Labor and Delivery Marianne F. Moore. Critical Factors in Labor Passage Passage.

LaborLabor and Delivery and DeliveryMarianne F. MooreMarianne F. Moore

Critical Factors in LaborCritical Factors in Labor

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PositionPosition (Maternal)(Maternal)


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Position (Maternal)Position (Maternal)

PlacentalPlacental

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Skeletal StructuresSkeletal Structures Pelvis TypesPelvis Types GynecoidGynecoid AnthropoidAnthropoid AndroidAndroid PlatypelloidPlatypelloid

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Soft Tissue StructuresSoft Tissue Structures CervixCervix Cervical ScarringCervical Scarring

VaginaVagina ObstructionsObstructions ““Tissue Dysplasia”Tissue Dysplasia”

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ContractionsContractions DurationDuration

FrequencyFrequency

IntensityIntensity

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ContractionsContractions IncrementIncrement

AcmeAcme

DecrementDecrement

PsychePsyche

Immediate IssuesImmediate Issues FatigueFatigue

AnxietyAnxiety

Trust in Medical Care Trust in Medical Care and Selfand Self

Ability to Receive and Ability to Receive and Use SupportUse Support

PsychePsyche

Pre-Existing IssuesPre-Existing Issues Motivation for the Motivation for the PregnancyPregnancy

Self-ConfidenceSelf-Confidence

Personal ExpectationsPersonal Expectations

Relationship with Support Relationship with Support Person(s)Person(s)

Culture and Its’ View of Culture and Its’ View of ChildbirthChildbirth

Obstetric/ Family HistoryObstetric/ Family History

Childbirth Education Childbirth Education ClassesClasses

Maternal PositionMaternal Position

Bedrest:Bedrest: Low semi-Fowler’s Low semi-Fowler’s

Necessary position with epidural placementNecessary position with epidural placement Patient is tipped to one side to avoid vena cava Patient is tipped to one side to avoid vena cava

syndromesyndrome Changing position from one side to other changes Changing position from one side to other changes

relationship of presenting part to maternal pelvisrelationship of presenting part to maternal pelvis


Bedrest:Bedrest: Side-lying or “runner’s position” Side-lying or “runner’s position”

Useful for rest in early laborUseful for rest in early labor Also a good position for sleep in advancing pregnancyAlso a good position for sleep in advancing pregnancy Needs lots of pillows for comfort and correct Needs lots of pillows for comfort and correct

positioningpositioning


Upright Positions:Upright Positions:

Chair/RockerChair/Rocker WalkingWalking Stair Climbing (especially 2 at a time)Stair Climbing (especially 2 at a time) Birthing BallBirthing Ball Squatting/Squat BarSquatting/Squat Bar Toilet sittingToilet sitting


Positions to help back labor:Positions to help back labor:

Leaning over the bedLeaning over the bed All foursAll fours Pelvic rockingPelvic rocking Leaning on the hallway barsLeaning on the hallway bars Slow dancingSlow dancing CounterpressureCounterpressure

PlacentaPlacenta

Low-lying placenta may cause Low-lying placenta may cause the baby to assume a the baby to assume a transverse lietransverse lie

May also impede descent of May also impede descent of the babythe baby

Cardinal MovementsCardinal Movements

EngagementEngagement



DescentDescent



DescentDescent

FlexionFlexion



DescentDescent

FlexionFlexion

Internal RotationInternal Rotation



DescentDescent

FlexionFlexion


ExtensionExtension



DescentDescent

FlexionFlexion


ExtensionExtension

RestitutionRestitution



DescentDescent

FlexionFlexion


ExtensionExtension

RestitutionRestitution

External RotationExternal Rotation


EngagementEngagementDescentDescentFlexionFlexionInternal RotationInternal RotationExtensionExtensionRestitutionRestitutionExternal RotationExternal Rotation

Expulsion Expulsion (BIRTH!)(BIRTH!)

Signs of LaborSigns of Labor

LighteningLightening

Frequent UrinationFrequent Urination

Sciatic Nerve DiscomfortSciatic Nerve Discomfort

Back DiscomfortBack Discomfort


LighteningLightening Frequent UrinationFrequent Urination Sciatic Nerve DiscomfortSciatic Nerve Discomfort Back DiscomfortBack Discomfort Braxton-Hicks Braxton-Hicks (Warm-Up)(Warm-Up) Contractions Contractions Vaginal DischargeVaginal Discharge Bloody showBloody show NestingNesting


Rupture of membranesRupture of membranes Called PROM if before contractions startCalled PROM if before contractions start Amount of fluid can varyAmount of fluid can vary AssessAssess

Time of RuptureTime of Rupture Color of fluidColor of fluid Clarity of fluidClarity of fluid Fetal movement since rupture?Fetal movement since rupture? Have contractions started?Have contractions started?


What is “False Labor”?What is “False Labor”? Looks/feels like labor to mother but no change Looks/feels like labor to mother but no change

in cervixin cervix Abdominal/groin painAbdominal/groin pain Changing level or type of activity makes Changing level or type of activity makes

contractions go awaycontractions go away Contractions don’t get stronger, longer or Contractions don’t get stronger, longer or

closer together (intensity, duration, frequency)closer together (intensity, duration, frequency) Contractions do not change the dilatation or Contractions do not change the dilatation or

effacement of cervixeffacement of cervix


What is “True Labor”?What is “True Labor”? Contractions that efface or dilate the cervixContractions that efface or dilate the cervix Contractions usually cause low back pain or Contractions usually cause low back pain or

suprapubic pressure (or both)suprapubic pressure (or both) Contractions are regular and rhythmicContractions are regular and rhythmic Changing type or level of activity does NOT Changing type or level of activity does NOT

make them go awaymake them go away Contractions get longer, stronger, closer Contractions get longer, stronger, closer

together (duration, intensity, frequency)together (duration, intensity, frequency)

Theories About the Onset of Theories About the Onset of LaborLabor

Progesterone Deprivation TheoryProgesterone Deprivation Theory

Oxytocin TheoryOxytocin Theory

Fetal Endocrine Control TheoryFetal Endocrine Control Theory

Prostaglandin TheoryProstaglandin Theory

Physiologic changes Physiologic changes with L & Dwith L & D

Labor is hard physical workLabor is hard physical work



Increases in systolic and diastolic Increases in systolic and diastolic BPBP

Physiologic changesPhysiologic changeswith L & Dwith L & D


Increases in systolic and diastolic BPIncreases in systolic and diastolic BP

Increased cardiac outputIncreased cardiac output



Increases in systolic and diastolic BPIncreases in systolic and diastolic BP

Increased cardiac outputIncreased cardiac output

Fluid and electrolyte loss:Fluid and electrolyte loss: diaphoresisdiaphoresis hyperventilationhyperventilation elevated temperatureelevated temperature


Peristalsis slows in most of GI Peristalsis slows in most of GI tract, except lower colontract, except lower colon


Peristalsis slows in most of GI tract, Peristalsis slows in most of GI tract, except lower colonexcept lower colon

Decreased absorption of solidsDecreased absorption of solids




Anorexia is commonAnorexia is common




Anorexia is commonAnorexia is common

Nausea and vomiting can occur Nausea and vomiting can occur during transitionduring transition

Persistent fetal heart rate changes Persistent fetal heart rate changes may indicate changes in fetal well-may indicate changes in fetal well-beingbeing

Fetal Response to LaborFetal Response to Labor


Persistent fetal heart rate changes may Persistent fetal heart rate changes may indicate changes in fetal well-beingindicate changes in fetal well-being

Most fetuses are well equipped for Most fetuses are well equipped for the stress of laborthe stress of labor


Persistent fetal heart rate changes may Persistent fetal heart rate changes may indicate changes in fetal well-beingindicate changes in fetal well-being

Most fetuses are well equipped for the Most fetuses are well equipped for the stress of laborstress of labor

Initial assistance to the fetus is Initial assistance to the fetus is provided through the mother provided through the mother (position change, fluids, O2)(position change, fluids, O2)


Persistent fetal heart rate changes may Persistent fetal heart rate changes may indicate changes in fetal well-beingindicate changes in fetal well-being Most fetuses are well equipped for the Most fetuses are well equipped for the stress of laborstress of labor Initial assistance to the fetus is provided Initial assistance to the fetus is provided through the mother (position change, through the mother (position change, fluids, O2)fluids, O2)

A more thorough discussion is in A more thorough discussion is in the section on fetal monitoringthe section on fetal monitoring

Stages of LaborStages of Labor

Stage 1Stage 1 Onset of labor to complete dilatation (10 cms)Onset of labor to complete dilatation (10 cms)


Stage 1Stage 1 onset of labor to complete dilatation (10cms)onset of labor to complete dilatation (10cms)

Stage 2Stage 2 Complete dilatation to birthComplete dilatation to birth




Stage 3Stage 3 Birth to delivery of the placentaBirth to delivery of the placenta




Stage 3Stage 3 Birth to delivery of the placentaBirth to delivery of the placenta

Stage 4Stage 4 Delivery of the placenta until 1-4 hours after delivery Delivery of the placenta until 1-4 hours after delivery

(depends on the mother)(depends on the mother)

First Stage of LaborFirst Stage of Labor

PhasesPhases Latent, also called earlyLatent, also called early

LatentLatent Phase of Labor Phase of Labor Lasts from onset until 4 cms dilatedLasts from onset until 4 cms dilated Contractions: mild, 30-45 seconds longContractions: mild, 30-45 seconds long

Regular and increasing in frequency, usually 5-10 minutes apartRegular and increasing in frequency, usually 5-10 minutes apart

Work: primarily effacementWork: primarily effacement Length:Length:

Primipara:8 hours, up to 24 hoursPrimipara:8 hours, up to 24 hours Multipara: 5 hours, up to 14 hoursMultipara: 5 hours, up to 14 hours

Client is happy, talkative, outgoingClient is happy, talkative, outgoing


PhasesPhases LatentLatent ActiveActive

ActiveActive Phase of Labor Phase of Labor From 4 to 7 cm dilatationFrom 4 to 7 cm dilatation Contractions: moderate, 45-60 secondsContractions: moderate, 45-60 seconds

From 2-5 minutes apartFrom 2-5 minutes apart

Work: Dilatation and descentWork: Dilatation and descent Length:Length:

Primipara: 4.5 hours, on average Primipara: 4.5 hours, on average Multipara: 2.4 hours, on average Multipara: 2.4 hours, on average

Client becomes introspective, serious and tenseClient becomes introspective, serious and tense


PhasesPhases LatentLatent ActiveActive

TransitionTransition

TransitionTransition From 8-10 cms dilated (10 cm is complete!)From 8-10 cms dilated (10 cm is complete!) Contractions: strong, last 60-90 secondsContractions: strong, last 60-90 seconds

every 2-3 minutesevery 2-3 minutes a “break” can occur at 10 cms, for 20 minutes or so, especially if Mom is a “break” can occur at 10 cms, for 20 minutes or so, especially if Mom is

very tiredvery tired

Work: descent and some dilatationWork: descent and some dilatation Length:Length:

Primiparas: 3.6Primiparas: 3.6 Multiparas: variesMultiparas: varies

Client discouraged, irritable. Client discouraged, irritable. “Can’t do this!”“Can’t do this!”

Second Stage of LaborSecond Stage of Labor From complete dilatation to birthFrom complete dilatation to birth Contractions last 60-90 seconds with strong intensityContractions last 60-90 seconds with strong intensity

every 1.5-2 minutesevery 1.5-2 minutes a “break” can occur at 10 cms, for 20 minutes or so, especially if a “break” can occur at 10 cms, for 20 minutes or so, especially if

Mom is very tiredMom is very tiredLasts 15 minutes to 2 hours (average)Lasts 15 minutes to 2 hours (average)

With epidural, can be up to 3 hoursWith epidural, can be up to 3 hours

Perineum bulges, labia separate and head crownsPerineum bulges, labia separate and head crowns

Behaviors in Second StageBehaviors in Second Stage

Urge to bear down is strongUrge to bear down is strong

Pushing feels more productive to many mothers; Pushing feels more productive to many mothers; they are eager to pushthey are eager to push

Exhausted mothers may find the exertion Exhausted mothers may find the exertion overwhelmingoverwhelming

Burning as head crowns often causes fear of Burning as head crowns often causes fear of “splitting open”“splitting open”

Pushing causes very intense sensationsPushing causes very intense sensations

that can frighten unprepared mothersthat can frighten unprepared mothers

Pushing TechniquesPushing Techniques Directed pushingDirected pushing Begins when mother is completely dilatedBegins when mother is completely dilated Patient takes two good breaths, then takes Patient takes two good breaths, then takes

and holds a third breath.and holds a third breath. While holding the breath, she pulls back While holding the breath, she pulls back

her knees and pushes for a count of 10her knees and pushes for a count of 10 Cycle repeated X 3Cycle repeated X 3

Pushing TechniquesPushing Techniques

Spontaneous PushingSpontaneous Pushing Mother is encouraged to wait to push until the Mother is encouraged to wait to push until the

urge to bear down is overwhelmingurge to bear down is overwhelming

With some multips, this can occur at 8-10 cmsWith some multips, this can occur at 8-10 cms She is then told to breathe until the urge is strong, She is then told to breathe until the urge is strong,

push until she needs to breathe, and repeat until push until she needs to breathe, and repeat until the urge is gonethe urge is gone

Urge usually strong at +1 stationUrge usually strong at +1 station Pushing starts 1-2 per contraction, can get to 3-4 Pushing starts 1-2 per contraction, can get to 3-4

pushes per contraction as head descendspushes per contraction as head descends

Pushing TechniquesPushing Techniques

Waiting for the urge to push referred to Waiting for the urge to push referred to as “laboring downas “laboring down Urge to push with epidurals may not occur Urge to push with epidurals may not occur

until long after 10 cmuntil long after 10 cm

Studies show no advantage to directed Studies show no advantage to directed pushingpushing Laboring down and spontaneous Laboring down and spontaneous pushing result in shorter pushing times pushing result in shorter pushing times and less fetal stressand less fetal stress

EpisiotomyEpisiotomy Surgical incision of the perineal bodySurgical incision of the perineal body

MidlineMidline cut in a straight line along the median raphecut in a straight line along the median raphe

(from the vaginal orifice towards the rectum)(from the vaginal orifice towards the rectum) Divides the insertions of the perineal musclesDivides the insertions of the perineal muscles

Mediolateral Mediolateral (usually right)(usually right) Begins in the midline of the Begins in the midline of the posterior fourchette (to avoid posterior fourchette (to avoid Bartholin’s gland) and Bartholin’s gland) and extends at a 45 degree angle extends at a 45 degree angle downwardsdownwards

Benefits of EpisiotomyBenefits of Episiotomy

Hastens delivery if there is fetal Hastens delivery if there is fetal distressdistress

May be needed if the perineum is May be needed if the perineum is unyieldingunyielding

May give more room for maneuvers May give more room for maneuvers with shoulder dystociawith shoulder dystocia

May give room for use of forceps or May give room for use of forceps or vacuumvacuum

Risks of EpisiotomyRisks of Episiotomy

Fecal and/or urinary incontinenceFecal and/or urinary incontinence Pain in the area can persist for 6 Pain in the area can persist for 6 months or moremonths or more Increased pain with intercourseIncreased pain with intercourse BleedingBleeding BruisingBruising SwellingSwelling InfectionInfection

Third Stage of LaborThird Stage of Labor From birth of infant to delivery of the placentaFrom birth of infant to delivery of the placenta

Lasts from 5-30 minutesLasts from 5-30 minutes

Contraction of the uterus decreases the surface Contraction of the uterus decreases the surface area under the placenta and causes the placenta to area under the placenta and causes the placenta to “buckle”; a hematoma forms and extends, pushing “buckle”; a hematoma forms and extends, pushing the placenta off the uterine wallthe placenta off the uterine wall

Third Stage of LaborThird Stage of Labor

Signs of separationSigns of separation Uterus becomes globularUterus becomes globular The fundus The fundus (top of the uterus)(top of the uterus) rises rises Gush of dark red bloodGush of dark red blood Umbilical cord lengthens Umbilical cord lengthens (as uterus (as uterus

descends)descends)

Gentle traction on the cord assists in Gentle traction on the cord assists in delivery and decreases bleedingdelivery and decreases bleeding Hemorrhage is primary concernHemorrhage is primary concern

Fourth Stage of LaborFourth Stage of Labor

Lasts 1-4 hours after deliveryLasts 1-4 hours after delivery Beginning of physiologic readjustment of the Beginning of physiologic readjustment of the

mother’s bodymother’s body

250-500 cc blood loss is common250-500 cc blood loss is common

Causes drop in systolic and diastolic Causes drop in systolic and diastolic BP, tachycardia, increased pulse BP, tachycardia, increased pulse pressurepressure


Uterus is contracted, midline and near the Uterus is contracted, midline and near the umbilicusumbilicus

Oxytocin is given after delivery of the Oxytocin is given after delivery of the placenta to increase uterine contraction and placenta to increase uterine contraction and decrease bleedingdecrease bleeding

Bladder may be hypotonic from anesthesia, Bladder may be hypotonic from anesthesia, analgesia, traumaanalgesia, trauma

Vital signs, fundal height and vaginal flow Vital signs, fundal height and vaginal flow checked every 15 minutes X 5 checked every 15 minutes X 5 (1(1stst hour) hour)


Baby should be given to mother for Baby should be given to mother for bonding and to initiate breastfeeding as bonding and to initiate breastfeeding as soon as possiblesoon as possible

Shaking/chilling is commonShaking/chilling is common Ending of the physical exertion of laborEnding of the physical exertion of labor

Most women are hungry, thirsty and Most women are hungry, thirsty and tiredtired

Nursing Care During LaborNursing Care During Labor

Admission assessmentAdmission assessment Date and Time of AdmissionDate and Time of Admission Primary Care Provider: Mom and InfantPrimary Care Provider: Mom and Infant EDC, Gravida / ParityEDC, Gravida / Parity AllergiesAllergies Maternal Medical HistoryMaternal Medical History Medications Taken During PregnancyMedications Taken During Pregnancy Problems with previous pregnanciesProblems with previous pregnancies


Admission assessment Admission assessment (continued):(continued): Problems with this pregnancyProblems with this pregnancy When labor startedWhen labor started Contraction pattern Contraction pattern (frequency, duration, (frequency, duration,

intensity)intensity) Any vaginal dischargeAny vaginal discharge Membranes ruptured or intact: Membranes ruptured or intact:

amount/color/odoramount/color/odor


Admission assessment Admission assessment (continued)(continued) Fetal movement?Fetal movement? Fetal heart tone assessment/reactive?Fetal heart tone assessment/reactive? Vital signs, including temperatureVital signs, including temperature Vaginal exam for dilatation, effacement Vaginal exam for dilatation, effacement

and stationand station Labs: MBT, infectious status, GBS?Labs: MBT, infectious status, GBS? Psychological statusPsychological status

Electronic Fetal MonitoringElectronic Fetal Monitoring

External Contraction Assessment:External Contraction Assessment: Tocodynamometer Tocodynamometer (toco for short)(toco for short) placed at the top of the placed at the top of the

fundusfundus Uterus rises and moves forward during the increment, then Uterus rises and moves forward during the increment, then

reverses with decrementreverses with decrement Creates typical “hills” on monitor screen/paperCreates typical “hills” on monitor screen/paper Appearance of the tracing depends on maternal position, Appearance of the tracing depends on maternal position,

weight, parityweight, parity

Electronic Fetal MonitoringElectronic Fetal Monitoring

External Fetal Assessment:External Fetal Assessment: Ultrasound transducer detects sound Ultrasound transducer detects sound

waveswaves Prefers the loudest soundPrefers the loudest sound Affected by position of the fetal heart Affected by position of the fetal heart

in relation to the transducerin relation to the transducer Affected by thickness of maternal Affected by thickness of maternal

abdomenabdomen

Electronic Fetal MonitoringElectronic Fetal Monitoring Internal Contraction AssessmentInternal Contraction Assessment

Internal Uterine Pressure Catheter Internal Uterine Pressure Catheter (IUPC)(IUPC) Directly measure pressure exerted by Directly measure pressure exerted by

uterus in mmHguterus in mmHg

Internal Fetal AssessmentInternal Fetal Assessment Fetal scalp Electrode Fetal scalp Electrode (FSE)(FSE) Directly measure fetal heart rateDirectly measure fetal heart rate Can add assessment of short-term/beat-Can add assessment of short-term/beat-

to-beat variabilityto-beat variability

Fetal Heart Rate MonitoringFetal Heart Rate Monitoring BaselineBaseline A 10 beat range that describes FHR between A 10 beat range that describes FHR between

contractions over a 10 minute time periodcontractions over a 10 minute time period Normally 110 bpm to 160 bpmNormally 110 bpm to 160 bpm

Fetal Heart Rate MonitoringFetal Heart Rate Monitoring Bradycardia: Below 110 bpmBradycardia: Below 110 bpm

Moderate bradycardia from 81-110 bpmModerate bradycardia from 81-110 bpm Severe bradycardia less than 80 bpm for 2-3 minutesSevere bradycardia less than 80 bpm for 2-3 minutes

Causes to considerCauses to consider Maternal hypotension Maternal hypotension (common with epidural)(common with epidural) Late Late (profound)(profound) fetal asphyxia fetal asphyxia Prolonged umbilical cord compressionProlonged umbilical cord compression Fetal arrhythmia Fetal arrhythmia

Fetal Heart Rate MonitoringFetal Heart Rate Monitoring

Tachycardia: above 160 bpmTachycardia: above 160 bpm Mild: 161-180 bpmMild: 161-180 bpm Severe: 181 bpm or greaterSevere: 181 bpm or greater


Fetal tachycardia Fetal tachycardia (continued)(continued)

Causes to considerCauses to consider Maternal feverMaternal fever DehydrationDehydration Betasympathomimetic drugs Betasympathomimetic drugs (e.g. terbutaline)(e.g. terbutaline) Early fetal hypoxiaEarly fetal hypoxia Maternal hyperthyroidismMaternal hyperthyroidism Fetal arrhythmiaFetal arrhythmia Fetal anemiaFetal anemia


VariabilityVariability Measure of the interplay of the Measure of the interplay of the

sympathetic and parasympathetic nervous sympathetic and parasympathetic nervous systemssystems

Assessed as a sign of fetal well-beingAssessed as a sign of fetal well-being


Long Term VariabilityLong Term Variability Larger rhythmic fluctuations of Larger rhythmic fluctuations of

FHRFHR Occur 3-5 times per minuteOccur 3-5 times per minute Normal range of 6-10 bpm Normal range of 6-10 bpm Increases w/movement; decreases Increases w/movement; decreases

with sleepwith sleep

ClassificationsClassifications Decreased 0-5 bpmDecreased 0-5 bpm Average/ moderate 6-25 bpmAverage/ moderate 6-25 bpm Marked/ saltatory 25 bpm+Marked/ saltatory 25 bpm+


Short Term VariabilityShort Term Variability Difference between R wave to Difference between R wave to

R wave in successive R wave in successive heartbeatsheartbeats

Represents actual fluctuations Represents actual fluctuations from one heartbeat to the nextfrom one heartbeat to the next

Average 2-3 bpmAverage 2-3 bpm

ClassificationClassification Present or absentPresent or absent

Fetal Heart Rate MonitoringFetal Heart Rate Monitoring Sinusoidal PatternSinusoidal Pattern

Wavelike baselineWavelike baseline Amplitude of 5-15 bpmAmplitude of 5-15 bpm Regular oscillating pattern 2-Regular oscillating pattern 2-

5 cycles per minute5 cycles per minute Absence of short or long Absence of short or long

term variabilityterm variability Associated with severe Associated with severe

asphyxia, Rh asphyxia, Rh isoimmunization, anemia, isoimmunization, anemia, fetal-maternal hemorrhage, fetal-maternal hemorrhage, abruptions, or fetal acidosisabruptions, or fetal acidosis

Narcotics produce a Narcotics produce a pseudosinusoidal patternpseudosinusoidal pattern

Fetal Heart Rate MonitoringFetal Heart Rate Monitoring AccelerationsAccelerations

Transient rises in fetal Transient rises in fetal heart rate above the heart rate above the established baselineestablished baseline

Non-periodicNon-periodic Usually movement relatedUsually movement related Two (2) 15 bpm Two (2) 15 bpm

accelerations that last for accelerations that last for 15 seconds = reactive 15 seconds = reactive non-stress testnon-stress test

PeriodicPeriodic Response to stress of Response to stress of

contractioncontraction


DecelerationsDecelerations Periodic decreases in fetal heart rate from Periodic decreases in fetal heart rate from

the baselinethe baseline Relationship to contractions and waveform Relationship to contractions and waveform

determines type of decelerationdetermines type of deceleration

Fetal Heart Rate MonitoringFetal Heart Rate Monitoring Early decelerationsEarly decelerations

Uniform in appearance and Uniform in appearance and mirror the corresponding mirror the corresponding contractioncontraction

Caused by pressure on the Caused by pressure on the fetal headfetal head

FHR rarely drops below 100 FHR rarely drops below 100 bpm or more than 30 bpm bpm or more than 30 bpm lower than baselinelower than baseline

Usually occur between 4-7 Usually occur between 4-7 cmcm

Benign, unless the baby is Benign, unless the baby is not descending into the not descending into the pelvispelvis

Fetal Heart Rate MonitoringFetal Heart Rate Monitoring Late decelerationsLate decelerations

Due to uteroplacental Due to uteroplacental insufficiencyinsufficiency

Reflect decreased blood flow Reflect decreased blood flow during contractions with during contractions with decreased oxygenationdecreased oxygenation

Have a smooth uniform Have a smooth uniform shape shape (saucer-like)(saucer-like)

Begin after contraction is Begin after contraction is established and nadir is at established and nadir is at end of ctxend of ctx

Often coupled with Often coupled with decreased variabilitydecreased variability

Ominous, must be treated/ Ominous, must be treated/ provider notifiedprovider notified

Fetal Heart Rate MonitoringFetal Heart Rate Monitoring Variable decelerationsVariable decelerations

Vary in onset, occurrence, Vary in onset, occurrence, duration, intensity and duration, intensity and waveformwaveform

There is a visually abrupt There is a visually abrupt drop in FHRdrop in FHR

Thought to be due to cord Thought to be due to cord compressioncompression

Positional or due to Positional or due to decreased AFIdecreased AFI

May be non-periodic or May be non-periodic or periodicperiodic

If they last >60 seconds or If they last >60 seconds or are less than 70 bpm, are less than 70 bpm, then are a cause for alarmthen are a cause for alarm

Otherwise innocuousOtherwise innocuous

Fetal Heart Rate MonitoringFetal Heart Rate Monitoring Prolonged Prolonged decelerationsdecelerations FHR decreases from the FHR decreases from the

baseline for 2-10 minutesbaseline for 2-10 minutes Can be caused by cord Can be caused by cord

prolapse or maternal prolapse or maternal hypotension hypotension (with regional (with regional anesthesia)anesthesia)

If baseline becomes If baseline becomes tachycardic, indicates tachycardic, indicates hypoxia and stresshypoxia and stress

Nursing Role in LaborNursing Role in Labor

Accurate assessment of fetal response Accurate assessment of fetal response to labor to labor

Accurate assessment of maternal Accurate assessment of maternal response to laborresponse to labor

Accurate assessment of the emotional Accurate assessment of the emotional responses of the woman and her responses of the woman and her support systemsupport system


InterventionsInterventions

Fetal Support-correct adverse FHR Fetal Support-correct adverse FHR changeschanges Maternal hydrationMaternal hydration Maternal oxygenationMaternal oxygenation Maternal position changesMaternal position changes

Nursing Role in LaborNursing Role in Labor Maternal support: correct deficienciesMaternal support: correct deficiencies Maternal nutrition and hydrationMaternal nutrition and hydration Maternal oxygenationMaternal oxygenation Pain copingPain coping

Facilatation of the maternal support Facilatation of the maternal support systemsystem Helping the support person to help the motherHelping the support person to help the mother Suggestions and actual demonstration of Suggestions and actual demonstration of

helpful behaviorshelpful behaviors


Our role is Our role is To assure safe passage through the To assure safe passage through the

transition of birth for mother and babytransition of birth for mother and baby To help birth a new familyTo help birth a new family

Labor and Delivery Marianne F. Moore. Critical Factors in Labor Passage Passage.

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