MATERNITY EXAM 2 INFO
MODULE 6: LABOR & DELIVERY PART 1
Labor & Delivery
2 women are admitted to the labor & delivery unit in active labor. Both deliver healthy baby
boys.
o Sue, a 26-year-old G2 P1, has a labor that lasts 6 hours, and delivers w/ no episiotomy
or lacerations
o Mary, a 35-year-old G1 P0, has a labor that lasts 18 hours, and has significant perineal
swelling, bruising, and a 4th degree laceration
Why did they women have such different experiences?
o Different pelvis shape
Forces o labor: the 5 P’s!
o Powers
o Passageway
o Passenger
o Position
o (psyche)
abnormalities in these can mean a risk for the baby, mother, or both
1st P=Powers (contractions= first stage of labor) (maternal pushing= 2nd stage)
purpose:
o dilate cervix
o aid in expulsion
originate in fundus
interval in between contractions inhibits blood flow to fetus
effective contractions follow a rhythm and progressively lengthen in duration and intensity
measure by:
o frequency (how often they occur)
o duration (how long they are)
each contraction has 3 phases
intensity: palpation, patient sensation, use of fetal monitor
o mild (nose)
o moderate (chin)
o strong (forehead)
IUPC (intrauterine pressure catheter)
o Mild (<40 mmHg)
o Moderate (40-70 mmHg)
o Strong (>70 mmHg)
2 P=Passageway
nd
Route the fetus must travel
o Maternal pelvis
o Maternal soft tissue- cervix
o Gynecoid is true female pelvis and about 50% women have
o 3 subdivisions
inlet (upper pelvic opening)- where fetus presents to first
mid-pelvis (pelvic cavity)- where ischial spines are
outlet (lower pelvic opening)
cervix- needs to be “ripe”
o effacement- cervix becoming shorter and thinner w/ contractions
o dilation
o what is the Bishop Score???
o Cervix goes from 0 cm-10 cm-ish
3 P=Passenger
rd
Fetus and it’s ability to move though passage way
Fetal attitude: pose assumed in uterine, flexion or extension
, Fetal lie: relationship of long axis of fetus (spine) to long axis of mother (spine)
Longitudinal- up and down, 99% of babies
Transverse- sideways
Fetal presentation- portion of fetus coming to cervix first
o 95% sephalic (head presenting part)
more flexed the head is the smaller the diameter
more extended the greater the diameter and more difficulty baby will have getting through
pelvis
Fetal Presentation
breech position: buttocks first 3-4%
o frank breech: legs close to body
o full breech: legs crossed and close to body
o footling: one leg out
shoulder transverse: presenting shoulder first into birth canal
o 1%
o CANNOT be delivered this way
Station
Relation of presenting part to maternal pelvis
Zero station= presenting part engaged in pelvis at level of the ischial spines
Can be determined by vaginal exam by locating ischial spines and noting the relationship of
presenting part of them
4th P= Fetal Position
Relation of presenting part to maternal pelvis
o 3 letters
direction presenting part faces
either left or right and it’s MOM’s L or R
presenting part
O= occiput (most common fetal head is flexed)
M= mentum (chin, fetal head is extended)
Sa= sacrum (breech presentation)
A= acromium process (breech presentation)
Relationship to pelvis
A= anterior
P= posterior
T= transverse
Fetal Position
Most common: LOA (left occiput anterior)
Important to know position because it determines ease of labor in process, determine if any
problems could be anticipated, and tells you best position to determine fetal heart rate
Leopold’s maneuvers: done to determine fetal presentation and position
o 1st: superior surface of fundus
o 2nd: each side of uterus
o 3rd: suprapubic area
o 4th: fetal attitude and extension (only if in cephalic presentation)
MODULE 6: LABOR & DELIVERY PART 2
Maternal Assessment
Focused assessment to determine condition of mother/baby:
Maternal History
allergies
current or recent medications
frequency and time of on set of contractions
amniotic membranes
o were they spontaneously ruptured, fluid color
vaginal bleeding
, pregnancy history
o previous pregnancies (GTPAL)
o type of delivery/c-section
o complications
Maternal testing/prenatal labs
blood type/Rh
hematocrit/hemoglobin
group beta strep (prophylactic antibiotics if positive, given prior to delivery or intrapartum if
vaginal birth)
hepatitis B
HIV (antiviral meds if positive)
Ultrasonography
Nonstress tests
True or false labor
Maternal and Fetal Physical Assessment
Maternal Assessment
Vital signs
Uterine activity
Bladder status/I&O
Bloody show/bleeding
Membrane status (nitrazine, amnisure, fern test)
o Nitrogen test: uses litmus paper, pH based, detects alkaline nature of amniotic fluid and
the paper turns blue showing rupture of membranes
o Amnisure: most common, detects a protein in the amniotic fluid, a kit that comes and
uses monoclonal antibodies to detect
o Fern test: not very practical, sample of amniotic fluid and put on slide
Response to labor
Maternal discomfort
Cultural needs
Fetal Assessment
Fetal presentation and station
Fetal heart rate
Fetal gestation and growth
Electronic Fetal Monitoring
External EFM- pair of belts wrapped around abdomen, one uses Doppler technology to detect
fetal heart rate, one sensor for each baby, other belts measure contraction at top of fundus
measuring duration and frequency of contractions
Internal EFM- electrode used on body part of fetus closest to cervix usually scalp, records fetal
heart rate, contractions monitored w/ special tube called intra-uterine pressure catheter
**needs membranes ruptured for this ** can put fetus at risk for infection if mom HIV positive,
or mom at risk for infection, assesses frequency, duration, AND INTENSITY of
contractions
What do we look at in a fetal heart rate tracing?
Fetal assessment
Baseline FHR
Variability- minimal, marked
Accelerations
Periodic changes (decelerations)
o Early (head compression)
o Late (placental insufficiency)
o Variable (cord compression)
Fetal assessment: tachycardia
Fetal Heart Rate
Baseline normal 110-160
Tachycardia- lasting at least 10 min***** (excluding accelerations/decelerations)
o Mild 161-180
, o Severe >180
Represents increase in sympathetic nervous system or sympathetic tone, or decrease in
parasympathetic tone
Usually associated w/ decreased variability overall
Fetal heart rate decrease as gestational age advances
Premies- more sympathetic tone and less parasympathetic so heart rates are higher but not
just because premie
Caused by fever, mom fever, dehydration, hyperthyroidism, anemia in mom and fetus, anxiety
of mom, smoking, fetal hypoxemia or coreoamneinitis
Fetal assessment: bradycardia
Bradycardia (below 110 at least 10 min)
Mild: 100-109
Moderate: 70-99
Severe: < 70
Most likely result of persistent increase in vagal tone of parasympathetic nervous system
Can be caused by maternal supine positioning, maternal hypothermia, cardiac anatomic
defects, congenital heart disease, decompensating fetus
Fetal Heart Rate
Variability: variations in the fetal heart rate, product of the integrated activity between the
sympathetic and the parasympathetic branches of the autonomic nervous system, reflects status of
the central nervous system
Normal variability: 6-25 bpm
Absent variability: fetus could be asleep, or anacephaly or lack of brain and nervous system
issues
o Meds in the mom can cause this
o Fetal hypoxia
May need to immediately deliver fetus
Minimal variability less than or equal to 5 bpm
Marked variability > 25 bpm
The nurse knows that the fetus is best oxygenated during which of the following?
-relaxation between the uterine contraction
Periodic Changes in FHR
Occur in response to contractions and fetal movement
Short term changes in rate rather than baseline
Last a few seconds to 1 or 2 minutes
Four responses are:
o Accelerations
Typically good, good reaction between CNS, parasympathetic and sympathetic
HR goes up to 15 bmp and lasts 15 seconds
Nonstress test
o Early decelerations
“mirror image” of contraction
pressure on fetal skull- quite common in labor
nursing interventions – document that’s it
o Late decelerations
Occur late in contraction
Indicates fetal hypoxia
Nursing interventions- stop potassium and oxytocin, move mom to left lateral
side, increase IV rate *promote profusion to baby *, administer oxygen to baby,
call doctor
May have to deliver
o Variable decelerations: abrupt decrease in fetal HR
Equal to or more than 15 beats per minute, lasting 15 seconds or more
Less than 2 min in duration
MODULE 6: LABOR & DELIVERY PART 1
Labor & Delivery
2 women are admitted to the labor & delivery unit in active labor. Both deliver healthy baby
boys.
o Sue, a 26-year-old G2 P1, has a labor that lasts 6 hours, and delivers w/ no episiotomy
or lacerations
o Mary, a 35-year-old G1 P0, has a labor that lasts 18 hours, and has significant perineal
swelling, bruising, and a 4th degree laceration
Why did they women have such different experiences?
o Different pelvis shape
Forces o labor: the 5 P’s!
o Powers
o Passageway
o Passenger
o Position
o (psyche)
abnormalities in these can mean a risk for the baby, mother, or both
1st P=Powers (contractions= first stage of labor) (maternal pushing= 2nd stage)
purpose:
o dilate cervix
o aid in expulsion
originate in fundus
interval in between contractions inhibits blood flow to fetus
effective contractions follow a rhythm and progressively lengthen in duration and intensity
measure by:
o frequency (how often they occur)
o duration (how long they are)
each contraction has 3 phases
intensity: palpation, patient sensation, use of fetal monitor
o mild (nose)
o moderate (chin)
o strong (forehead)
IUPC (intrauterine pressure catheter)
o Mild (<40 mmHg)
o Moderate (40-70 mmHg)
o Strong (>70 mmHg)
2 P=Passageway
nd
Route the fetus must travel
o Maternal pelvis
o Maternal soft tissue- cervix
o Gynecoid is true female pelvis and about 50% women have
o 3 subdivisions
inlet (upper pelvic opening)- where fetus presents to first
mid-pelvis (pelvic cavity)- where ischial spines are
outlet (lower pelvic opening)
cervix- needs to be “ripe”
o effacement- cervix becoming shorter and thinner w/ contractions
o dilation
o what is the Bishop Score???
o Cervix goes from 0 cm-10 cm-ish
3 P=Passenger
rd
Fetus and it’s ability to move though passage way
Fetal attitude: pose assumed in uterine, flexion or extension
, Fetal lie: relationship of long axis of fetus (spine) to long axis of mother (spine)
Longitudinal- up and down, 99% of babies
Transverse- sideways
Fetal presentation- portion of fetus coming to cervix first
o 95% sephalic (head presenting part)
more flexed the head is the smaller the diameter
more extended the greater the diameter and more difficulty baby will have getting through
pelvis
Fetal Presentation
breech position: buttocks first 3-4%
o frank breech: legs close to body
o full breech: legs crossed and close to body
o footling: one leg out
shoulder transverse: presenting shoulder first into birth canal
o 1%
o CANNOT be delivered this way
Station
Relation of presenting part to maternal pelvis
Zero station= presenting part engaged in pelvis at level of the ischial spines
Can be determined by vaginal exam by locating ischial spines and noting the relationship of
presenting part of them
4th P= Fetal Position
Relation of presenting part to maternal pelvis
o 3 letters
direction presenting part faces
either left or right and it’s MOM’s L or R
presenting part
O= occiput (most common fetal head is flexed)
M= mentum (chin, fetal head is extended)
Sa= sacrum (breech presentation)
A= acromium process (breech presentation)
Relationship to pelvis
A= anterior
P= posterior
T= transverse
Fetal Position
Most common: LOA (left occiput anterior)
Important to know position because it determines ease of labor in process, determine if any
problems could be anticipated, and tells you best position to determine fetal heart rate
Leopold’s maneuvers: done to determine fetal presentation and position
o 1st: superior surface of fundus
o 2nd: each side of uterus
o 3rd: suprapubic area
o 4th: fetal attitude and extension (only if in cephalic presentation)
MODULE 6: LABOR & DELIVERY PART 2
Maternal Assessment
Focused assessment to determine condition of mother/baby:
Maternal History
allergies
current or recent medications
frequency and time of on set of contractions
amniotic membranes
o were they spontaneously ruptured, fluid color
vaginal bleeding
, pregnancy history
o previous pregnancies (GTPAL)
o type of delivery/c-section
o complications
Maternal testing/prenatal labs
blood type/Rh
hematocrit/hemoglobin
group beta strep (prophylactic antibiotics if positive, given prior to delivery or intrapartum if
vaginal birth)
hepatitis B
HIV (antiviral meds if positive)
Ultrasonography
Nonstress tests
True or false labor
Maternal and Fetal Physical Assessment
Maternal Assessment
Vital signs
Uterine activity
Bladder status/I&O
Bloody show/bleeding
Membrane status (nitrazine, amnisure, fern test)
o Nitrogen test: uses litmus paper, pH based, detects alkaline nature of amniotic fluid and
the paper turns blue showing rupture of membranes
o Amnisure: most common, detects a protein in the amniotic fluid, a kit that comes and
uses monoclonal antibodies to detect
o Fern test: not very practical, sample of amniotic fluid and put on slide
Response to labor
Maternal discomfort
Cultural needs
Fetal Assessment
Fetal presentation and station
Fetal heart rate
Fetal gestation and growth
Electronic Fetal Monitoring
External EFM- pair of belts wrapped around abdomen, one uses Doppler technology to detect
fetal heart rate, one sensor for each baby, other belts measure contraction at top of fundus
measuring duration and frequency of contractions
Internal EFM- electrode used on body part of fetus closest to cervix usually scalp, records fetal
heart rate, contractions monitored w/ special tube called intra-uterine pressure catheter
**needs membranes ruptured for this ** can put fetus at risk for infection if mom HIV positive,
or mom at risk for infection, assesses frequency, duration, AND INTENSITY of
contractions
What do we look at in a fetal heart rate tracing?
Fetal assessment
Baseline FHR
Variability- minimal, marked
Accelerations
Periodic changes (decelerations)
o Early (head compression)
o Late (placental insufficiency)
o Variable (cord compression)
Fetal assessment: tachycardia
Fetal Heart Rate
Baseline normal 110-160
Tachycardia- lasting at least 10 min***** (excluding accelerations/decelerations)
o Mild 161-180
, o Severe >180
Represents increase in sympathetic nervous system or sympathetic tone, or decrease in
parasympathetic tone
Usually associated w/ decreased variability overall
Fetal heart rate decrease as gestational age advances
Premies- more sympathetic tone and less parasympathetic so heart rates are higher but not
just because premie
Caused by fever, mom fever, dehydration, hyperthyroidism, anemia in mom and fetus, anxiety
of mom, smoking, fetal hypoxemia or coreoamneinitis
Fetal assessment: bradycardia
Bradycardia (below 110 at least 10 min)
Mild: 100-109
Moderate: 70-99
Severe: < 70
Most likely result of persistent increase in vagal tone of parasympathetic nervous system
Can be caused by maternal supine positioning, maternal hypothermia, cardiac anatomic
defects, congenital heart disease, decompensating fetus
Fetal Heart Rate
Variability: variations in the fetal heart rate, product of the integrated activity between the
sympathetic and the parasympathetic branches of the autonomic nervous system, reflects status of
the central nervous system
Normal variability: 6-25 bpm
Absent variability: fetus could be asleep, or anacephaly or lack of brain and nervous system
issues
o Meds in the mom can cause this
o Fetal hypoxia
May need to immediately deliver fetus
Minimal variability less than or equal to 5 bpm
Marked variability > 25 bpm
The nurse knows that the fetus is best oxygenated during which of the following?
-relaxation between the uterine contraction
Periodic Changes in FHR
Occur in response to contractions and fetal movement
Short term changes in rate rather than baseline
Last a few seconds to 1 or 2 minutes
Four responses are:
o Accelerations
Typically good, good reaction between CNS, parasympathetic and sympathetic
HR goes up to 15 bmp and lasts 15 seconds
Nonstress test
o Early decelerations
“mirror image” of contraction
pressure on fetal skull- quite common in labor
nursing interventions – document that’s it
o Late decelerations
Occur late in contraction
Indicates fetal hypoxia
Nursing interventions- stop potassium and oxytocin, move mom to left lateral
side, increase IV rate *promote profusion to baby *, administer oxygen to baby,
call doctor
May have to deliver
o Variable decelerations: abrupt decrease in fetal HR
Equal to or more than 15 beats per minute, lasting 15 seconds or more
Less than 2 min in duration
