OBSTETRICAL NURSING: A REVIEW

Part 1: Normal Obstetrics

Let’s get started!!!

NORMAL LABOR (THEORIES OF LABOR ONSET)

 Oxytocin Stimulation Theory
 Uterine Stretch Theory
 Progesterone Deprivation Theory
 Prostaglandin Theory
 Theory of the Aging Placenta
 Fetal-Adrenal Response Theory
 Fetal Adrenal Response Theory

SIGNS OF LABOR WRISLIR

 Weight Loss – 2-3 pounds ( progesterone)
 Ripening of the Cervix – “soft”
 Increased Braxton Hicks – “irregular, painless”
 Show – “ruptured capillaries + operculum = pinkish color”
 Lightening – “the baby dropped”
- 2 weeks (primi) and before or during (multi)
 Relief of respiratory discomfort
 Increased frequency of urination
 Leg pains
 Muscle spasms
 Increased vaginal discharge
 Decreased fundal height
 Increased Level of Activity – large amount of epinephrine (AG)
 Rupture of Membranes – gush or steady trickle of clear fluid

FALSE LABOR
CANDAC
Contraction disappear with ambulation
Absence of cervical dilation
No DIF
Discomfort @ abdomen
Absence of show
Contraction stops when sedated
TRUE LABOR
CUPPAD
Contraction persists when sedated
Uterine contraction DIF
Progressive cervical dilation
Presence of show
Ambulation increase contractions
Discomfort radiates to lumbosacral area
LENGTH OF LABOR
ESSENTIAL FACTORS OF LABOR (5Ps)
 Passages
 Power
 Passenger
 Person
 Position
 Hard – bony pelvis
 Soft – lower uterine segment, cervix, vagina, pelvic floor and perineum
 Primary – involuntary uterine contraction
 Secondary – mother “ bears down”
 Fetal positions, presentation, attitude
 Maternal attitude during labor

 Maternal position during labor /delivery

PASSAGES
 FUNCTIONS (Sit Sit)
○ Serves as birthcanal
○ It provides attachment to muscles, fascia and ligaments
○ Supports uterus during pregnancy
○ It provides protection to the organs found within the pelvic cavity
 TYPES (GAPA)
○ Gynecoid – normal female type of pelvis
- most ideal for childbirth
- round shape, found in 50% of women
○ Android – male pelvis
- presents the most difficulty during childbirth
- found in 20% of women
○ Platypelloid – flat pelvis, rarest, occurs to 5% of women
○ Anthropoid – apelike pelvis, deepest type of pelvis found in 25% of
women

DIVISION OF PELVIS
 False Pelvis – “provide and direct”
 True Pelvis – “the tunnel” IPO
Inlet or Pelvic Brim – entrance to true pelvis
ANTEROPOSTERIOR DIAMETER DOT
 • Diagonal Conjugate – midpoint of sacral promontory to
the lower margin of symphysis pubis (12.5 cm)
• Obstetric Conjugate – midpoint of sacral promontory to
the midline of symphysis pubis (11 cm)
• True Conjugate – midpoint of sacral promontory to the
upper margin of symphysis pubis (11.5 cm)
Pelvic Canal – situated between inlet and outlet
- designed to control the speed of descent of the fetal
head
Outlet – most important diameter of the outlet.

POWERS 3I
Involuntary – not within the control of the parturient

Intermittent – alternating contraction and relaxation

Involves discomfort (compression, stretching and hypoxia)

PHASES OF UTERINE CONTRACTIONS

1. Increment/Crescendo – “ready, get set”
2. Acme/Apex – “go”
3. Decrement/Decrescendo – “stop”
INTENSITY - strength of uterine contraction
Mild – slightly tensed fundus
Moderate – firm fundus
Strong – rigid, board like fundus
FREQUENCY – rate of uterine contraction
- measured from the beginning of a contraction to the beginning of
the next contraction

DURATION – length of uterine contraction

- measured from the beginning of a contraction to the end of the
same contraction

INTERVAL – measured from the end of contraction to the beginning of the next
contraction
PASSENGER
 HEAD BOTu
- Biggest part of the fetal body
- Olways the presenting part
- Turn to present smallest diameter

 CRANIAL BONES 1 FOSE, 2 PaTe

1 frontal bone 2 parietal bone
 1 occipital bone 2 temporal bone
1 sphenoid bone
1 ethmoid bone
 SUTURE LINES – allow skull bones to overlap (molding) and for further brain
development (SFC La)
 Sagittal Suture – between 2 parietal bones
 Frontal Suture – between 2 frontal bones
 Coronal Suture – between frontal and parietal
 Lamdiodal Suture – between parietal and occipital

 FONTANELS – intersection of suture lines

 Anterior Fontanel or Bregma – intersection of SFC
- diamond shaped, closes b/n 12 – 18 months
- 3 x 4 cm
 Posterior Fontanel or Lambda – intersection of Sla -
triangular shaped, closes b/n 2 – 3 months
 DIAMETERS OF THE FETAL HEAD
AP > T (fetal head)
1.Tranverse Diameters BBB
 Biparietal – most important TD
- greatest diameter presented to the pelvic inlet’s AP and at the
outlet’s TD
- average measurement is 9.5 cm
 Bitemporal – average measurement is 8 cm
 Bimastoid – average measurement is 7 cm

2. Anteroposterior Diameters SOO

 Suboccipitobregmatic – smallest APD
- fully flexed (presenting part)
- measured from the inferior aspect of occiput to the
anterior fontanel
- average measurement is 9.5 cm
 Occipitofrontal – head partially extended and presenting part is the anterior
fontanel
- average size is 12. 5 cm
 Occipitomental – head is extended and the presenting part is the face
- measured from the chin to the posterior fontanel
- average size is 13.5 cm

FETAL LIE – relationship of the long axis of the fetus to the long axis of the mother
Longitudinal Lie – “parallel”
Transverse Lie – “right angle/lying crosswise”
Oblique Lie – “slanting”

Attitude or Habitus – degree of flexion or relationship of the fetal parts to each other.
PRESENTATION AND PRESENTING PART
POSITION
 LOA (Left Occipitoanterior) – most favorable & common fetal position
- fetus in vertex presentation (occiput)
- fetus usually accommodates itself on the left because the placement of the
bladder is at the right
 LOP/ROP – mother will suffer more back pains
 FHT Breech: Upper R or L Quadrant (above Umbilicus)
 FHT Vertex: Lower R or L Quadrant (below Umbilicus)
 STATION - relationship of the presenting part of the fetus to the ischial spine of
the mother.
 Minus (-) station – presenting part is above the ischial spine
 Zero (0) station – presenting part is at the level of the ischial spine
 Positive (+) station – presenting part is below the level of the ischial spine
 FLOATING – head is movable above the pelvic inlet
 +1 station – fetus is engaged
 +2 station – fetus is in midpelvis
 +4 station – perineum is bulging
THE PERSON
FACTORS affecting labor PRC PCP
Perception & meaning of childbirth
Readiness & preparation for childbirth
Coping skills
Past experiences
Cultural & social background
Presence of significant others and support system
STAGES OF LABOR
STAGE 1 – DILATATION STAGE
Starts from first true uterine contraction until the cervix is completely effaced and
dilated.
Dilatation – widening of cervical os to 10 cm
Effacement – thinning to 1- 2 cm
CAUSES: 1. Ferguson Reflex
2. Fetal head and intact BOW serves as
a wedge to dilate the cervix
Maternal Assessment During Labor
1. Check V/S q 4hrs during the first stage
- temp q hour if membranes are already ruptured (
risk of infection)
- BP b/n contractions, in left lateral pos, q 15 – 20
mins after giving anesthesia
 - a rapid pulse indicates hemorrhage &
dehydration
2. Uterine contraction
Manual: fingers over fundus, you feel it about 5 secs before the client feels it
Techniques:
1. assess contraction (DIIF)
2. check contraction q 15 – 30 mins during the first stage
3. refer immediately if:
- duration more than 90 secs
- interval less than 30 secs
- uterus not relaxing completely after each
contraction
3. Show – slightly blood-tinged mucus discharge
4. Internal Examination – to assess status of amniotic fluid, consistency of cervix,
effacement/dilatation, presentation, station and pelvic measurement.
- do it during relaxation
- less IE done once membrane have ruptured
- start with middle finger then index finger
7. Status of Amniotic Fluid (if ruptured)
 Danger of cord prolapse if fetal head is not yet engaged.
 Danger of serious intrauterine infection if delivery does not occur in 24 hours
 NITRAZINE PAPER TEST
- used to assess whether membrane ruptured or not.
 Procedure: “Insert and Touch”
○ Yellow – intact BOW
○ Blue – ruptured
 Normal Color of AF – clear, colorless to straw colored
 Green tinged – meconium stain (fetal distress in non – breech presentation)
 Yellow/Gold – hemolytic disease
 Gray/Cloudy – infection
 Pinkish/Red stained – bleeding
 Brownish/Tea Colored/Coffee Colored – fetal death

OTHER TEST TO DETERMINE STATUS OF AMNIOTIC FLUID

Ferning pattern of cervical mucus
(“swab – dry – view”)
Nile blue sulfate staining of fetal squammous cells
FETAL ASSESSMENT DURING LABOR
FHT Monitoring
Latent Phase – every hour
Active Phase – every 30 minutes
Second Stage of Labor – every 15 minutes
FHT is taken more frequently in high – risk cases
Normal FHT Pattern
Baseline rate: 120 – 160 bpm
 Early Deceleration – FHT @ contraction, Normal @ end of contraction (head
compression)
Acceleration - FHT when fetus moves
 Abnormal FHT Pattern
 Bradycardia – 100 – 119 bpm – moderate
- below 100 bpm – marked
CAUSES: 1. fetal hypoxia (analgesia &
anesthesia)
2. maternal hypotension
3. prolonged cord compression
MGT: 1. place mother on left side
2. assess for cord prolapse
3. administer oxygen
 Tachycardia – 161 – 180 bpm – moderate
- above 180 bpm – marked
CAUSES: 1. maternal fever, dehydration
2. drugs (atrophine, terbutaline, ritodrine, etc.
MGT: 1. D/C oxytocin, position on LLP
2. give 02 at 8 – 10 lpm
3. prepare for birth if no improvement
 Variable Pattern – deceleration at unpredictable times of uterine contraction
CAUSE: sign of cord compression
MGT: release pressure on the cord
 Sinusoidal Pattern – no variability in FHT
CAUSE: hypoxia, fetal anemia & prematurity

Location of FHT

CARE OF THE PARTURIENT

 LATENT PHASE
○ Cervical Dilation: 0 – 4 cm
○ Nature of Contraction: Duration: < 30 secs
Interval: 3 – 5 mins
○ Length of Latent Phase: Primis – 6 hours
Multis – 4 – 5 hours
○ Attitude of mother: feel comfortable, walking and sitting at this time
○ Nsg Responsibilties: TGC
1. Teach breathing techniques
2. Give instructions
 3. Conversation is possible (cooperative &
focus mother)

2. ACTIVE PHASE
○ Cervical Dilation: 4 – 7 cm
○ Nature of contractions: Duration: 30 – 50 secs
Intensity: moderate to strong
○ Length of Active Phase: Primis – 3 hours
Multis – 2 hours
○ Attitude of mother: prefer to stay in bed, withdraws from her environment
and self – focused
○ Nsg Responsibilities: CPIC
1. Coach woman on breathing and relaxation techniques
2. Prescribed analgesics given during active phase
3. Instruct woman to remain in bed, minimize noise, raise side
rails, NPO
4. Check BP 30 mins after giving analgesics (hypotension)

3. TRANSITION PHASE
○ Cervical Dilatation: 8 – 10 cm
○ Nature of Contractions: Duration: 50 – 60 secs
Interval: 2 -3 mins
Intensity: moderate to strong
○ Length of Transition Phase:
Primis – 1 hour (baby delivered within 10 contractions or 20 mins)
Multis – 30 mins (baby delivered within 10 contractions or 20 mins)
○ Attitude of mother: feel discouraged, ask midwife/nurse repeatedly when
labor will end, not in control of her emotions and sensations, irritated,
may not want to be touched
○ Nsg Responsibilities: RRE
1. Reassure woman that labor is nearing end & baby will be born
soon
2. Reinforce breathing and relaxation techniques
3. Encourage fast-blow breathing to remove the urge to bear down
 CARE OF THE BLADDER – encourage the woman to void q 2 hrs to: DIPC
○ Delay fetal descent
○ Increases the discomfort of labor
○ Predispose to UTI
○ Can be traumatized during labor
 FOODS & FLUIDS – NPO on active phase
○ Clear fluids on latent phase
 POSITIONING – LLP - best position bcoz  RIPES
○ Relieves pressure – IVC
○ Improves urinary function
○ Prevent hypotensive syndrome
○ Encourage anterior rotation of the fetal head
 ○ Squatting is ideal position – directs presenting part towards the cervix
promoting dilatation

AMBULATION – during the latent phase to shorten the first stage, to decrease the need
for analgesia, FHT abnormalities & to promote comfort
NO WALKING IF BOW IS RUPTURED
IV FLUIDS – reasons: PLUA
Prevent dehydration/fluid & electrolyte imbalances
Life – line for emergencies
Usually required before administration of A/A
Administration of oxytocin after delivery to prevent atony
PERINEAL PREP
Clean & disinfect the external genitalia
Provide better visualization of the perineum
ENEMA – emptying the colon of fecal matters to:
Prevent infection
Facilitate descent of fetus
Stimulate uterine contractions
CONTRAINDICATIONS: NIRVAA
Not given during active phase
If premature labor bcoz of danger of cord prolapse
Rupture of BOW
Vaginal bleeding
Abnormal fetal presentation & position
Abnormal fetal heart rate pattern
 SECOND STAGE – EXPULSIVE STAGE
MECHANISM OF LABOR: EDFIRE ERE
 Engagement

 Descent – entrance of the greatest biparietal diameter of the fetal head to the
pelvic inlet

 Flexion – the chin of the fetus touches his chest enabling the smallest
diameter (suboccipitobregmatic) to be presented to the pelvis for delivery

 Internal Rotation – when the head reach the level of the ischial spine, it
rotates from transverse diameter to AP diameter so that its largest diameter
is presented to the largest diameter of the outlet. This movement allows the
head to pass through the outlet.
  Extension – the head of the fetus extend towards the vaginal opening. As
the head extend, the chin is lifted up and then it is born.
 External Rotation – when the head comes out, the shoulder which enters the
pelvis in transverse position turns to anteroposterior position for it become in
line with the anteroposterior diameter of the outlet & pass through the pelvis.

 Expulsion – when the head is born, the shoulder & the rest of the body
follows without much difficulties.

 Duration of Second Stage: Primis – 50 mins

Multis – 20 mins
 Assessment: monitor FHT q 15 mins in normal case and every 5 mins in high
risk cases if not yet delivered

 Transfer to the DR: Primis – cervix fully dilated

Multis – cervix is 8 cm dilated

Delivery Position
 Lithotomy – used when forcep delivery & episiotomy are to be performed.
 Dorsal Recumbent – head of the bed is 35 – 45˚ elevated, knees are
flexed & feet flat on bed. This position facilitates the pushing effort of the
mother.
 Left Lateral Position – indicated for woman with heart disease.
 ASSISTING THE MOTHER IN THE DR
 Coach the mother to push effectively
 Instruct the woman to pant
 Dorsiflex the affected foot and straigthen the leg until the cramps
disappear
 Perform ironing on vaginal orifice if the presenting part moves towards
the outlet
 When the head is crowning, instruct the mother to pant.
 Perform Ritgen’s Maneuver while delivering the fetal head to:
• Slows down delivery of the head
• Lets the smallest diameter of the head to be born
• Facilitates extension of the head
 Just after delivery, immediately wipe the nose & mouth of secretions then
suction.

8. Take note of the exact time of baby’s birth

9. After the delivery of the baby, place the newborn in dependent position to
facilitate drainage of secretions.
10. Place the infant over the mother’s abdomen to help contract the uterus.
11. Clamping the cord:
After the pulsation stops
 Clamp the cord twice and cut in between 8 – 10 inches from
umbilicus
After cutting the cord, look for 2 arteries & 1 vein
12. Wrap the infant & bring to the nursery.
 THIRD STAGE – PLACENTAL DELIVERY
METHODS OF PLACENTAL SEPARATION:
 Schultz Mechanism – separation of the placenta starts from the center
- the shiny & smooth fetal side is delivered first
- 80% of placental separation
2. Duncan Mechanism – separation begins from the edges of placenta
- the dirty maternal side is delivered first
- 20% of placental separation
MANAGEMENT:
 Watchful waiting.
 Do not hurry placental delivery.
 Rest a hand over the fundus to make sure the uterus remains
firm
 Wait for signs of placental delivery
• Calkin’s sign – uterus is firm, globular & rising to the level of
umbilicus
• Sudden gush of blood from vagina
• Lengthening of the cord

2. Manage the uterus to keep it contracted.

3. Administer methergin as prescribed.
4. Never leave the client unattended.
5. Oxygen & emergency equipment made available.
 THE FOURT STAGE – PUERPERIUM
MANAGEMENT:
 Repair of lacerations.
CLASSIFICATION OF PERINEAL LACERATIONS
First Degree – fourchette, vaginal mucous membrane,
perineal skin
Second Degree – fourchette, vaginal mucous membrane,
perineal skin, muscles of perineal body
Third Degree – fourchette, vaginal mucous membrane,
perineal skin, muscles of perineal body & anal sphincter
Fourth Degree - fourchette, vaginal mucous membrane,
perineal skin, muscles of perineal body, anal sphincter &
mucous membrane of rectum
2. After repair of lacerations & episiotomy, perineum is cleansed, the legs are lowered
from stirrups at the same time.
3. Check V/S of the mother every 15 mins for the first hour & every 30 mins for the next
2 hours until stable.
4. Check uterus & bladder q 15 mins.
“Go Topnotchers!”
“if God is with you, 100% of the battle is won!”