MODULE 2

INTRAPARTUM
PROCESSES OF LABOR AND
BIRTH
• 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
 MODULE 2 PART 1
KEY FACTORS RELATED TO
PROGRESS OF LABOR
THE PASSAGE
 KEY FACTORS RELATED TO PROGRESS OF
LABOR

• PASSAGEWAY (BIRTH CANAL)

• PASSENGER (FETUS)
• POSITION OF THE MOTHER AND FETUS
• PHYSIOLOGICAL FORCES OF LABOR
• PSYCHOSOCIAL CONSIDERATIONS
 BIRTH PASSAGE
• SIZE OF PELVIS
• TYPE OF PELVIS
• CERVICAL DILATATION, EFFACEMENT
• ABILITY OF VAGINA AND INTROITUS TO
EXPAND
 BIRTH PASSAGE
• FOUR CLASSIC PELVIC TYPES
• GYNECOID

• ANDROID

• ANTHROPOID

• PLATYPELLOID
Figure 15–1 Comparison of Caldwell-Moloy pelvic types.
 BIRTH PASSAGE
CERVICAL DILATATION AND EFFACEMENT
• DILATATION—MEASURED IN CENTIMETERS
FROM 0 TO 10
– 0 CM—CERIVX CLOSED
– 10 CM—FULL DILATATION
• EFFACEMENT—MEASURED IN PERCENTAGE 0
TO 100%
Figure 15–11a 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.
Figure 15–11b Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head.
Figure 15–11c Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic fluid exerts hydrostatic
pressure.
Figure 15–11d Complete effacement and dilatation.
 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
 MODULE 2 PART 2
THE PASSENGER (FETUS)
• FETUS
–SIZE OF FETAL HEAD
–FETAL ATTITUDE
–FETAL LIE
–FETAL PRESENTATION
–IMPLANTATION SITE OF
PLACENTA
 PASSENGER
• FETAL HEAD
• SUTURES
– FRONTAL
– SAGITTAL
– CORONAL
– LAMBOIDAL

– MOLDING
– FONTANELLES
Figure 15–2 Superior view of the fetal skull.
 PASSENGER
LANDMARKS OF FETAL SKULL
• MENTUM
• SINCIPUT
• ANTERIOR FONTANELLE (BREGMA)
• VERTEX
• POSTERIOR FONTANELLE
• OCCIPUT
Figure 15–4a 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.
Figure 15–6a Cephalic presentation. Vertex presentation. Complete flexion of the head allows the suboccipitobregmatic diameter to
present to the pelvis.
Figure 15–6c 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.
 PASSENGER
FETAL LIE AND PRESENTATION
• FETAL LIE-- Relation of long axis of fetus
to long axis of the mother
–Longitudinal
–Transverse
• FETAL PRESENTATION—the body part of
the fetus that first enters the pelvis
 PASSENGER (PRESENTATION)

CEPHALIC PRESENTATION (95%)

• VERTEX—SUBOCCIPTOBREGMATIC

• MILITARY--OCCIPITOFRONTAL

• BROW--OCCIPITOMENTAL

• FACE--SUBMENTOBREGMATIC
 PASSENGER (PRESENTATION)

BREECH PRESENTATION (3%)

• COMPLETE—HIPS FLEXED, KNEES FLEXED
• FRANK—HIPS FLEXED, KNEES EXTENDED
• FOOTLING—HIPS & FEET EXTENDED,
FEET,FOOT PRESENT TO MATERNAL PELVIS
• KNEELING—HIPS EXTENDED, KNEES FLEXED
 PASSENGER (PRESENTATION)

SHOULDER (TRANSVERSE) PRESENTATION

(2%)
• TRANSVERSE LIE—SHOULDER IS USUAL
PRESENTING PART

• COMPOUND—USUALLY ARM OR HAND

PRESENTING ALONG PRESENTING PART
 MODULE 2 PART 3
POSITION OF MOTHER AND
FETUS
 POSITION OF FETUS IN RELATION TO
MOTHER’S PELVIS
ENGAGEMENT
• WHEN THE WIDEST DIAMETER OF THE
PRESENTING PART HAS REACHED OR PASSED
THE PELVIC INLET
• ENGAGMENT USUALLY CORRESPONDS TO O
STATION
• FLOATING—WHEN PRESENTING PART IS
ENTIRELY OUT OF THE PELVIS AND FREELY
MOVABLE IN THE INLET
Figure 15–8 Measuring the station of the fetal head while it is descending. In this view the station is 22/23.
 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
 FETAL POSITION IN RELATION TO
MOTHER’S PELVIS

• RIGHT OR LEFT SIDE OF MATERNAL

PELVIS

• ANTERIOR (A), POSTERIOR (P), OR

TRANSVERSE (T) DETERMINES
• WHETHER LANDMARK IS IN FRONT,
BACK OR SIDE OF PELVIS

• LANDMARK OF FETAL PRESENTING

PART:

–(O) OCCIPUT, (M) MENTUM, (S)

SACRUM, (A) ACROMION PROCESS
Figure 15–9 Categories of presentation. Source: Courtesy Ross Laboratories, Columbus, OH.
 MODULE 2 PART 4A
PHYSIOLOGICAL FORCES OF
LABOR
 PHYSIOLOGIC FORCES OF LABOR
• PRIMARY FORCES—UTERINE MUSCLE
CONTRACTIONS
– CONTRACTION PHASES---INCREMENT, ACME,
DECREMENT
– DESCRIBED WITH FREQUENCY, DURATION, AND
INTENSITY
SECONDARY FORCES—ABDOMINAL MUSCLES
USED IN PUSHING
 PHYSIOLOGIC FORCES OF LABOR
• FREQUENCY, DURATION, INTENSITY OF
CONTRACTION

• EFFECTIVENESS OF MATERNAL PUSHING

• DURATION OF LABOR
 CAUSES OF LABOR UNCLEAR

• POSSIBLE CHANGES IN PROGESTERONE AND

ESTROGEN LEVELS

• RESEARCH ON POSSIBLE CAUSES

– FETAL MEMBRANES, DECIDUAS
– PROGESTERONE WITHDRAWAL, PROSTAGLANDIN
– CORTICOTROPHIN-RELEASING HORMONE
 LABOR
• FORCES OF LABOR
• FREQUENCY, DURATION, INTENSITY
(STRENGTH)
• THREE PHASES OF CONTRACTIONS
– INCREMENT
– ACME
– DECREMENT
Figure 15–10 Characteristics of uterine contractions.
 SIGNS OF LABOR
• LIGHTENING
• BRAXTON HICKS CONTRACTIONS
• CERVIAL CHANGES
• BLOODY SHOW
• RUPTURE OF MEMBRANES
• SUDDEN BURST OF ENERGY
• WEIGHT LOSS
• N&V, DIARRHEA, BACKACHE
 TRUE LABOR/FALSE LABOR
• TRUE • FALSE
• CONTRACTIONS • CONTRACTIONS
REGULAR, INCREASE IRREGULAR, NO
IN DURATION & CHANGE IN
STRENGTH DURATION,
• INTERVAL SHORTENS STRENGTH
• DILATATION & • INTERVAL IRREGULAR
EFFACEMENT OR NO CHANGE
PROGRESS • NO DILATATION OR
• INTENSITY INCREASES EFFACEMENT
WITH WALKING • WALKING LESSENS
OR HAS NO EFFECT
ON CONTRACTIONS
MODULE 2 PART 4B
STAGES OF LABOR
• FIRST STAGE OF LABOR
–STARTS WITH BEGINNING OF
REGULAR CONTRACTIONS TO
FULL DILATATION

• FIRST STAGE IS DIVIDED INTO

THREE PHASES: LATENT, ACTIVE,
AND TRANSITION
 PHASES OF LABOR—FIRST STAGE
• LATENT---0--3 CENTIMETERS,
CONTINUING EFFACEMENT

• ACTIVE---4--7 CENTIMETERS, COMPLETE

EFFACEMENT

• TRANSITION 8--10 CENTIMTERS

ENGAGEMENT
 CONTRACTION CHARACTERISTICS
• LATENT PHASE
– MILD—10-30MIN. LASTING 20-40 SECONDS
– MODERATE—5-7MIN. LASTING 30-40
SECONDS

• ACTIVE PHASE
– MODERATE TO STRONG—2-3 MIN.
LASTING 40-60 SECONDS

• TRANSITION
– STRONG—1-1/2-2 MIN. LASTING 60-90
SECONDS
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
 PSYCHOLOGIC ADAPTIONSTO LABOR:
ACTIVE PHASE
• ANXIETY INCREASES
• FEARS LOSS OF CONTROL
• MAY HAVE DECREASED ABILITY TO COPE
• LESS TALKATIVE
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
 SECOND STAGE OF LABOR

–BEGINS WITH COMPLETE

CERVICAL DILATATION AND
ENDS WITH THE BIRTH OF THE
INFANT
THIRD STAGE OF LABOR

BEGINS WITH BIRTH OF

INFANT AND ENDS WITH THE
DELIVERY OF THE PLACENTA
 FOURTH STAGE OF LABOR

• BEGINS WITH DELIVERY OF

PLACENTA TO 4 HOURS AFTER
 LABOR REVIEW
• DESCRIBE THE FIVE CRITICAL
FACTORS THAT INFLUENCE LABOR IN
THE ASSESSMENT OF A MOTHER’S
AND FETUS’ PROGRESS IN LABOR
AND BIRTH
 MODULE 2 PART 5
MATERNAL PHYSIOLOGIC
ADAPTION TO LABOR
• CARDIAC OUTPUT INCREASES

• WBC CAN INCREASE TO 25,000mm

• BP INCREASES

• ACID/BASE BALANCE—MAY SEE > Ph

EARLY IN LABOR
• RENAL -- >IN RENIN, PLASMA RENIN
ACTIVITY, ANGIOTENSIN

• VOIDING CAN BE AFFECTED BY

EDEMA,DISPLACEMENT

• GI—DECREASED MOTILITY, DELAYED

STOMACH EMPTYING
INTRAPARTAL NURSING ASSESSMENT

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

• POVERTY
• NUTRITION
• PRENATAL CARE
• CULTURAL BELIEFS
• ENVIRONMENT
• USE OF DRUGS/ALCOHOL
• DOMESTIC VIOLENCE
 MATERNAL PSYCHOSOCIAL ISSUES
• EMOTIONAL STATUS
• SOCIOCULTURAL BELIEFS
• PREVIOUS CHILDBIRTH EXPERIENCE
• SUPPORT
• MENTAL AND PHYSICAL PREPARATION
 INTRAPARTAL ASSESSMENT-- STAGE ONE

• VITAL SIGNS
• WEIGHT
• LUNGS
• FUNDUS
• EDEMA
• HYDRATION
• PERINEUM
INTRPARTAL ASSESSMENT STAGE ONE
• LABOR STATUS
• FETAL STATUS
• LAB VALUES
• CULTURAL INFLUENCES
• RESPONSE TO LABOR
• CHILDBIRTH PREPARATION
• ANXIETY
• SUPPPORT
• PALPATION

• ELECTRONIC MONITORING OF
CONTRACTIONS

– TOCO—EXTERNATION ASSESSMENT OF
CONTRACTIONS
– IUPC—INTERNAL ASSESSMENT OF
CONTRACTIONS
 LABOR EVALUATION METHODS

• CERVICAL ASSESSMENT
–VAGINAL EXAM
• DILATATION
• EFFACEMENT
• STATION
Figure 16–2 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.
 FETAL ASSESSMENT
• FETAL POSITION
– PALPATION—LEOPOLD’S MANEUVER
– INSPECT SIZE AND SHAPE OF WOMAN’S
ABDOMEN
– VAGINAL EXAM TO DETERMINE PRESENTING
PART
– FETAL HEART RATE
– ULTRASOUND
 A B C D

Figure 16–3a Palpating the presenting part (portion of the fetus that enters the pelvis first). Left occiput anterior (LOA). The occiput (area over the occipital
bone on the posterior part of the fetal head) is in the left anterior quadrant of the woman’s pelvis. When the fetus is LOA, the posterior fontanelle (located just
above the occipital bone and triangular in shape) is in the upper left quadrant of the maternal pelvis.
Figure 16–4 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.
Figure 16–5d Fourth maneuver: Facing the woman’s 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.
 MODULE 2 PART 7A
FETAL HEART RATE(FHR)
MONITORING
• DOPPLER
• ELECTRONIC FETAL HEART RATE
MONITOR
• BASELINE RATE—120-160BPM
• FETAL TACHYCARDIA,
BRADYCARDIA
 EXTERNAL MONITORING
• EXTERNAL—ULTRASONIC TRANSDUCER
–HIGH FREQUENCY SOUND WAVES
REFLECT MECHANICAL ACTION OF
FETAL HEART

• DIFFICULT TO OBTAIN CONTINUOUS,

ACCURATE RECORD
Figure 16–8 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.
 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
Figure 16–9a Technique for internal, direct fetal monitoring. Spiral electrode.
Figure 16–9b Attaching the spiral electrode to the scalp.
 FHR MONITORING
• VARIABILITY
–BEAT TO BEAT CHANGES IN FETAL
HEART RATE
–INDICATION OF AN INTACT CNS

–SHORT TERM (STV)

–LONG TERM (LTV)
FHR MONITORING
Figure 16–10 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.
Figure 16–11a Short- and long-term variability. Increased LTV; STV present.
Figure 16–11b Average LTV; STV absent.
Figure 16–11c Absent LTV; STV present.
Figure 16–11d Absent LTV; STV absent.
 FHR MONITORING
• ACCELERATIONS

• DECELERATIONS

–EARLY
–LATE
–VARIABLE
Figure 16–12 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.
 FETAL ASSESSMENT
• SCALP STIMULATION

• FETAL BLOOD SAMPLING (FBS)

• NORMAL SCALP pH > 7.25, 7.20-7.25
BORDERLINE, <7.20 NONREASSURING
– MEMBRANES MUST BE RUPTURED
– CERVIX DILATED 2-3CM
– PRESENTING PART -2 STATION OR LOWER
 MODULE 2 PART 8
NURSING INTERVENTIONS
IN FIRST AND SECOND STAGES OF
LABOR
 FIRST STAGE-- LATENT PHASE

–DILATATION, EFFACEMENT, STATION

–MEMBRANE ASSESSMENT
–COMFORT LEVEL
–VS, FHR
–UTERINE CONTRACTIONS EVERY 30-60
MIN.
–TEACHING
 LATENT PHASE
– ENCOURAGE AMBULATION
– ENCOURAGE VOIDING Q2H
– COMFORT MEASURES
– NUTRITION OFFER FLUIDS
– PAIN ASSESSMENT
– EPIDURAL MONITORING
– IDENTIFY AND OBSERVE SUPPORT
PERSON(S)
 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
 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!
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
 MODULE 2 PART 9
INTRAPARTUM NURSING
INTERVENTIONS
THE DELIVERY
• THE DELIVERY
–PUSHING

–BIRTHING POSITIONS

–LABOR SUPPORT
Figure 15–13 Mechanisms of labor. A, B, Descent. C, Internal rotation. D, Extension. E, External rotation.
 INTRAPARTAL NURSING CARE: THE
THIRD STAGE
• DELIVERY OF THE PLACENTA
–SCHULTZ MANUEVER
–DUNCAN MANUEVER

PLACENTA ACCRETA
RETAINED PLACENTA
INTRAPARTAL NURSING CARE: THE
FOURTH STAGE
–VS
–FUNDUS
–LOCHIA
–PERINEUM/ABDOMINAL INCISION
–BLADDER
–COMFORT LEVEL
–COMFORT MEASURES—WHAT ARE
THEY?
 INTRAPARTAL NURSING CARE: THE
FOURTH STAGE
–CONTINUE PITOCIN
ADMINISTRATION---WHY?
–PAIN MEDICATION
–DIET
–HEMODYNAMIC CHANGES

• CULTURAL CONSIDERATIONS
ADAPTION TO EXTRAUTERINE LIFE
• IMMEDIATE CARE OF THE NEWBORN
–RESPIRATORY ASSESSMENT

–CIRCULATORY ASSESSMENT

–THERMOREGULATION—HOW WOULD
YOU ACHIEVE THIS?
 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
 MODULE 2 PART 10
MATERNAL ANALGESIA AND
ANESTHESIA
MATERNAL ANALGESIA & ANESTHESIA

• PAIN PERCEPTION AFFECTED BY:

–PREVIOUS EXPERIENCE
–CULTURAL EXPECTATIONS, BELIEFS
–FATIGUE, FEAR, ANXIETY
–ENVIRONMENT
–SUPPORT SYSTEM
 MATERNAL ANALGESIA
• STADOL
• DEMEROL
• MORPHINE

• OPIATE ANTAGONIST—NARCAN

• REGIONAL ANALGESIA
 MATERNAL ANESTHESIA
• REGIONAL ANESTHESIA

– EPIDURAL

– CONTINUOUS EPIDURAL

– SPINAL
 A

B C D

Figure 18–3c Tip of needle in epidural space. Source: Bonica, J. J. (1972). Principles and practice of obstetric analgesia and
anesthesia (p. 631). Philadelphia: Davis.
Figure 18–4 Levels of anesthesia for vaginal and cesarean births. Source: Reprinted with permission of Ross Laboratories,
Columbus, OH. From Clinical Education Aid No. 17.
 MATERNAL ANESTHESIA
• LOCAL INFILTRATION

• PUDENDAL

• GENERAL
 ANALGESIA AFTER DELIVERY
• EPIDURAL NARCOTIC ANALGESIA
(DUROMORPH)
– CONTRAINDICATIONS

– SIDE EFFECTS

– DOSAGE
 MODULE 2 PART 11A
BIRTH RELATED PROCEDURES
 BIRTH RELATED PROCEDURES
• AMNIOTOMY

–ARTIFICIAL RUPTURE OF
MEMBRANES (AROM

– SPONTANEOUS RUPTURE (SROM)

 AMNIOTOMY
AFTER 3CM MAY SHORTEN LABOR
(AROM) CAN BE A STIMULATION OF
LABOR

FHR ASSESSED BEFORE AND AFTER

AROM—WHY?
 BIRTH RELATED PROCEDURES

• LABOR INDUCTION—STIMULATION OF
UTERINE CONTRACTIONS

• INDICATED INDUCTION

• ELECTIVE INDUCTION
 BIRTH RELATED PROCEDURES
• ELECTIVE INDUCTIONS
–INCREASE IN LAST 10 YEARS
–CONTROVERSY, CONTROVERSY!!!!!!!
–RISKS
–EVIDENCE BASED PRACTICE—LATE
PRETERM NEWBORNS-- 34-37 WEEKS
 BIRTH RELATED PROCEDURES
• LABOR INDUCTION: STRIPPING OF
MEMBRANES
ADVANTAGES:
LABOR USUALLY OCCURS WITHIN
24HOURS
DISADVANTAGES:
CAN BE PAINFUL
UTERINE CONTRACTIONS
BLOODY DISCHARGE
 BIRTH RELATED PROCEDURES
LABOR INDUCTION/AUGMENTATION
RISKS:
• HYPERSTIMULATION OF THE UTERUS
• UTERINE RUPTURE
• WATER INTOXICATION
• NONREASSURING FETAL HEART RATE
PATTERNS
 BIRTH RELATED PROCEDURES
• CERVICAL RIPENING—PROSTAGLANDIN
E2
–RISKS
• UTERINE HYPERSTIMULATION
• NONREASSURING FETAL STAUS
• HIGHER INCIDENCE OF POSTPARTUM
HEMORRHAGE
• UTERINE RUPTURE
 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
• VERSION
–EXTERNAL
• EXTERNAL MANIPULATION
–INTERNAL
• USED TO DELIVER SECOND TWIN
DURING VAGINAL BIRTH IF NOT
DESCENDING OR IN DISTRESS--
RARE
MODULE 2 PART 11B
BIRTH PROCEDURES
 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
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)
 BIRTH RELATED PROCEDURES
• VACCUM EXTRACTION

–MATERNAL RISKS

–NEONATAL RISKS
 EPISIOTOMY

• SURGICAL INCISION OF PERINEUM TO

ENLARGE OUTLET
• RESEARCH—EVIDENCE BASED PRACTICE
• PREVENTATIVE MEASURES
• TWO TYPES:
– MEDIAN
– MEDIOLATERAL
 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
 BIRTH RELATED PROCEDURES
• INDICATIONS FOR CESAREAN BIRTH
• BREECH PRESENTATION
• PREVIOUS CESAREAN BIRTH
• MAJOR CONGENITAL ANOMALIES
• CERVICAL CERCLAGE
• NON-REASSURING FHR PATTERNS
 BIRTH RELATED PROCEDURES
• CESAREAN BIRTH
SKIN INCISIONS
• TRANSVERSE (PFANNENSTIEL)
• VERTICAL
• UTERINE INCISIONS
–TRANSVERSE
–SELHEIM (LOWER UTERINE SEGMENT)
–CLASSIC (UPPER SEGMENT OF
CORPUS)
 BIRTH RELATED PROCEDURES
• PREPARATION FOR C-BIRTH

–MAJOR SURGERY

–SPINAL ANESTHESIA

– MANY TIMES PARENTS HAVE LITTLE TIME TO

PREPARE PSYCHOLOGICALLY
 BIRTH RELATED PROCEDURES
• AMNIOINFUSION
– INCREASES FLUID VOLUME IN UTERUS BY
INSTILLATION OF NORMAL SALINE INTO THE
UTERUS
– DECREASES PRESSURE ON THE CORD—
VARIABLE DECELERATIONS
– PROMOTES INCREASED PERFUSION TO
FETUS
– CAN DILUTE HEAVY MECONIUM FLUID
– USED IN PRETERM LABOR WITH PPROM
 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