalities can also be responsible. Mild bradycardia (to 80 or 90 BPM) with retention of beat-to-beat variability is common during the second stage of labor and not of great concern so long as delivery occurs relatively soon. Moderate to severe bradycardia (below 80 BPM) with loss of beat-to-beat variability, particularly in association with late decelerations, is more troubling and may indicate fetal distress, requiring prompt resolution. Early decelerations are periodic slowing of the fetal heartbeat, synchronized exactly with the contractions. These dips are rarely more than 20 or 30 BPM below the baseline. These innocent changes are thought to be due, in many cases, to fetal head compression within the birth canal. Variable decelerations are variable in onset, duration and depth. They may occur with contractions or between contractions. Typically, they have an abrupt onset and rapid recovery (in contrast to other types of decelerations which gradually slow and gradually recover. Variable decelerations are thought to represent a vagal response to some degree of umbilical cord compression. They are not caused by hypoxia, although if severe enough, frequent enough and persistent enough, can ultimately lead to some degree of fetal acidosis. Mild or moderate variable decelerations are common and not considered threatening. Mild variable decelerations do not dip below 70 BPM and last less than 30 seconds. Severe variable decelerations dip below 60 BPM for at least 60 seconds ("60 x 60"). If persistent and not correctable by simple means, they can be threatening to fetal well-being. Late decelerations are repetitive, gradual slowings of the fetal heartbeat toward the end of the contraction cycle. They are felt to represent some degree of uteroplacental insufficiency. If persistent and not correctable, they represent a threat to fetal well-being. Prolonged decelerations last more than 60 seconds and occur in isolation. Causes include maternal supine hypotension, epidural anesthesia, paracervical block, tetanic contractions, and umbilical cord prolapse.

Some of these are largely self-correcting, such as the deceleration following paracervical block, while others (maternal supine hypotension) respond to simple measures such as repositioning. Other causes (such as umbilical cord prolapse) require prompt intervention to avoid or reduce the risk of fetal injury.

Second stage: expulsion


This stage brim. Ideally it has successfully also passed below the interspinous diameter. This is the narrowest part of the pelvis. If these have been accomplished, all that will remain is for the fetal head to pass below the pubic arch and out through the introitus. This is assisted by the additional maternal efforts of "bearing down" or pushing. The fetal head is seen to 'crown' as the labia part. At this point, the woman may feel a burning or stinging sensation. Birth of the fetal head signals the successful completion of the fourth mechanism of labour (delivery by extension), and is followed by the fifth and sixth mechanisms (restitution and external rotation).

begins when the cervix is fully dilated, and ends when the baby is finally born. As pressure on the cervix increases, the Ferguson reflex increases uterine contractions so that the second stage can go ahead. At the beginning of the normal second stage, the head is fully engaged in the pelvis; the widest diameter of the head has successfully passed through the pelvic

A newborn baby with umbilical cord ready to be clamped

Pain Relief
Various cultures approach the pain of labor differently and individuals vary in their responses to labor pains. Some women will need little or no help with pain relief, while others will benefit from it. While no analgesic is 100% safe 100% of the time, pain relief is generally very safe and provides for a much happier experience for the woman and her family. The following principles may be helpful:
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A small number of women in labor will have virtually no pain and they do not need any analgesia. The majority of women will have moderate discomfort, particularly toward the end of labor and they will generally appreciate some analgesia. Some women will experience severe pain during labor and they will benefit from your most intensive efforts. Giving analgesics prior to the onset of active labor (before 4 cm dilatation) will usually slow the labor process, although for some (those with a prolonged latent phase), it may actually speed up labor.

Focused breathing (Lamaze techniques) during contractions can be very helpful in reducing or eliminating the need for pharmacologic analgesia. Hypnotherapy can provide similar relief, as can massage therapy. Narcotic analgesics can be highly effective at treating the pain of labor. They are generally safe for the baby, although it is better to avoid large doses toward the end of labor in order to avoid respiratory depression in the newborn. The greatest safety with narcotics is achieved when an antagonist (naloxone or Narcan) is available to treat the baby should depression appear. Good dosages for this purpose include:
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Morphine 2.5-5 mg IV every 60-90 minutes Morphine 7.5 - 15 mg IM every 3-4 hours

More frequent, smaller doses are better than larger, less-frequent doses. Smaller doses given IV are immediately effective, but wear off quickly. Whether that is an advantage or disadvantage depends on how close the woman is to delivery and her need for immediate pain relief. Paracervical blocks (up to 20 cc of 1% Lidocaine in divided doses) can stop the pain of contractions for up to an hour and a half. Care must be taken to prevent excessive fetal uptake of the Lidocaine, which can lead to fetal bradycardia. Continuous lumbar epidural anesthetic is effective and versatile, but requires skilled providers. In some settings, this can be very appropriate, but in other operational settings, these resources may not be available.

Inhalation of 50% nitrous oxide with 50% oxygen, can give very effective pain relief during labor and is safe for the mother and baby. It is safest when self-administered by the mother, under the guidance of her birth attendant. If she feels dizzy or starts to achieve anesthetic levels of the nitrous, she will naturally release the mask, reversing the effects of the nitrous oxide. Less commonly used is a self-administered volatilized gas of methoxyflurane. It is capable of achieving anesthetic levels and so must be very closely monitored.

Third stage: placenta


In this stage, the uterus expels the placenta (afterbirth). The placenta is usually birthed within 1530 minutes of the baby being born. Maternal blood loss is limited by contraction of the uterus following birth of the placenta. Normal blood loss is less than 600 mL.

Episiotomy

Sometimes, a small incision is made in the perineum to widen the vaginal opening, reduce the risk of laceration, and speed the delivery. There are two forms, midline and mediolateral. A midline episiotomy is safe, and avoids major blood vessels and nerves. It heals well and quickly and is reasonably comfortable after delivery. If the fetal head is still too big to allow for delivery without tearing, the lacerations will likely extend along the line of the episiotomy. Lacerations through the rectal sphincter and into the rectum are relatively common with this type of episiotomy.

A mediolateral episiotomy avoids the problems of tearing into the rectum by directing the forces laterally. However, these episiotomies bleed more, take longer to heal, and are generally more uncomfortable after delivery. In an operational setting, the major question is not so much where to put the episiotomy, but whether to perform this procedure at all.
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If you don't perform an episiotomy, you are increasing the risk of vulvar lacerations, but these are usually (not always) small, non-threatening lacerations that will heal well without further complications. If you perform a midline episiotomy, you will have fewer vulvar lacerations, but the few you have are more likely to be the trickier 3rd and 4th degree lacerations involving the anal sphincter and rectum. If you perform a mediolateral episiotomy, you will avoid the 3rd and 4th degree lacerations, but you may open the ischio-rectal fossa to contamination and infection and increase the intrapartum blood loss.

The best approach is an individualized one, that takes into account your own training and expertise, the clinical circumstances, and the operational circumstances.

Anesthesia
Although the perineum of a full-term patient is stretchy and compliant, the passage of a baby through the birth canal and vulva is usually uncomfortable. In a hospital setting, anesthesia for the delivery might consist of:
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Local infiltration Pudendal block Epidural Spinal (saddle block) General anesthetic

In many operational settings, the only available anesthesia for delivery will be local infiltration. Use 1% Lidocaine and inject just beneath the skin. Don't inject into the deeper tissues because there are no significant numbers of nerves there. Use 10-20 cc total. The maximum dose of Lidocaine you can give at any one time to avoid Lidocaine toxicity is 50 cc of 1% Lidocaine. Try not to use the whole 50 cc for the delivery as you may need more for the repair of any lacerations.

Clamp and Cut the Umbilical Cord

After the baby is born, leave the umbilical cord alone until the baby is dried, breathing well and starts to pink up. During this time, keep the baby more or less level with the placenta still inside the mother. Once the baby is breathing, put two clamps on the umbilical cord, about an inch (3 cm) from the baby's abdomen. Use scissors to cut between the clamps. If you don't have clamps and scissors, use anything available to accomplish the same purpose. In this example, the radio-opaque threads from a 4 x 4 gauze pad have been removed and used to tie the cord before cutting it with a pocket knife.

The Placenta
Anywhere from a few minutes after delivery to an hour later, the placenta will separate and deliver. While you are awaiting delivery of the placenta, don't pull on the cord or massage the uterus to try and make it deliver more quickly. Pulling to vigorously on the cord, in the right clinical setting, may lead uterine inversion (the uterus turns inside out), a very serious and dangerous complication. Massaging the uterus often only causes dis-coordinated contractions which slow a clean shearing of the placenta. As the placenta detaches and descends through the birth canal, the woman will again feel contractions and the urge to bear down. As she does this, the placenta will be expelled. Make sure all the fetal membranes come out with the placenta. Inspect the placenta for completeness. If a portion is missing, she will need to have her uterus explored and the missing piece removed.

Also inspect the cord to make sure there are 3 blood vessels present (2 arteries and 1 vein). Two-vessel cords are associated with certain congenital anomalies.

Uterine Massage
After delivery of the placenta, the uterus normally contracts firmly, closing off the open blood vessels which previously supplied the placenta. Without this contraction, rapid blood loss would likely prove very problematic or worse.

To encourage the uterus to firmly contract, oxytocin 10 mIU IM can be given after delivery. Alternatively, oxytocin 10 or 20 units in a liter of IV fluids can be run briskly (150 cc/hour) into a vein. Breast feeding the baby or providing nipple stimulation (rolling the nipple between thumb and forefinger) will cause the mother's pituitary gland to release oxytocin internally, causing similar, but usually milder effects. A simple way to encourage firm uterine contraction is with uterine massage. The fundus of the uterus (top portion) is vigorously massaged to keep it the consistency of a tightened thigh muscle. If it is flabby, the patient will likely continue to bleed.

Breastfeeding during and after the third stage, the placenta is visible in the bowl to the right. The third stage can be managed either expectantly or actively. Expectant management (also known as physiological management) allows the placenta to be expelled without medical assistance. Breastfeeding soon after birth and massaging of the top of the uterus (the fundus) causes uterine contractions that encourage birth of the placenta. Active management utilizes oxytocic agents and controlled cord traction. The oxytocic agents augment uterine muscular contraction and the cord traction assists with rapid birth of the placenta. A Cochrane database study suggests that blood loss and the risk of postpartum bleeding will be reduced in women offered active management of the third stage of labour. However, the use of ergometrine for active management was associated with nausea or vomiting and hypertension, and controlled cord traction requires the immediate clamping of the umbilical cord. Although uncommon, in some cultures the placenta is kept and consumed by the mother over the weeks following the birth. This practice is termed placentophagy.

Station
Refers to the relationship of the fetal presenting part to the level of the ischial spines. When the presenting part is at the ichial spines the station is 0 (synonymous with engagement). If the presenting fetal part is above the spines, the distance is measured and described as minus stations, which range from -1 to -4 cm. If the presenting part is below the ischial spines, the distance is stated as plus stations ( +1 to +4 cm). At +3 and +4 the presenting is at the perineum and can be seen.(Pilliteri, Adele.(2009). Maternal & Child health nursing:care of the childrearing family. Lippencott Williams & Wilkins: New York.)

Fourth stage
The "fourth stage of labor" is a term used in two different senses:
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It can refer to the immediate puerperium, or the hours immediately after delivery of the placenta. It can be used in a more metaphorical sense to describe the weeks following delivery.

D. NURSING MANAGEMENT /INTERVENTION 1. Pre-operative preparation of the patient


The preoperative preparation and assessment is a vital part of the anaesthetic care given to patients scheduled for both routine and emergency surgery. All patients should be seen and assessed by the anaesthetist who is responsible for the administration of their anaesthetic. This practice not only avoids the chance of mistakes during "hand overs" but ensures continuity and rapport for both the anaesthetist and the patient.

a. Physical
Patients are usually asked to remove personal items (e.g., jewelry, eyeglasses, hairpieces, contact lenses, dentures) before surgery. This policy protects the patient and prevents the items from being lost or damaged. Depending on the procedure, eyeglasses or hearing aids may be worn.

2. Intraoperative Anesthesia/DR technique


The doctor who administers the anesthesia (anesthesiologist) performs a brief physical examination; takes a patient history; and obtains information regarding medication used on a regular basis, drug allergies, and prior adverse reactions to anesthesia. This information helps the anesthesiologist select the most suitable anesthetic agents and dosages to avoid complications. a. Skin preparation 1. Check the physician's order and explain the procedure to the patient, including the reason for the extensive preparations to avoid causing undue anxiety. Provide privacy, wash your hands thoroughly, and put on gloves. 2. Place the patient in a comfortable position, drape him with the bath blanket, and expose the preparation area. For most surgeries, this area extends 12 (30.5 cm) in each direction from the expected incision site. However, to ensure privacy and avoid chilling the patient, expose only one small area at a time while performing skin preparation. 3. Position a linen-saver pad beneath the patient to catch spills and avoid linen changes. Adjust the light to illuminate the preparation area. 4. Assess skin condition in the preparation area, and report any rash, abrasion, or laceration to the physician before beginning the procedure. Any break in the skin increases the risk of infection and could cause cancellation of the planned surgery. 5. Have the patient remove all jewelry in or near the operative site.

6. Put on gloves and, as ordered, begin removing hair from the preparation area by clipping any long hairs with scissors. If ordered, shave all remaining hair within the area to remove microorganisms. Perform the procedure as near to the time of surgery as possible so that microorganisms will have minimal time to proliferate. Use only a sterilized or sterile disposable razor with a sharp new blade to avoid the risk of infection from a contaminated razor. 7. Use a gauze pad to spread liquid soap over the shave site, or use the pad provided in the disposable kit.

8. Pull the skin taut in the direction opposite the direction of hair growth because this makes the hair rise and facilitates shaving. 9. Holding the razor at a 45-degree angle, shave with short strokes in the direction of hair growth to avoid skin irritation and achieve a smooth clean shave.

10. If possible, avoid lifting the razor from the skin and placing it down again to minimize the risk of lacerations. Also avoid applying pressure because this can cause abrasions, particularly over bony prominences. 11. Rinse the razor frequently and reapply liquid soap to the skin as needed to keep the area moist. 12. Change the rinse water if necessary. Then rinse the soap solution and loose hair from the preparation area, and inspect the skin. Immediately notify the physician of any new nicks, lacerations, or abrasions, and file a report if your facility requires it. 13. Proceed with a 10-minute scrub to ensure a clean preparation area. Wash the area with a gauze pad dipped in the antiseptic soap solution. Using a circular motion, start at the expected incision site and work outward toward the periphery of the area to avoid recontaminating the clean area. Apply light friction while washing to improve the antiseptic effect of the solution. Replace the gauze pad as necessary.

14. Carefully clean skin folds and crevices because they harbor greater numbers of microorganisms. Scrub the perineal area last, if it's part of the preparation area, for the same reason. Pull loose skin taut. If necessary, use cotton-tipped applicators to clean the umbilicus and an orangewood stick to clean under nails. Be sure to remove any nail polish because the anesthetist uses nail bed color to determine adequate oxygenation and may place a probe on the nail to measure oxygen saturation. 15. Dry the area with a clean towel, and remove the linen-saver pad.

16. Give the patient any special instructions for care of the prepared area, and remind him to keep the area clean for surgery. Make sure the patient is comfortable. 17. Properly dispose of solutions and the trash bag, and clean or dispose of soiled equipment and supplies according to your facility's policy

b. Draping
Part of the role of the perioperative nurse is to pull the correct drapes as well as instruments prior to each procedure. In order to provide the best protection for each procedure, the perioperative nurse needs to think through the basic principles of draping. Principles of Draping 1. Isolate Dirty from clean (e.g., groin, colostomy and equipment from the area to be prepped). Isolation is accomplished by using an impervious drape, usually fabricated from a plastic material. Any impervious material can be used. 2. Barrier Provides an impervious layer; must have a plastic film to prevent strike-through. 3. Sterile Field Creation of a sterile field is through sterile presentation of the drape and aseptic application technique. If the drape used is not impervious, an additional impervious layer needs to be added. 4. Sterile Surface Because skin cannot be sterilized, it is necessary to apply an incise drape to create a sterile surface. Only an incise drape can create a sterile surface. 5. Equipment Cover Sterile drapes cover nonsterile equipment or organize equipment used on the sterile field. This helps to protect the patient from the equipment as well as to protect and prolong the life of the equipment. 6. Fluid Control Collection of fluid keeps the patient dry, decreases healthcare worker exposure and decreases clean up. A fluid control system should be used any time the procedure is known to include large amounts of body fluids

Delivery Set
In our range of surgical instruments, we offer delivery set that are used across various maternity hospitals. These set are carefully manufactured, which ensures flawless range of delivery set. Our range of delivery set are designed keeping in mind its application and are safe and hygienic to use. It assist the surgeons to carry their task efficiently and with ease.

1. Mayo scissors -use to cut the umbilical cord

2. Kelly clamp (curve) with latex band -use to clamp the cord towards the baby

3. Kelly clamp (straight) - use to clamp the cord towards the placenta

4. suction catheter -Suction oral and nasal secretions of baby

5.Several sterile gauze

6.Needle Holder - used to hold the needle

9. Mayo table -where all instruments are placed

3. Post Operative a. Presentation of Complications


Labor complications
The second stage of labor may be delayed or lengthy due to:
y y y y y y

malpresentation (breech birth (i.e. buttocks or feet first), face, brow, or other) failure of descent of the fetal head through the pelvic brim or the interspinous diameter poor uterine contraction strength active phase arrest cephalo-pelvic disproportion (CPD) shoulder dystocia

Secondary changes may be observed: swelling of the tissues, maternal exhaustion, fetal heart rate abnormalities. Left untreated, severe complications include death of mother and/or baby, and genitovaginal fistula. These are commonly seen in Third World countries where births are often unattended or attended by poorly trained community members.

Maternal complications
Vaginal birth injury with visible tears or episiotomies are common. Internal tissue tearing as well as nerve damage to the pelvic structures lead in a proportion of women to problems with prolapse, incontinence of stool or urine and sexual dysfunction. Fifteen percent of women become incontinent, to some degree, of stool or urine after normal delivery, this number rising considerably after these women reach menopause. Vaginal birth injury is a necessary, but not sufficient, cause of all non

hysterectomy related prolapse in later life. Risk factors for significant vaginal birth injury include:
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a baby weighing more than 9 pounds the use of forceps or vacuum for delivery. These markers are more likely to be signals for other abnormalities as forceps or vacuum are not used in normal deliveries. the need to repair large tears after delivery

Pelvic girdle pain. Hormones and enzymes work together to produce ligamentous relaxation and widening of the symphysis pubis during the last trimester of pregnancy. Most girdle pain occurs before birthing, and is known as diastasis of the pubic symphysis. Predisposing factors for girdle pain include maternal obesity. Infection remains a major cause of maternal mortality and morbidity in the developing world. The work of Ignaz Semmelweis was seminal in the pathophysiology and treatment of puerperal fever and saved many lives. Hemorrhage, or heavy blood loss, is still the leading cause of death of birthing mothers in the world today, especially in the developing world. Heavy blood loss leads to hypovolemic shock, insufficient perfusion of vital organs and death if not rapidly treated. Blood transfusion may be life saving. Rare sequelae include Hypopituitarism Sheehan's syndrome. The maternal mortality (MMR) rate varies from 9/100,000 live births in the US and Europe, to 900/100,000 live births in Sub-Saharan Africa. Every year, more than half a million women die in pregnancy or childbirth.

Fetal complications
Mechanical fetal injury Risk factors for fetal birth injury include fetal macrosomia (big baby), maternal obesity, the need for instrumental delivery, and an inexperienced attendant. Specific situations that can contribute to birth injury include breech presentation and shoulder dystocia. Most fetal birth injuries resolve without long term harm, but brachial plexus injury may lead to Erb's palsy or Klumpke's paralysis. Neonates are prone to infection in the first month of life. Some organisms such as S. agalactiae (Group B Streptococcus) or (GBS) are more prone to cause these occasionally fatal infections. Risk factors for GBS infection include:
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prematurity (birth prior to 37 weeks gestation) a sibling who has had a GBS infection prolonged labor or rupture of membranes

Untreated sexually transmitted infections are associated with congenital and perinatal infections in neonates, particularly in the areas where rates of infection remain

high. The overall perinatal mortality rate associated with untreated syphilis, for example, approached 40%. Neonatal death Infant deaths (neonatal deaths from birth to 28 days, or perinatal deaths if including fetal deaths at 28 weeks gestation and later) are around 1% in modernized countries. The "natural" mortality rate of childbirthwhere nothing is done to avert maternal deathhas been estimated as being between 1,000 and 1,500 deaths per 100,000 births. (See main article: neonatal death, maternal death) The most important factors affecting mortality in childbirth are adequate nutrition and access to quality medical care ("access" is affected both by the cost of available care, and distance from health services). "Medical care" in this context does not refer specifically to treatment in hospitals, but simply routine prenatal care and the presence, at the birth, of an attendant with birthing skills. A 1983-1989 study by the Texas Department of Health highlighted the differences in neonatal mortality (NMR) between high risk and low risk pregnancies. NMR was 0.57% for doctor-attended high risk births, and 0.19% for low risk births attended by non-nurse midwives. Conversely, some studies demonstrate a higher perinatal mortality rate with assisted home births. Around 80% of pregnancies are low-risk. Factors that may make a birth high risk include prematurity, high blood pressure, gestational diabetes and a previous cesarean section. Intrapartum asphyxia Intrapartum asphyxia is the impairment of the delivery of oxygen to the brain and vital tissues during the progress of labor. This may exist in a pregnancy already impaired by maternal or fetal disease, or may rarely arise de novo in labor. This can be termed fetal distress, but this term may be emotive and misleading. True intrapartum asphyxia is not as common as previously believed, and is usually accompanied by multiple other symptoms during the immediate period after delivery. Monitoring might show up problems during birthing, but the interpretation and use of monitoring devices is complex and prone to misinterpretation. Intrapartum asphyxia can cause long-term impairment, particularly when this results in tissue damage through encephalopathy.

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