Download Module III Speaker Notes - Alaska State Hospital and Nursing Home

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Note to Instructor:
If your participants completed the case study from Module
II: Physiologic and Psychosocial Adaptation to Pregnancy,
now is a good time to review the case study and reinforce
the concepts.
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The authors, reviewers, and nurse planners for this
module report no conflicts of interest or relevant
financial relationships.
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Note to Instructors: Mandatory Disclosure of Commercial
Relationships
At the beginning of each Perinatal Orientation and Education
course or module presentation, you are required to make a
statement disclosing potential conflicts of interest to the course
participants. A statement is also required if there are NO conflicts
of interest or relevant financial relationships with commercial
interests or if there are conflicts or relationships to disclose.
Instructors will say the statement that applies to their situation.
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The following statements are listed in the Program Overview
and Manual For Administrators and Instructors and are provided
as examples for your reference during this disclosure. The
following information reflects ANCC accreditation guidelines
regarding disclosure of commercial relationships:
•  “To ensure conformance with accreditation guidelines,
Instructors teaching this course are required to report any
potential or actual conflicts of interest or relevant financial
relationships they, their spouses or partners currently have or
have had within the previous 12 months with AWHONN,
Above Learning, or any company or other commercial interest
that provides goods or services mentioned during this course.”
•  If you have conflicts of interest or relevant financial
relationships with commercial interests to disclose:
•  This is a sample of a conflict of interest statement:
“The accrediting organizations for this meeting require
me to make a disclosure statement at the beginning of
this course: “I have a financial relationship with XXXXX
company/corporation as follows: (list the general nature
of the relationship, e.g., employment, honoraria, stock
ownership, research grants, etc.). I also have a financial
relationship with Above Training as follows:…”
•  The individual must also provide a disclosure
document to the participants explaining the nature of
relationship by indicating the following:
•  Name of the individual
•  Name of the organization with which there is a
commercial interest
•  Name of the relationship the individual has with the
commercial interest
•  If you have NO conflicts of interest or relevant financial
relationships with commercial interests to disclose:
•  This is a sample of a NO conflict of interest statement: “The
accrediting organizations for this meeting require me to
make a disclosure statement at the beginning of this course:
I have no relevant financial relationships with AWHONN,
Above Learning, or any company or other commercial interest
that provides goods or services mentioned during the course.”
The purpose of this module is to provide an overview of
the physiologic and anatomic processes of normal labor.
Labor support, pain management, and nursing care of the
laboring woman will be presented. An overview of
dysfunctional labor, assisted birth, and cesarean birth are
included, along with discussion of risk factors for and
management of postpartum hemorrhage.
Note to Instructor:
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The use of visual aids, such as anatomic models and
charts, is recommended to reinforce concepts related to the
process of normal childbirth.
After completion of this module, the learner should be able
to:
•  Identify maternal coping behaviors, cultural
variations, and nursing strategies related to labor
and birth
•  Describe the nursing care provided during the four
stages of labor
•  Differentiate between normal and dysfunctional
labor progress
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•  Discuss maternal and fetal conditions that may
affect the process and outcomes of labor
•  Identify supportive methods of pain relief used
during labor that may also facilitate labor progress
•  Differentiate between induction and augmentation of
labor and describe the various agents used
•  Describe the nursing care provided for a cesarean
birth in the preoperative, intraoperative, and
postoperative phases
•  Discuss the recognition and management of potential
complications in the immediate post-anesthesia care
recovery period after cesarean birth
•  Identify appropriate nursing interventions utilized
during an initial postpartum hemorrhage
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•  Discuss the recognition and management of potential
complications in the immediate post-anesthesia care
recovery period after cesarean birth.
•  Identify appropriate nursing interventions utilized
during an initial postpartum hemorrhage
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We must remember that the first patient that we are
caring for is the mother. Every woman deserves quality
supportive nursing care during all phases of labor and
birth. Supporting the family is also an important aspect of
the healthcare team’s role. As we move through the
following slides we will explore the factors that affect the
labor process.
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There are five classic “Ps” that affect labor: power,
psychology, passageway, passenger, and position. Let’s
examine how each influences the progress of labor.
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Powers refer to involuntary contractions and voluntary
maternal effort that combine to expel the fetus out of
the uterus. Uterine contractions are the primary
powers responsible for labor initiation and progress.
The primary powers result in effacement and dilation
of the cervix and descent of the fetus. Contractions
must be adequate and coordinated but not too frequent,
as can occur with poor regulation of an oxytocin
infusion.
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During the second stage of labor, the secondary
powers are the bearing-down efforts that the mother
uses to supplement the involuntary contractions. These
secondary forces assist with the descent of the
presenting part and expulsion of the fetus. Pushing or
bearing-down efforts create increased intraabdominal
pressure that compresses the uterus and facilitates the
expulsive efforts. Bearing-down efforts add to the
force of contractions, and they are most effective when
the obstetric conditions are optimal for descent — that
is, when the cervix is not only completely dilated, but
the fetus is at a +1 or +2 station and in an anterior fetal
position (Roberts, 2003; Roberts & Hanson, 2007).
These features of labor will be defined and described
shortly.
By the end of pregnancy, the mother’s body has undergone
significant physiologic changes to prepare her for birth.
The fetus has developed, grown and under normal
circumstances, by term, is ready to survive in the
extrauterine environment.
Several theories have been proposed to explain the onset
of labor. Both maternal and fetal factors are thought to
influence the onset of labor as the mother and fetus prepare
for the process of labor and birth (Simpson, 2008b).
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Maternal factors include the following:
•  Endogenous (from within the body) oxytocin is
synthesized in the hypothalamus, transported to the
posterior lobe of the pituitary gland, and released into
the maternal circulation. Oxytocin helps to stimulate
contraction of the uterine muscle to initiate and
maintain labor. Oxytocin is also released in response to
breast stimulation, sensory stimulation of the lower
genital tract, and cervical stretching.
The Process of Labor and Birth
•  The fetal presenting part puts pressure on the cervix,
causing release of oxytocin by the posterior pituitary.
Oxytocin and prostaglandin enhance calcium binding in
the uterine muscle, which stimulates contractions.
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•  The uterine muscles are stretched, resulting in the
release of prostaglandin.
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•  Decreased progesterone levels allow estrogen to
stimulate uterine contractility. With lowered levels of
progesterone, the myometrium loses resistance as
uterine contractions act on the resistance of the cervix.
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•  Current work is being done on theories relating to
membrane-associated estrogen receptors, such as
GPR30, which may influence onset of contractions.
Fetal factors may include the following:
•  Production of prostaglandin by the fetal membranes
and decidua causes the uterus to contract.
•  The fetal adrenal glands produce cortisol in increasing
amounts that act on the placenta to decrease
progesterone formation and increase prostaglandin
release.
•  Placental aging and degradation can stimulate
contractions.
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•  Rupture of membranes may begin the process of
labor.
Signs of impending labor may include any of the following
(Felton, 2011; Lowdermilk, 2012a):
•  Lightening (commonly referred to as “when the baby
drops”): This process occurs when the fetus begins to
enter into the pelvis causing the fundal height to drop. It
usually occurs about 2–4 weeks before labor begins in
primigravidas. Once lightening takes place, women can
usually breathe easier and feel less congested, as
pressure on the diaphragm is relieved. With this shift,
though, pressure on the urinary bladder is increased,
causing increased urinary frequency.
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•  Increased vaginal discharge: Women may notice the
passage of a mucus plug during the last month of
pregnancy. Bloody or serosanguineous discharge comes
from the small capillaries that rupture as the cervical
tissue begins to dilate and efface.
•  Sudden burst of energy (“nesting”): Many women feel
the need to get things in order, which may be associated
with increasing estrogen levels that cause a decrease in
progesterone levels via the progesterone-binding
protein.
•  Gastrointestinal (GI) symptoms: Women may
experience nausea, vomiting, diarrhea, or indigestion.
•  Cervical change: The cervix may dilate (or begin to
open) or efface (start to thin) or both. Many patients
will be slightly dilated or effaced for several weeks
prior to the onset of true labor.
•  Bloody show: Women may notice a small to moderate
amount of bloody or serosanguineous discharge.
•  Rupture of the membranes
•  Lower back pain
•  Weight loss: In the days preceding labor, weight loss of
about 0.5–1.5 pounds may be observed secondary to
water loss from electrolyte shifts as estrogen and
progesterone levels change.
•  Uterine contractions: Regular or irregular mild to
moderate uterine contractions may occur. At this stage,
contractions help to facilitate cervical preparation for
labor.
•  The true definition of labor is: effacement and
dilation of the cervix and descent of the fetus.
First, let’s discuss the primary powers. There are pacemaker
points in the muscle layers of the upper uterine segment
where involuntary contractions originate. From these
pacemaker points, contractions move downward over the
uterus, causing constriction of blood vessels that cross the
uterine muscle (Lowdermilk, 2012a). Think of contractions as
coming in waves, traversing the uterus, then subsiding until the
next wave begins. This transmission is possible because of the
“gap junctions” that have formed in preparation for labor
between the cells of the myometrium and the uterine muscle.
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Contractions are assessed and described using the
following terms:
•  Frequency is the time from the beginning of one
contraction to the beginning of the next contraction and is
usually measured in minutes.
•  Duration is the length of time the contraction lasts and is
usually described in seconds.
•  Intensity is a measure of the strength of the contraction at its
peak when palpated or when assessed using an intrauterine
pressure catheter (IUPC). Contraction strength is palpated by
gently feeling the uterus with your fingertips during the
contraction. The human hand can sense a contraction at around
30 mmHg. Strength may also be measured with an IUPC in
millimeters of mercury (mmHg) of pressure. Contraction
intensity is described as mild, moderate, or firm on palpation.
•  Resting tone is the normal intrauterine pressure between
contractions or in the absence of contractions. Resting tone
is assessed either by palpation (soft or strong) or by IUPC
measurement in mm Hg of pressure. All muscle, even
when relaxed, has a small amount of “tone”. Normal
resting tone is 5–20 mmHg.
When electronic fetal monitoring (EFM) is in use, the external
tocotransducer measures frequency and duration of contractions
but does not accurately measure the strength of contractions. The
tocotransducer creates a graphic display of the contraction that
looks like a normal curve or waveform. Many things, such as
maternal position and weight, can alter how high or low the
contraction is displayed on the tracing paper. Therefore, when
using a tocotransducer, palpation is required to assess the strength
of uterine contractions and to validate the findings of the EFM.
It may be difficult to palpate contractions or electronically
monitor the preterm patient. The tocotransducer should be
placed at the fundus (even if below the umbilicus). Low
amplitude, high frequency contractions in the preterm patient
can be an indicator of increasing uterine irritability or
chorioamnionitis in the PPROM patient (Doret et al., 2005).
As you can see on the tracing, a contraction consists of
three phases: the increment (usually steep and rapid), the
acme (or peak of the contraction), and the decrement
(sometimes more prolonged than the increment) in a
wavelike pattern (Lowdermilk, 2012a). During the
interval, or resting phase, between contractions, the uterus
and placenta refill with blood, permitting the exchange of
oxygen, carbon dioxide, and nutrients.
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Duration of uterine contractions is counted from the
beginning of the contraction to the end of the
contraction, usually described in seconds.
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Determination of contraction duration is a combination
of palpation, patient sensation and fetal monitor
tracing. Remember that the external tocotransducer is an
approximate reading of the onset and offset of the
contraction. The internal uterine pressure catheter (IUPC)
is a mmHg reading of intrauterine pressure and should be
an accurate measure of the onset and offset of the
contraction as long as it is correctly calibrated.
Contraction frequency is counted from the beginning of
one contraction until the beginning of the next
contraction, usually described in minutes and reported
in conjunction with duration (Simpson, 2008b). Interval
markings on the fetal monitor paper will enable the nurse
to assess this parameter. Contractions are seldom exactly
the same number of minutes apart and so are often reported
as a range.
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Palpation of uterine contractions is a key labor assessment
parameter. During a mild contraction, the fundus is easily
indented and feels like the pressure of touching a
fingertip to the tip of the nose. During a moderate
contraction, the fundus is more difficult to indent and
feels like the pressure of touching a fingertip to the
chin. During a strong contraction, the fundus is difficult
to indent and feels like touching a fingertip to the
forehead. Using an IUPC, a mild contraction is
generally less than 40 mmHg, a moderate contraction
ranges between 40 and 70 mm Hg, and a strong
contraction is generally greater than 70 mmHg.
Note to Instructor:
Ask your participants to palpate their chin, nose, and
forehead as you describe contraction intensity. You may
also want to use additional teaching adjuncts, such as
educational models or a knitted uterus model to
demonstrate how uterine contractions help efface and
dilate the cervix.
Resting tone is described as soft or firm by palpation
(Simpson, 2008b) or in mmHg if using an IUPC. It is
during the resting period that the uterine vessels provide
blood flow to the placenta, allowing for the maternal-fetal
exchange of respiratory gases (Ali, 2009). Therefore,
assurance of adequate resting tone is key to enhancing
fetal oxygenation. The uterus should feel soft to the
examiner’s hand between contractions. Resting tone
using the IUPC should be between 5 and 20 mmHg.
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As you can see, an IUPC will immediately indicate onset
of a contraction. The human hand can feel the onset of
uterine activity at approximately 15–20 mmHg. Patients
generally can feel the onset of a contraction at 20–30
mmHg, although that is highly variant per patient. The
external toco indication of onset will be highly variable
and is dependent on where the toco is placed, the position
of the patient and relative adiposity of the patient.
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In 2008, the NICHD defined uterine activity (Macones,
Hankins, Spong, Hauth, & Moore, 2008). Uterine
contractions are quantified as the numbers of
contractions present in a 10-minute window, averaged
over 30 minutes. Normal contraction pattern is defined
as 5 or less contractions in 10 minutes, averaged over a
30-minute window. Tachysystole is defined as greater
than 5 contractions in 10 minutes, averaged over a 30minute window.
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When tachysystole occurs, it should always be qualified
as to the presence or absence of associated fetal heart
rate decelerations. Tachysystole can occur with both
spontaneous and stimulated labor. Actions taken in the
presence of tachysystole may differ depending on
whether the contractions are spontaneous or
stimulated. The terms hyperstimulation and
hypercontractility are not defined and should be
abandoned.
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Effective uterine contractions result in effacement and
dilation of the cervix. Tachysystole can occur in
spontaneous labor or with the use of oxytocin or laborstimulating medications. It can result in fetal
deoxygenation, because there is too short an interval, or
period of relaxation, between uterine contractions for
oxygenated blood to re-perfuse the uterus. The next slide
shows an example of a pattern of tachysystole.
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Let’s look at this fetal heart rate (FHR) and uterine activity
tracing as we discuss evaluation of contractions. An IUPC
is in use. This tracing demonstrates tachysystole. This is a
9 minute fetal heart rate tracing.
Consider the following questions:
•  What is the resting tone? (25–45 mmHg)
•  What is the frequency, duration and intensity? (q 1–2
min x 50–60 seconds with prolonged [> 2 min]
contraction at the end)
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•  How is the fetus responding? (decreased variability
and decelerations)
•  What would be your next steps? (get help, stop any
medications causing contractions, turn to side, consider
supplemental oxygen)
Note to Instructor:
To enhance the learning experience you can engage your
learners by asking the questions included in the note. The
answers to the questions are in italics.
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Risk factors for labor dystocia have been categorized as
those contributing to slow progress in the first stage of
labor and those associated with a longer second stage of
labor and are related to the five Ps. The risk factors
listed on this slide were derived from review of thousands
of medical records of women who delivered by cesarean
birth for dystocia (ACOG, 2003a). What’s important to
remember here, though, is that none of these factors are
absolute predictors of labor dystocia (ACOG, 2003a). For
example, a woman who has a large fetus but who also has
a proportionately adequate-sized pelvis may progress
normally though labor. Adequate pelvic dimensions may
also permit normal rotation and descent of the fetus that is
in posterior position.
ACOG (2003a) also cautions that a diagnosis of labor
dystocia, or failure to progress, should not be made before
an adequate trial of labor has been accomplished. Keeping
this in mind, labor abnormalities can be classified as
slower-than-normal progress, or protraction disorders, and
complete cessation of progress, or arrest disorders. For
example, a protraction disorder may be identified when the
rate of cervical dilation and descent in the active phase of
the first stage of labor is less than 1 cm per hour. An arrest
disorder may be diagnosed when fetal descent stops
completely during the second stage of labor. In either case,
before opting for assisted vaginal birth or cesarean birth,
the clinician should evaluate possible causes and
implement interventions aimed at correcting the problem,
such as changing the maternal position to help fetal
rotation or augmenting labor when indicated (Simpson &
James, 2008).
Both fixed and dynamic factors affect labor. Fixed factors,
those that cannot be changed, include: maternal age,
parity, co-morbidities, pelvic size and shape, fetal size,
presentation, gestational age, obesity and uterine
abnormalities. Dynamic factors, those which can
change, include hydration, multiple gestation, maternal
psychological status or anxiety, pain, positioning,
contractions (including use of tocolytics or induction/
augmentation agents) and other medications.
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Now let’s move on to the third P — passageway. The
passageway is composed of the mother’s bony pelvis,
tissues of the cervix, the pelvic floor, the vagina, and the
introitus. The size and shape of the mother’s pelvis should
be evaluated, ideally, before labor begins. This assessment
is important because the size and shape of the maternal
bony pelvis significantly influence how and whether the
fetus (the passenger) will be able to travel through the birth
canal (the passageway) (Lowdermilk, 2012a).
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During labor, the tissues of the lower uterine segment
distend to accommodate the fetus, placenta, and amniotic
sac. As labor progresses, the cervix effaces and dilates, as
we’ve discussed. The pelvic floor separates the pelvic
cavity from the perineal area and supports fetal anterior
rotation and descent into the birth canal. The soft tissues of
the vagina and introitus, having developed under the
influence of pregnancy hormones, stretch to accommodate
the passage of the fetus from the mother to the external
environment (Lowdermilk, 2012a).
We will discuss this further when we discuss the
mechanisms of labor.
Note to Instructor:
The next series of slides focuses on caring for the woman
in labor. You may want to pause at this point to answer
questions about the content covered thus far.
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The third P is psychology. Pregnancy is a time of
continual change, both physically and emotionally. The
perinatal nurse plays an important role in the woman’s
psychosocial adaptation to pregnancy and the transition to
motherhood. The nurses knowledge of normal
developmental and psychosocial processes allows for
identification of problems or alterations in the experiences
(Driscoll, 2008). We have already reviewed the
developmental milestones in Module I: Preconception and
Interconception Health. The psychosocial assessment
should focus on normalcy, health, strengths, and
developmental concepts. Throughout pregnancy, it is
relatively easy to focus on the physical and physiologic
changes taking place. However, it is important to recognize
that pregnancy and labor affect the woman’s psyche and
spirit, as well as her body. Whenever possible, a holistic
approach to care is essential (Driscoll, 2008).
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Women’s expectations of the childbirth experience may
influence their reactions to the labor and birth process.
Past personal experiences as well as previous birth
experiences can influence the progress of labor,
particularly if past experiences were negative. Anxiety can
stimulate catecholamine release that may cause ineffective
contractions and dysfunctional labor. When women do not
know or understand what is happening to them or what is
being said, anxiety and fear may escalate (Piotrowski,
2012c). Women should be assessed for their understanding
of the sensations, expectations, and knowledge of birth
processes during pregnancy and in labor (AWHONN,
2008).The quality of labor support, the presence or absence
of primary support persons, childbirth preparation, and
medical and nursing interventions may also affect the
woman’s perception of the labor experience. Cultural
factors should also be evaluated for each woman in labor.
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The cultural framework your patient comes from can have
a significant psychological impact on your patient’s labor
process. Cultural values and beliefs may influence the
woman’s reaction to labor (Piotrowski, 2012c). Women
should be encouraged to make staff who care for them
aware of practices that are important to them. For example,
if your patient is Muslim, she may prefer to have only
female providers. A Jewish patient may have dietary
requirements to “keep kosher”. An Asian patient may
desire to eat only fish and rice prepared by her mother or
mother-in-law for the first 3 days. The Hispanic patient
may believe in the “evil eye” and expect that you touch her
child whenever giving a compliment. The Mennonite
woman may prefer that her education be written and not
televised. It is important to be aware of the cultural
background of your patient and the impact it can have on
her labor process and progress. Be sure not to assume that
cultural norms apply to all women of culture. Do not
stereotype a woman because she is of a particular descent,
and assess the appropriateness of cultural norms for her as
an individual.
For an extended discussion on cultural care of the laboring
family, see Module I: Preconception and Interconception
Health.
We have discussed the first patient – the mother. We will
now go on to discuss factors that impact upon the
passenger and second patient – the fetus.
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The next P that influences the process and progress of
labor is the fetus — the passenger. Fetal descent through
the birth canal is determined by the size of the fetal
head, fetal lie, fetal presentation, fetal attitude, and
fetal position. The fetal head adapts to the maternal pelvis
through the processes of molding, flexing, and rotating to
fit through the birth canal. The normal, full-term fetal head
is the largest fetal part to fit through the pelvis. The head or
vertex enters the pelvis first in about 96% of all births
(Lowdermilk, 2012a).
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The fetal skull consists of seven bony plates that are held
together by membranous sutures identified as the sagittal,
lambdoidal, frontal, and coronal sutures. The fontanels are
the “soft spots” located where the sutures intersect. During
labor, and as the fetus descends through the birth canal, the
bony plates change position slightly, resulting in molding
of the head. Molding permits the fetal head to adapt to the
shape of the mother’s pelvis during labor. The fetal head
will mold as a result of some resistance in the pelvis
(Lowdermilk, 2012a).
Some fetal heads are too large to fit through the pelvis.
This condition is referred to as cephalopelvic disproportion
(CPD). CPD may also occur when the fetal head is of
normal size, but the pelvic architecture is too small to
accommodate the head. The fetal shoulders may hinder
descent and expulsion during delivery, but under normal
circumstances, usually the position of one shoulder at a
lower level in utero than the other creates a diameter that is
smaller than the fetal skull, thus allowing passage through
the birth canal (Lowdermilk, 2012a).
Note to Instructor:
Learning will be enhanced by having an anatomic model
or chart available to demonstrate fetal descent into the
pelvis, lie, position, presentation, and attitude for the next
series of slides.
The physical relationship of the fetal head to the
maternal anatomy will determine the outcome of the
labor process. There are several factors that have to be
considered when evaluating this relationship:
•  Is the fetus in the vertex position? Is anything
presenting with the head (hand, arm, etc.)?
•  Will the head fit through the pelvis?
•  Will the fetal head mould enough to fit through the
pelvis? (Is there caput?)
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•  Will the fetus rotate into the correct positions as it
descends?
•  Has there been a previous vaginal delivery and what
size was that baby in relationship to this one?
Fetal lie refers to the relationship of the long axis (that
is, the spine) of the fetus to the long axis of the mother.
There are two primary lies: longitudinal and transverse
(Lowdermilk, 2012a):
•  Longitudinal (also called vertical) lie occurs when the
long axis of the fetus is parallel to the long axis of the
mother.
•  Transverse (also called horizontal) lie occurs when the
long axis of the fetus is at a right angle, or
perpendicular, to that of the mother.
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•  Oblique lie occurs less frequently and usually converts
to either longitudinal or transverse during labor.
This video clips shows variations in fetal lie.
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Fetal position or presentation refers to the fetal part that
enters the pelvis passing through the birth canal during
labor. Cephalic presentations are illustrated on this
slide (Lowdermilk, 2012a):
•  Occiput, or vertex, occurs when the fetal head is fully
flexed. The occiput is the presenting part in the lower
uterine segment.
•  Sinciput, also known as “military position,” occurs
when the head is neither flexed nor extended. The
anterior fontanel is felt as the presenting part.
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•  Brow presentation occurs when the fetal head is
extended. The brow is the presenting part.
•  Face presentation occurs when the head is
hyperextended so that the chin, or mentum, is the
presenting part. Brow and face presentations require a
larger pelvic diameter than does occiput presentation to
fit through the birth canal during a vaginal delivery.
If there is ever any doubt about the fetal presentation, it is
necessary to get another nurse or the provider to assess the
patient.
There are three types of breech presentation
(Lowdermilk, 2012a). Frank breech is when the buttocks
is the presenting part. Typically, the fetal thighs are flexed
onto the abdomen, and the legs are extended onto the
chest. With a complete breech presentation, the legs and
thighs are flexed onto the abdomen. With a footling
breech presentation, one or both feet are extended at the
knees and hips. The footling breech may present with one
or both feet first.
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In a shoulder presentation, the fetus is in a transverse or
oblique lie and the scapula is typically the presenting part.
Shoulder presentation is rare (Lowdermilk, 2012a).
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Attitude refers to the relationship of the fetal parts to
each other and the degree of flexion or extension of the
fetal head. Normally, there is moderate flexion, with the
fetal chin flexed onto the chest and the extremities
flexed onto the abdomen. If the head is extended or
flexed in such a way that the diameter of the head exceeds
the diameter of maternal pelvic architecture, labor may be
prolonged or assisted vaginal birth or cesarean birth may
be needed (Lowdermilk, 2012a).
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The next P focuses on fetal positioning. Position refers to
the relationship between the fetus and the four
quadrants of the mother’s pelvis (Lowdermilk, 2012a).
The fetal position is described by a three-letter
abbreviation:
•  The first letter signifies the position of the presenting
part to the side of the mother’s pelvis: left (L) or right
(R).
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•  The second letter is the first letter of the name of the
presenting part — for example, O for occiput if the
head is the presenting part, S for sacrum if the buttocks
is the presenting part, or M for mentum if the chin is the
presenting part.
•  The third letter refers to the presenting part in
relationship to the anterior (A), posterior (P), or
transverse (T) plane of the maternal pelvis.
Let’s look at some of these example on the slide together.
LOA: Left occiput anterior
ROA: Right occiput anterior
LOP: Left occiput posterior
ROP: Right occiput posterior
LOT: Left occiput transverse
ROT: Right occiput transverse.
LSA: Left sacral anterior
RSA: Right sacral anterior
Note to Instructor:
You may want to have an anatomic model or chart
available to visually reinforce fetal positions in the pelvis.
When determining the fetal position, while doing a
vaginal exam, feel for the fontanels and determine the
shape. A triangle shaped fontanel is the posterior
fontanel. Because of the moulding of the fetal head, you
will usually feel the triangle-shaped or posterior fontanel.
A diamond shaped fontanel is the anterior fontanel. If you
feel this fontanel, be suspicious that the baby is in direct
OP position or military position.
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Then feel for the direction the suture line is running,
horizontal, vertical or oblique to the right or left. The
fontanel and suture line should allow you to determine
position.
This assessment can take a long time to perfect — be
patient with yourself and keep trying!
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Station refers to the relationship of the presenting part
to the ischial spines of the pelvic midplane and is usually
represented as a measurement in centimeters above and
below the ischial spines. Engagement is a related term that
indicates that the widest transverse diameter of the
presenting part has passed through the maternal pelvic inlet
into the true pelvis. The fetal head, then, is usually engaged
when the occiput reaches the ischial spines, or zero
station. When the presenting part has not reached zero
station, it is said to be unengaged (Lowdermilk, 2012a).
Station is usually identified in centimeters above and
below the ischial spines:
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•  When the presenting part is above the ischial spines, or
above zero station, station ranges from -5 cm to -1 cm.
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•  When the presenting part is below the ischial spines, or
below zero station, station ranges from +1 cm to +5 cm.
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Birth is imminent when the presenting part is between +4
cm and +5 cm. Arrest of descent of the presenting part may
indicate CPD (Lowdermilk, 2012a).
Station is the last part of the assessment done during
the vaginal exam. Using the pads of the fingers, starting
posteriorly, smoothly move your fingers to the anterior
side along the vaginal sidewall. As you pass over the
ischial spine, you will feel a small protrusion under the
tissue. Be gentle — this is tender and your patient may
find this uncomfortable or complain of an “electrical
shock” feeling.
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Repeat this on the other side. When you have determined
where the ischial spines are located, evaluate the distance
of the spines from the vaginal os to use as a reference
for future exams.
Let’s begin integrating the information discussed so far
into assessment and care of the woman in labor.
Assessment begins at the time of first contact with the
woman in the obstetric care setting and continues
throughout labor (Piotrowski, 2012c). The elements of
initial labor assessment include current and previous
pregnancy history, labor symptoms and indicators of
progress, review of prenatal records and laboratory data,
physical examination, and assessment of the fetus.
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All women who present to the labor and birthing unit
should be asked about allergies and current medication
regimens, including over-the-counter medication. The
initial history begins with assessment of the current and
previous pregnancy; labor and birth history; labor
symptoms; review of the prenatal records, physical
examination, and laboratory data; and review of cultural
factors.
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The prenatal record is reviewed to determine prenatal care
history, results of screening tests and procedures, the
individual woman’s needs, and the presence of risk factors.
The past pregnancy, labor, and birth history is evaluated to
identify previous problems and the presence of risk factors
that might affect the current labor and birth. The age of the
woman should be taken into consideration to plan for
individual developmental and age-specific needs. For
example, a 14-year-old girl’s physical and developmental
needs differ from that of a 40-year-old woman, and risk
factors for pregnancy complications are different between
adolescent and older pregnant women.
Note to Instructor:
Take some time to review the slide and identify where the
maternal history can be found in the prenatal record.
Other factors to be assessed when the woman is admitted
to the obstetric care setting include but may not be limited
to the following (American Academy of Pediatrics [AAP]
& American College of Obstetricians and Gynecologists
[ACOG], 2012):
•  Frequency and duration of contractions
•  Documentation of fetal well-being
•  Urinary protein concentration
•  Cervical dilation and effacement (unless
contraindicated)
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•  Fetal presentation and station of presenting part
•  Status of membranes
•  Date and time of arrival
•  Estimation of fetal weight and assessment of
maternal pelvis using Leopold’s maneuvers
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The cervical examination is a primary obstetric assessment
to differentiate true from false labor and to determine the
mother’s labor status. Effacement refers to thinning and
shortening of the cervix. Prior to the onset of labor, the
cervix is approximately 2–3 cm in length and about 1 cm
thick. It is “taken up” or obliterated during the thinning
of the lower uterine segment during labor. When the
cervix is 100% effaced, only a thin edge can usually be
palpated. In primigravidas, effacement typically occurs
before dilation. In subsequent pregnancies, once the
cervical tissue has undergone the forces of labor,
effacement and dilation tend to occur together
(Lowdermilk, 2012a).
During dilation, the force of the contraction and pressure
from the fetal presenting part make the diameter of the
cervix expand from closed (usually less than 1 cm) to 10
cm (complete dilation) to allow the full-term fetus to
descend and be born. When the cervix is completely or
fully dilated, it usually cannot be palpated. Complete
dilation marks the end of the first stage of labor
(Lowdermilk, 2012a).
The next slide will provide a visual aid to demonstrate the
progression from a closed cervix to 10 cm of dilation and
from a thick cervix to a fully effaced cervix.
These are the stages of cervical dilation as the mother
progresses from a thick, closed cervix (normal cervix) to a
fully effaced, 10 cm dilated cervix (complete dilatation).
Note to Instructor:
It will also be helpful to have a physical chart available to
demonstrate cervical dilation.
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The video clip demonstrates the changes in the cervix
during effacement and dilation.
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Let’s talk for a moment about precautions regarding
cervical examinations. Conditions that may
contraindicate an examination, such as complete
placenta previa, should be ruled out prior to performing
the procedure. The frequency of cervical examinations
during labor will vary depending on the woman’s
individual circumstances. In general, the frequency of
cervical examinations should be limited but should be
sufficient to determine labor progress without increasing
the risk of infection. For example, limit cervical
examinations once the woman’s membranes have
ruptured to reduce the risk of an ascending infection. It is
important to assess gestational age before performing a
cervical examination. Women with preterm labor often
require limited cervical examinations to reduce the risk of
infection.
Now let’s discuss how to assess fetal position.
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A very useful, noninvasive technique called Leopold’s
maneuvers can be used to assist in understanding the fetal
position in utero. These simple maneuvers identify fetal lie
(longitudinal, transverse, or oblique), attitude (flexed or
extended), and presentation (vertex or breech). The patient
should empty her bladder and should be positioned with
her knees slightly flexed and a wedge placed under one
hip. The nurse should explain the procedure to the woman.
Leopold’s maneuvers may be difficult with women who
are obese, have tense or guarded abdominal muscles, or
have polyhydramnios. In these situations, it may be
necessary to assess fetal position with ultrasound
examination (Simpson, 2008b).
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Note to Instructor:
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The slides following this video clip provide a verbal review
of Leopold’s maneuvers.
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The first maneuver is performed to identify fetal lie and
presentation. Standing at the woman’s side, your hands
should be placed at the top and side of the fundus. Palpate
to determine where the longitudinal axis of the fetus is
located. As you palpate, the fetal head will feel round,
firm, and moveable. When the fetus is in the breech
position, the presenting part typically feels softer, is less
regular in shape, and moves less freely than the head (Ali,
2009).
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The second maneuver is performed to identify the
location of the fetal back. Remain standing at the woman’s
side, facing her, and place your hands on either side of the
middle of the abdomen. One hand is used to gently push
the contents of the abdomen toward the other hand to
stabilize the fetus for palpation. Beginning at the middle of
the abdomen near the fundus, the hand that is palpating
moves posterior toward the woman’s back. Determine
which part of the fetus lies on the side of the abdomen.
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Locate and palpate the smooth contour of the fetal back
using the palmar surface of one hand. Palpate for
irregularities in contour. These irregularities are likely
to be the small parts of the fetus (feet and hands).
Reverse the position of the hands and repeat the maneuver
on the other side (Ali, 2009).
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The third maneuver is performed to identify the presenting
part. Remain facing the woman. Using the middle finger
and thumb, grasp the part of the fetus that is located
over the pelvic brim (just above the symphysis pubis).
Using firm but gentle pressure, identify whether the head is
the presenting part. This step should confirm what you
were feeling during the first two maneuvers. If the
presenting part is movable, it is likely not engaged in the
pelvis. On the other hand, if the presenting part is fixed
and difficult to move, it is likely to be engaged. This third
maneuver is also referred to as Pallach’s maneuver, or
grip (Ali, 2009).
The fourth and final maneuver is performed to assess the
descent of the presenting part. Turn to face the woman’s
feet. The hands should be placed on the sides of the
uterus, just below the umbilicus, with the fingertips
pointing toward the symphysis pubis. Press deeply, with
your fingers pointing toward the pelvic inlet to palpate
the cephalic prominence.
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This part of the maneuver may be uncomfortable for the
woman, so be sure to explain it before performing it. If the
cephalic prominence is on the same side as the fetal
back, then what you’re feeling is likely the occiput, or
crown, and the head will be slightly extended. If the
cephalic prominence is on the same side as the fetal
small parts, the head is flexed; you are likely feeling the
sinciput, and the fetus is in a vertex presentation.
The last part of this maneuver is done to assess whether the
presenting part has entered the pelvic inlet. Your hands will
move toward the pelvic brim. If your hands come together,
the presenting part is likely to be floating. If your hands
stay apart, the presenting part is likely to be either dipping
or engaged in the pelvis. You may now want to locate and
auscultate the fetal heart, which is usually heard best over
the curved part of the fetus closest to the anterior wall of
the uterus — typically, over the fetal back (Ali, 2009).
Now let’s discuss when to notify the primary care provider.
The nurse should notify the obstetric care provider if
any of the following conditions are present on the
assessment of labor (AAP & ACOG, 2012):
•  Vaginal bleeding
•  Acute abdominal pain
•  Temperature of 100.4°F (38°C) or higher
•  Preterm labor
•  Preterm rupture of membranes
•  Hypertension
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•  Indeterminate or abnormal fetal heart rate pattern
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•  Other conditions as determined by facility guidelines
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Notification should be timely in accordance with
institutional guidelines and provider orders. The date and
time of notification of the obstetric care provider should be
documented in the medical record.
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A complete review of systems should occur on
admission and then once per shift or more often if
indicated. Respiratory, cardiovascular, neurologic, GI, and
genitourinary systems should be reviewed. Routine care
should include an assessment of vital signs at least
every 4 hours during labor. The frequency may be
increased, particularly as active labor progresses, or if
other changes in the mother’s condition necessitates,
according to clinical signs and symptoms (AAP & ACOG,
2012; Simpson, 2008b).
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Now let’s review the mechanisms of labor.
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As you begin caring for the woman in labor, it’s important
to understand the mechanisms that take place as labor
progresses. Mechanisms are the processes or movements
required of the fetus to adapt and pass through the birth
canal. These mechanisms are referred to as “cardinal
movements” and are engagement, descent, flexion,
internal rotation, extension, external rotation, and
expulsion. Although these movements are listed separately
on this and the next slide, it’s important to remember that,
as labor progresses, some of the mechanisms occur
simultaneously. As you can see on the slide, engagement,
for example, involves both descent of the fetus and flexion
of the fetal head (Lowdermilk, 2012a). The mechanisms
described assume the fetus is in a cephalic presentation and
is progressing normally through the birth canal — as is the
case in the graphic on this and the next slide.
Engagement occurs as the biparietal diameter of the fetal
head passes through the pelvic inlet. Typically, the fetal
head descends into the pelvis in a parallel position to the
anteroposterior plane of the pelvis, known as a synclitic
position. If the fetal head descends in a tilted position, this
is known as asynclitism.
Descent is the process of movement of the presenting part
through the pelvis and is dependent on the intraamniotic
pressure, the force exerted on the fundus by uterine
contractions, the force of pushing efforts during the second
stage of labor, and the extension and straightening of the
fetal body as labor progresses.
Flexion occurs when the descending fetal head meets
resistance from the cervix, the pelvic wall, or the pelvic
floor. This mechanism permits a smaller diameter of the
fetal head to enter the pelvic outlet.
Internal rotation takes place as the fetal head continues to
descend from the pelvic inlet through the midpelvis to the
pelvic outlet. The fetal head enters the pelvic inlet in a
transverse position and rotates to an anteroposterior
position as it passes through the midpelvis to the pelvic
outlet. This rotation occurs because the pelvic outlet is
widest in the anteroposterior diameter.
Note to Instructor:
Script continues on next slide.
Extension occurs as the fetal head passes under the pubic
arch of the symphysis pubis. As the fetal head reaches the
perineum for birth, the occiput passes under the pubic arch,
followed by the face, then the chin.
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External rotation occurs once the head is delivered. The
fetal head usually rotates around to the position it was in as
it engaged in the pelvic inlet. This is also known as
restitution. The head then continues to rotate, and the
shoulders engage and descend. The anterior shoulder
usually descends first and is delivered, followed by the
posterior shoulder.
Expulsion is the delivery of the rest of the fetal body. This
action marks the end of the second stage of labor.
Labor is described in stages. The first stage of labor
begins with the onset of regular contractions and ends
when the cervix is completely dilated. The first stage of
labor is the longest and comprises three phases:
•  Latent (early labor)
•  Active
•  Transition
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The slide shows the average frequency, duration, and
intensity of contractions during the three phases of the first
stage of labor. Needless to say, these figures vary
depending on individual circumstances. During the latent
phase, the cervix effaces, and there is usually little descent
of the presenting part. The cervix usually dilates from 0 cm
to about 3 cm. Generally, the duration of the latent phase is
about 6 hours for both nulliparous and multiparous women
(Simpson, 2008b).
During the active and transition phases, contractions
increase in intensity and duration, dilation is more rapid,
and, under normal circumstances, the fetus continues to
descend. The cervix dilates from about 4 cm to 7 cm
during the active phase, and from about 7 cm to complete
dilation (10 cm) during the transition phase (Simpson,
2008b). The duration of the active phase varies
considerably. Typically, a rate of cervical dilation of 1.2 or
1.5 cm per hour is considered normal progress for
nulliparous and multiparous women, respectively. Fetal
descent typically progresses at a rate of 1 or 2 cm per hour
for nulliparous and multiparous women, respectively
(Simpson, 2008b). However, it’s important to know that
many factors, such as maternal pelvic structure, fetal size,
and timing and dosage of regional anesthesia influence the
duration of labor. Thus, labor management decisions are
now based more on assessment of maternal and fetal status
and less on time alone (ACOG, 2003a; Simpson, 2008b).
Before we discuss the second stage of labor, let’s discuss
ways to manage discomfort in labor.
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Many options are available for the pregnant woman to
manage the discomfort of labor. Ideally, preferences,
options, and interventions should be discussed with the
primary obstetric care provider during the prenatal
period, and informed decisions made. The choice of pain
management interventions depends on both maternal and
provider preference and may also depend on maternal and
fetal status during labor and at the time of delivery.
Information about pain relief, analgesia, and anesthesia is
often discussed in prenatal classes. The woman should be
encouraged to discuss her preferences and concerns
about pain management with her labor nurse.
Consultation with an anesthesia provider on admission to
the obstetric care setting is very helpful in developing the
plan of care for and timing of administration of analgesia
or placement of regional anesthesia. The perinatal nurse
should be familiar with different types of analgesia and
anesthesia and facility guidelines related to the care of the
patient receiving anesthesia or analgesia for labor pain
management.
Pain relief and discomfort management in labor is not just
about pharmacologic pain management. Labor support is a
key element of helping mothers manage the pain and
discomfort of labor, and the use of breathing and relaxation
techniques is the primary method preferred by many
women. In the next series of slides, we’ll examine both
nonpharmacologic and pharmacologic pain management
techniques and methods.
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Pain thresholds vary and are influenced by gender, social
status, ethnic considerations, and cultural influences.
Pain’s meaning and expression are learned in a variety of
ways, including from interactions with a person’s primary
social group. During the first stage of labor, uterine
contractions cause cervical dilation, effacement, and
transient hypoxia (local oxygen deficit from contraction of
the arteries that supply the uterus). Pain impulses are
transmitted by the spinal nerves that originate in the
uterus and cervix and in the lower thoracic and upper
lumbar sympathetic nerves. This type of pain is called
visceral pain, and it is usually felt over the lower
abdomen, radiating around to the lower back. Typically,
visceral pain is present during contractions and subsides
when the contraction subsides (Piotrowski, 2012b).
During the second stage of labor, the woman also feels
perineal pain that results from stretching of the tissues and
pressure on other sensitive pelvic organs and structures.
Pain impulses are transmitted by the spinal nerves and the
parasympathetic system from perineal tissues. This type of
pain is called somatic pain. Pain may be local and intense
and described as a burning sensation as the tissues stretch.
Labor pain may also be referred pain — that is, pain may
be felt in the back, flanks, or thigh. The pain experienced
following birth during the third stage of labor is typically
described as similar to the pain experienced during the
early stages of labor (Piotrowski, 2012b).
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It is important to recognize that culture can influence
women’s perception of and reaction to labor pain
(Piotrowski, 2012b). For example, Asian women may
show reactions to pain and may avoid verbal expression.
They may consider it impolite to accept medication when
it is first offered; it may be necessary to offer more than
once. Hispanic women tend to be stoic until the later
stages of labor, when they may become more vocal and
ask for medication. Middle Eastern women tend to be
vocal in response to their pain and may prefer medication
for pain relief. African American women may express
their pain openly, but their use of pain medication varies
(Piotrowski, 2012b).
Again, it is essential that we not stereotype women from
any cultural background. Perceptions, values, and
practices vary even within a particular ethnic group. For
example, Hispanic women may come from Spain, Mexico,
or Central or South America. Within each of these
subcultures, practices, values, and beliefs may vary widely.
Every woman’s experience of pain is different, and every
woman, regardless of her cultural background, should
have individualized support to manage the pain of
labor.
Let’s take some time to discuss how labor support
influences the woman’s perception of and ability to cope
with the pain of labor. In this next series of slides, we’ll be
examining the importance of labor support and how
positioning, breathing, and relaxation techniques can help
women manage the pain and discomfort of labor (Creehan,
2008).
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The support a woman receives during labor not only
influences her pain perception, it may influence maternal
or fetal outcome and the woman’s level of satisfaction with
the childbirth experience. Many organizations have
policies that limit the number of persons allowed into the
labor area. It is important to evaluate these policies to
include additional support persons as indicated. The
woman’s partner, family members, friends, or professional
or lay support persons should be welcomed and
encouraged to provide support throughout the duration of
labor (Creehan, 2008).
The nurse provides labor support to the woman and her
partner during the childbirth experience. AWHONN
believes that labor support provided by a professional
registered nurse is an important component of promoting
positive outcomes (AWHONN, 2011a).
Before we discuss positioning for labor support, let’s take a
few minutes to focus on breathing and relaxation
techniques. While breathing techniques may not eliminate
pain, they can be effective in helping the woman cope with
the pain and discomfort of labor. Rhythmic breathing
techniques help divert attention away from the pain
associated with contractions. A woman in labor may use
more than one breathing pattern to facilitate relaxation
(Creehan, 2008).
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Paced breathing is a technique taught in many childbirth
education classes. Childbirth education organizations such
as Lamaze, Bradley, and ICEA encourage the use of a
slow-paced, modified, patterned breathing technique. With
each of these techniques, women and their partners are
encouraged to modify the breathing patterns according to
their individual labor and birthing experience.
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A variety of relaxation techniques are also promoted by
childbirth preparation organizations and nurses should be
aware of and help women and their partners incorporate
these into their labor. Relaxation techniques and responses
help to counteract sympathetic nervous system arousal by
slowing down the heart and respiratory rates, increasing
uterine contractility, and helping to produce a sense of
tranquility. Relaxation techniques may include guided
imagery or focusing on an object or favorite photo,
massage, music, and biofeedback (Creehan, 2008).
Biofeedback may include the use of a partner or support
person coaching the woman through contractions or the
use of the fetal monitor to help the woman (and coach)
know when a contraction is starting, peaking and
subsiding. This type of activity can help the woman
maintain her breathing rhythm in addition to promoting
relaxation between contractions (Creehan, 2008).
Note to Instructors:
You may want to pause at this point and demonstrate a few
of the more commonly used breathing and relaxation
techniques.
Next, let’s discuss positioning. Women typically choose
positions of comfort and are more likely to change
positions with early labor. Modern technology may
impact the woman’s ability to change positions and find
comfort as labor progresses. Many nurses and physicians
encourage bedrest because it helps them feel more in
control. It is important to recognize that healthcare
providers can use modern technology and still allow
women to make choices for positioning and comfort
throughout labor (Creehan, 2008). We will discuss more on
positioning when we move on to the second stage of labor.
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Birthing balls are sometimes used by women in labor. The
birthing ball provides support for the woman’s body as
she assumes a variety of positions during labor. This may
enhance maternal comfort. A birthing ball helps the woman
use pelvic rocking, promotes mobility, and helps to
provide support for the woman in the upright position
(AWHONN, 2008).
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In recent years, research has demonstrated support for the
benefits and safety of hydrotherapy in labor, which offers
the mother who is having a normal, uncomplicated
pregnancy a degree of privacy, limited cervical
examinations, and limited medical intervention. Despite a
concern for potential morbidity and mortality with the use
of hydrotherapy in labor, repeated studies have shown no
increased risk of chorioamnionitis or postpartum
endometritis in women who use a tub or whirlpool,
regardless of membrane status (Creehan, 2008).
Hydrotherapy may produce weakness, dizziness, nausea,
maternal and fetal tachycardia, or maternal hypotension. It
is important to recognize that these conditions are usually
related to an increased body temperature or dehydration,
both of which may be prevented with appropriate nursing
interventions (Creehan, 2008).
While many women prefer nonpharmacologic pain and
discomfort management methods during labor, a variety of
medications are available that partially or completely
relieve pain. It’s important to bear in mind that the
principles of labor support, positioning, and relaxation
techniques we have just examined should be incorporated
into your care for laboring women, whether or not
pharmacologic pain management methods are used. Pain
management methods employed during labor are those
used to produce analgesia, anesthesia, or a combination of
both.
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Analgesia is the partial or full relief of painful
sensations using medications that decrease or alter the
perception of pain. Anesthesia is a more intense blockage
of all sensations and muscle movement. Anesthesia
results in partial or complete loss of pain and sensation,
with or without the loss of consciousness (Creehan,
2008). Many options are available for analgesia and
anesthesia in labor.
Women usually have the option to receive narcotics or
regional or local anesthesia, depending on individual
circumstances and provider expertise and availability, or a
combination of these options. General anesthesia is usually
reserved for urgent delivery (or circumstances in which
regional anesthesia is contraindicated) because of its
potential effects on maternal and fetal well-being. Let’s
first examine medications used to produce analgesia in
labor.
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Opioid narcotics bind to one or more of four different
receptor sites (mu, kappa, sigma, or delta) on nerve cells
located in the brain and spinal cord. Therefore, the effects
and side effects of various opioids differ depending on
the receptor sites to which they bind, or for which they
have an affinity. For example, morphine and
meperidine have a strong affinity for the mu receptors that
produce effective analgesia with dose-dependent
respiratory depression. Morphine has less risk of
neonatal respiratory depression than meperidine on the
newborn. Butorphanol (Stadol) and nalbuphine
(Nubain) have a strong affinity for kappa and sigma
receptors, producing effective analgesia with less
respiratory depression than morphine or meperidine
(Creehan, 2008).
Opioids typically do not eliminate pain but blunt or
diminish the perception of pain and allow women to rest or
sleep between contractions, depending on the dose and
route of administration and the stage of labor. Because
opioids may decrease the frequency and duration of
contractions when given in early labor, they are typically
not administered until a labor pattern is established
(Creehan, 2008). However, some patients who experience
a prolonged latent phase of labor may benefit from
analgesics administered earlier in labor.
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The sedation and respiratory depressant properties of
narcotics can affect both the mother and the fetus and
may result in transient decreased FHR variability.
Because of the potential for neonatal respiratory
depression, the timing of administration relative to the
anticipated time of birth should be considered. To
minimize the risk of respiratory depression, the birth
should occur between 1 and 4 hours after administration,
depending, in part, on the dose and route of administration.
Other neonatal side effects may include decreased muscle
tone and altered or ineffective sucking reflex with
difficulty initiating breastfeeding (Creehan, 2008).
Understanding narcotic onset, peak, and duration of
action can help you anticipate and prepare for additional
pain relief needs and the potential for maternal or neonatal
respiratory depression. It can also help you evaluate the
effectiveness of analgesia on a continuum.
POEP 3rd Edition • Module III
The Process of Labor and Birth
Narcotics may be administered by a variety of routes:
intramuscularly (IM), by intravenous (IV) bolus, or by
patient-controlled methods. Listed on this slide and the
next is information about narcotic analgesics typically used
in labor according to route of administration. On this slide,
the general ranges for onset, peak, and duration of action
for narcotic analgesics administered IM are listed
(Creehan, 2008). Let’s take a moment to review.
©2013 AWHONN
Note to Instructor:
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Dosing regimens may vary depending on individual patient
circumstances, the stage of labor, care provider orders,
and facility guidelines. For this slide and the next, please
review your facility guidelines and information about
dosing regimens for the analgesic drugs commonly ordered
by your facility's providers.
On this slide, you can see the general ranges for onset,
peak, and duration of action for narcotic analgesics
administered by the IV route (Creehan, 2008). These
medications should be administered by slow IV push
according to facility guidelines. Let’s look on the slide and
take a moment to review them.
Let’s move on now to anesthesia for labor and birth.
Note to Instructor:
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Review your facility guidelines for slow IV push
administration of narcotics in labor.
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Nitrous oxide is widely used for obstetric analgesia in
many developed countries. More than 60% of women in
Finland and the United Kingdom use nitrous oxide for pain
relief during labor. It’s use is limited to a few medical
centers and small hospitals in the United States. The most
commonly used inhaled type of analgesia contains a
50-50 blend of nitrous oxide and oxygen (Stewart &
Collins, 2012). It can be used in any stage of labor
because of it’s rapid onset of action and quick
clearance. The full analgesic effect usually occurs in 30
to 60 seconds after inhalation. Nitrous oxide generally is
self-administered as needed. The pregnant woman has
inhaled enough nitrous oxide when she is no longer able to
hold the mask to her face during contractions. It provides a
consistent but moderate analgesic. Most women
experience pain relief, a sense of euphoria, and decreased
anxiety and concern related to labor pain. Adverse effects
may include nausea, vomiting, and memory loss related
to the labor experience (Stewart & Collins, 2012). The
only devices approved by the U.S. Food and Drug
Administration (FDA) to administer nitrous is “Nitronox”.
Regional anesthesia is defined as the use of localized
methods, devices, technology, or agents that result in
partial or complete loss of sensation in a portion of the
patient’s body below the T8 to T10 level; with or without
diminished motor function (ACOG, 2002a; AWHONN,
2011a).
POEP 3rd Edition • Module III
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Epidural analgesia for labor pain management was
introduced in the United States during the 1960s. During
the 1970s, management of pain in labor evolved with the
discovery of opioid pain receptors in the spinal cord. This
knowledge led to the introduction of regional pain
management techniques using a combination of low doses
of anesthetic agents, such as bupivacaine or ropivacaine
and opioid narcotics, to provide effective pain relief
without significant motor blockade (American Society of
Anesthesiologists [ASA], 2007; Creehan, 2008).
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Routes for administration of regional analgesia and
anesthesia in labor now include epidural block, spinal
block, combined spinal-epidural block, and pudendal block
(Creehan, 2008). These methods are the most effective and
produce the least potential for central nervous system
depression of the mother and neonate (ACOG, 2002a).
Spinal anesthesia involves injecting an anesthetic agent
into the subarachnoid space from the third, fourth, or
fifth lumbar vertebrae. This type of anesthesia is also
referred to as “single-shot” anesthesia and is typically used
for shorter duration procedures or circumstances, such as
cesarean birth, the second stage of labor, rapidly
progressing labor, or postpartum tubal ligation. Spinal
anesthesia for management of pain throughout labor is of
limited use, because the duration of anesthesia ranges only
from about 30–250 minutes, depending on the agents used
(ACOG, 2002a).
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Epidural anesthesia is one of the most common and
effective forms of pain relief. Approximately 66% of all
laboring women receive epidural analgesia in labor.
Placement of the epidural involves introduction of a
catheter and injection of an anesthetic agent with or
without opiods into the epidural space between the
fourth and fifth lumbar vertebrae (Creehan, 2008).
Combined spinal and epidural anesthesia is initiated in
a two-step process. First, a needle is introduced into the
epidural space. Then a smaller gauge spinal needle is
placed through the epidural needle into the subarachnoid
space. An initial dose of opioid and local analgesia, such as
a combination of small doses of fentanyl and bupivacaine,
are injected through the subarachnoid space. The spinal
needle is then removed, and an epidural catheter is
threaded through the epidural needle. Once placement is
verified, the epidural catheter is secured, and medication is
administered (Creehan, 2008).
Patient-controlled epidural analgesia (PCEA) involves
periodic self-administration of anesthesia or analgesia
by the patient into an indwelling epidural catheter.
PCEA may also include a continuous basal infusion of
low-dose analgesia or anesthesia. This technique permits
the laboring woman to have more control over her pain
management (Poole, 2003).
Pudendal blocks are typically used to provide vaginal,
vulvar, and perineal anesthesia during the second stage
of labor. The pudendal block is initiated by injecting an
anesthetic agent through the lateral vaginal walls into the
area of the pudendal nerve (Creehan, 2008).
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Traditional epidural anesthesia is administered using a test
dose of anesthetic followed by a bolus dose of an
anesthetic agent once correct catheter placement is
confirmed. Using this method, women usually receive
effective anesthesia. Intermittent-dose epidural anesthesia
may result in significant loss of lower-extremity motor
control, particularly if an anesthetic agent alone is used
(Creehan, 2008). Re-injection of anesthetic agents is
required to maintain an adequate level of pain relief
throughout labor. Use of anesthetic only, or traditional
epidural, has also been associated with a reduced rate of
spontaneous vaginal birth (ASA, 2007).
Regional anesthesia techniques that include continuous
infusion with or without combined low-dose anesthetic and
analgesic regimens have a number of advantages over
traditional epidurals (ACOG, 2002a; Anim-Somuah,
Smyth, & Jones, 2011; Creehan, 2008; Kukulu & Demirok,
2008; Simkin & Bolding, 2004):
•  Continuous infusion permits titration of medication
over the course of labor and thus provides a more
constant level of pain relief.
•  Continuous flow of medication through the catheter
provides stability and reduces the potential for
migration of the catheter into the epidural vein or
through the subarachnoid space, thus decreasing the risk
of serious adverse reactions.
•  Continuous infusion epidural that is maintained
with a combination of an analgesic and low-dose
anesthetic provides optimal pain relief with a lesser
degree of lower-extremity motor blockade. This
method may permit ambulation for some women and is
associated with an increased rate of spontaneous
vaginal birth.
For many women, continuous infusion epidural with
combined analgesia and anesthesia results in effective pain
relief without obliterating the urge to push during the
second stage of labor. The maintenance of pain relief
throughout labor and second stage is associated with fewer
adverse outcomes (that is, use of forceps, cesarean birth,
and more extensive lacerations) than nonsustained pain
relief (Abenhaim & Fraser, 2008; Jacobson & Turner,
2008).
Listed on this slide are examples of some of the drugs
commonly used for local and regional anesthesia. This list
is not exhaustive; a variety of agents are used to provide
anesthesia for labor, vaginal birth, and cesarean birth. The
dosage regimen, onset, and duration of action will vary
widely depending on factors such as the type of regional
block used, the woman’s physical condition (Cunningham,
Leveno, Bloom, Rouse, & Spong, 2010), the stage of labor,
and anesthesia provider protocols.
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The mechanism of action of local anesthetics, such as
lidocaine, bupivacaine, and ropivacaine, is to produce a
reversible inhibition of nerve conduction. Generally, agents
such as bupivacaine are highly lipid-soluble and produce
effective conduction blockade at relatively low drug
concentrations. In contrast, lidocaine, which is less lipidsoluble, requires higher drug concentrations to achieve the
same conduction blockade (Poole, 2003). The proteinbinding capacity of local anesthetic agents influences the
duration of action. That is, an agent with a high protein
affinity will remain at a receptor site longer, thus
producing a longer duration of action than an agent with
lower affinity for proteins (Poole, 2003).
Lidocaine is typically used for local or pudendal anesthesia
and may be used for epidural block for cesarean birth but
is usually not used for labor anesthesia. Bupivacaine and
ropivacaine are used for labor and cesarean birth
anesthesia. These agents are also used in low-dose
regimens in combination with intrathecal opioid analgesics
such as fentanyl to produce effective anesthesia with less
profound motor blockade and reduced risk of systemic
toxicity (Cunningham et al., 2010; Poole, 2003).
Note to Instructor:
Please review your facility or anesthesia provider
guidelines for use of regional anesthesia and analgesia
agents.
In addition to known allergy or hypersensitivity to
anesthetic or analgesic agents, contraindications to the
administration of regional analgesia and anesthesia
include the following (Creehan, 2008):
•  Coagulation disorders
•  Local infection at the site of injection
•  Maternal hypotension and shock
•  Indeterminate fetal heart pattern requiring
immediate birth
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•  Maternal inability to cooperate
•  Allergy to local anesthetics
•  Last dose of low-molecular-weight heparin was
administered in the past 12 hours
Let’s talk now about nursing care of the woman receiving
regional anesthesia.
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Prior to initiation of regional anesthesia or analgesia, the
woman should be evaluated by a qualified anesthesia care
provider. An assessment of the woman's knowledge and
concerns about regional anesthesia should be conducted.
A focused history, physical examination, and assessment
of maternal vital signs should be performed by the
licensed anesthesia care provider and by the registered
nurse according to facility guidelines (ASA, 2007;
AWHONN, 2011a; Creehan, 2008). The FHR tracing
should be evaluated. If an indeterminate tracing is
identified, corrective measures should be initiated, and the
obstetric/anesthesia care provider should be notified before
initiating anesthesia (AWHONN, 2011a).
Health information that should be reviewed with the
anesthesia and obstetric care providers as needed includes
but may not be limited to the following:
•  Most recent food and fluid intake
•  Ordered laboratory studies
•  Obstetric, current labor, and medical history and
risk factors
•  Assessment of hypersensitivity to anesthetic and
analgesic drugs
To reduce the risk of anesthesia related vasodilation and
hypotension, an IV bolus of 500–1,000 mL of crystalloid
fluid is typically ordered. Assist the woman and the
anesthesia provider with positioning during catheter
insertion and initiation of anesthesia. The woman will need
your coaching and support to maintain her position). A
nurse-to-patient ratio of 1:1 is recommended during the
initiation of regional anesthesia and for the first 30 minutes
after (AWHONN, 2011a).
Note to Instructor:
Please review your facility’s anesthesia care provider
guidelines for preanesthesia IV fluids hydration with
participants.
To reduce the risk of anesthesia related vasodilation and
hypotension, an IV bolus of 500–1,000 mL of crystalloid
fluid is typically ordered. Assist the woman and the
anesthesia provider with positioning during catheter
insertion and initiation of anesthesia. The woman will need
your coaching and support to maintain her position). A
nurse-to-patient ratio of 1:1 is recommended during the
initiation of regional anesthesia and for the first 30 minutes
after (AWHONN, 2011a).
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Note to Instructor:
Please review your facility’s anesthesia care provider
guidelines for preanesthesia IV fluids hydration with
participants .
Nursing assessment for the woman in labor receiving
epidural analgesia/anesthesia requires knowledge of the
pharmacologic agents used, potential side effects, adverse
reactions, and the potential effects of regional anesthesia
and analgesia on uterine activity.
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There is insufficient evidence in the literature to support a
definitive recommendation for the frequency of assessment
of blood pressure (BP), respiration, and fetal status after
epidural analgesia/anesthesia is administered. Because
maternal BP may decrease significantly within the first
5–15 minutes following initiation or re-injection of
regional anesthesia, and because respiratory depression
may occur with administration of intrathecal opioids,
both maternal and fetal status should be assessed
during this time frame. One suggested frequency is that
BP may be assessed every 5 minutes for 15 minutes.
However, more or less frequent monitoring may be
indicated based on consideration of factors such as the type
of anesthesia/analgesia used, route and dose of
medications, the maternal and fetal response to
medications, maternal and fetal condition, the stage of
labor, and your facility guidelines. The frequency of
subsequent assessments should also be based on
consideration of these variables (AWHONN, 2011a;
Creehan, 2008). You should be aware of and follow
your hospital’s policy and procedure for frequency.
To minimize the risk of supine hypotension, assist the
woman to maintain a lateral or upright position with
uterine displacement (AWHONN, 2011a). It is important
to avoid severe spinal flexion, as it may decrease the
epidural space and increase the possibility of puncturing
the dura.
After initial placement and dosing of the catheter, and after
bolus dosing, assess the effectiveness of the anesthesia in
collaboration with the anesthesia care provider and
monitor for side effects and adverse reactions. Hot spots
or windows in epidural anesthesia are areas where the
anesthetic agent does not take affect and may occur in a
location where the nerve ending is not bathed in the
epidural medication.
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In the next few slides, we’ll discuss side effects and
adverse reactions in more detail. Ongoing assessment of
the degree of motor blockade and pain relief should be
performed throughout the period of anesthesia using your
facility’s designated assessment tools. For women who are
candidates for ambulation with regional anesthesia, motor
ability and strength should be assessed before walking.
Women who are able to walk should be assisted each time
they get up (AWHONN, 2011a; Creehan, 2008).
Note to Instructor:
Please review your facility guidelines for initial and
ongoing assessment of patients receiving regional
anesthesia and analgesia in labor.
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Hypotension is one of the most commonly observed side
effects of regional anesthesia (ACOG, 2002a).
Hypotension can result from anesthesia-induced
sympathetic blockade and vasodilation (Poole, 2003).
Administration of regional anesthesia may also result in
decreased uteroplacental blood flow and transient
alterations in the FHR, such as decelerations and
bradycardia. Side effects associated with the use of opioids
for regional analgesia include nausea, vomiting, pruritus,
and urinary retention. Pruritus typically begins within
the first hour of administration of opioids and should be
assessed by the woman’s description or a visual scale. The
anesthesia provider should be notified, and medications to
relieve itching should be administered when ordered
(AWHONN, 2011a; Creehan, 2008).
Other side effects are maternal temperature elevation
and postdural puncture headache (also referred to as
spinal headache). Postdural puncture headaches typically
occur as a result of leakage of fluid by inadvertent
puncture of the dura. Symptoms may be relatively mild or
may progress to more profound morbidity as we’ll discuss
on the next slide (AWHONN, 2011a; Creehan, 2008).
Maternal fever, defined as a temperature elevation greater
than 100.4°F (38°C), is a common side effect in women
who receive epidural anesthesia, and the risk increases
with prolonged labor (ACOG, 2002a). Although the exact
mechanism is unknown, maternal fever associated with
epidural analgesia may be caused by thermoregulatory
changes, such as an alteration in the production and
dissipation of heat resulting from epidural analgesia, or by
an intrauterine infection (Sharma & Leveno, 2003).
Maternal fever not associated with infection may be caused
by decreased maternal hyperventilation and decreased heat
loss resulting from pain relief or reduced perspiration and
altered thermoregulatory transmission from the periphery
to the hypothalamus caused by the sympathetic blockade
produced by administration of epidural anesthesia
(AWHONN, 2011a). Occasionally, even with proper
epidural placement, some women do not receive
adequate pain relief.
Anesthesia complications resulting in maternal and neonatal
mortality have decreased, particularly since the advent of
anesthesia techniques using lower concentrations and doses
of anesthetic and analgesic drugs (ACOG, 2002a;
Mahlmeister, 2003; Piotrowski, 2012a). However,
anesthesia complications can significantly affect maternal
and fetal well-being and require prompt recognition and
intervention to minimize the risk of serious sequelae.
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Injection-related emergencies typically occur during
initiation of anesthesia or with subsequent re-injection of an
epidural catheter. Pregnancy-related physiologic changes
result in decreased vascular resistance and engorgement of
the epidural veins that increase the risk of inadvertent
venous injection and catheter migration (Mahlmeister,
2003). Symptoms of intravascular injection may be mild and
transient and may include tinnitus (ringing in the ears),
visual disturbances, metallic taste in the mouth, and
circumoral numbness and tingling. These symptoms can
progress rapidly to slurred speech, agitation, seizures, or
cardiac arrest (Poole, 2003).
Inadvertent puncture of the dura or high spinal block
may result in profound hypotension, progressive respiratory
distress, loss of consciousness, or respiratory arrest
(Mahlmeister, 2003). Measures to correct hypotension
should be initiated. Emergency procedures for seizure
management and cardiac life support should be started,
including calling the emergency response team and the
obstetric and anesthesia provider. Maternal resuscitation and
hemodynamic stabilization may also serve to resuscitate the
affected fetus in utero; however, the possibility of
emergency delivery should be anticipated (Mahlmeister,
2003).
(Continued on the next page.)
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88 of 218 (continued)
(Continuedcomplications
from the previous
page.)
Anesthesia
resulting
in maternal and neonatal
mortality have decreased, particularly since the advent of
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lower exepidural
Pregnancy-related
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Note to
Instructor:metallic taste in the mouth, and
circumoral
numbness
tingling.
Thesereview
symptoms
This is a good
time toand
have
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yourcan
facility
progress rapidly to slurred speech, agitation, seizures, or
emergency and code team procedures related to managecardiac arrest (Poole, 2003).
ment of anesthesia emergencies.
Inadvertent puncture of the dura or high spinal block
may result in profound hypotension, progressive respiratory
distress, loss of consciousness, or respiratory arrest
(Mahlmeister, 2003). Measures to correct hypotension
should be initiated. Emergency procedures for seizure
management and cardiac life support should be started,
including calling the emergency response team and the
obstetric and anesthesia provider. Maternal resuscitation and
hemodynamic stabilization may also serve to resuscitate the
affected fetus in utero; however, the possibility of
emergency delivery should be anticipated (Mahlmeister,
2003).
(Continued on the next page.)
Now that we have discussed pain management strategies,
let’s move on to the second stage of labor. The second
stage of labor begins when the cervix is completely
dilated and ends with the birth of the fetus. The second
stage of labor may be completed within about 2 hours;
however, many women are able to push beyond 2 hours
without adverse maternal or fetal outcomes (AWHONN,
2008).
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Contractions occur with a frequency of about every 2–3
minutes, lasting 60–90 seconds, and are strong by
palpation. Under normal circumstances, descent of the
presenting part proceeds from 0 to +2 station or greater. A
hallmark sign of descent of the presenting part is when the
laboring woman experiences an uncontrollable urge to
push (Simpson, 2008b).
Pushing may cause increased maternal intrathoracic and
abdominal pressures when prolonged breath-holding
(closed glottis) pushing is used, which may result in
alterations in the FHR pattern. Pushing techniques using
the open glottis method and that permit the mother to push
whenever she feels the urge should be encouraged. Women
should be encouraged to push for about 4–6 seconds, with
a slight exhalation, for approximately five to six pushes per
contraction (AWHONN, 2008).
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Several analyses of the second stage of labor have resulted
in the identification of at least two phases of second stage
related to fetal descent and the quality of a mother’s
bearing-down efforts. While there is variation in how
rapidly women progress in the second stage related to
parity (nulliparas vs. multiparas), fetal position, and fetal
size, it has been recognized that not all women experience
an urge to bear down upon complete dilation of the cervix.
The urge to push often is “small” at the start of the
second stage and becomes more pronounced as the fetus
descends. The phase of more active, strenuous pushing is
associated with a decline in newborn pH due to reduced
oxygenation when the mother is holding her breath while
pushing for long intervals (Roberts, 2003).
To minimize the extent to which acidosis develops, it is
recommended that direction in strenuous pushing be
delayed until fetal rotation and descent have occurred and
the conditions for descent are optimal. At that time, you
can assist the woman to assume positions that enable her to
push effectively (Simpson & James, 2005).
According to ACOG (2003a), a variety of factors may
influence the duration of the second stage of labor:
•  Epidural analgesia
•  Occiput posterior (OP) position
•  Nulliparity
•  Short maternal stature
•  Complete cervical dilation with high maternal station
POEP 3rd Edition • Module III
The Process of Labor and Birth
The duration of the second stage of labor alone may not be
associated with adverse maternal or fetal outcomes. ACOG
defines prolonged (or arrested) second stage of labor
requiring further evaluation as follows (ACOG, 2003a):
©2013 AWHONN
•  For nulliparous women: Second stage exceeds 3
hours if regional anesthesia is used and 2 hours if no
anesthesia is used
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•  For multiparous women: Second stage exceeds 2
hours with regional anesthesia or 1 hour without
regional anesthesia
Furthermore, once a prolonged second stage of labor is
diagnosed, the decision to perform an operative birth
(such as forceps delivery, vacuum-assisted birth, or
cesarean birth) should be based not only on consideration
of time but also on evaluation of maternal and fetal
status and the skill and experience of the obstetrician
(ACOG, 2003a).
Part of your role during the second stage of labor is to
communicate information about the woman’s progress and
maternal–fetal status to the obstetric care provider. Equally
important is your role in helping the woman and her
partner to use positions and pushing techniques that can
facilitate progress during the second stage of labor.
We have briefly discussed positioning for maternal comfort
in the first stage of labor. Now let’s discuss positioning
during the second stage of labor. The position the mother
assumes during labor affects her anatomic and
physiologic responses to labor. Position changes can
relieve fatigue, improve circulation, and enhance
comfort while facilitating descent of the fetus.
Encouraging the mother to choose positions and move
freely whenever possible is beneficial and may enhance the
quality of uterine contractions (AWHONN, 2008; Roberts
& Hanson, 2007).
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Preparing the woman for the second stage of labor should
include assessment of (AWHONN, 2008):
•  Her knowledge of the progression of the second stage
of labor and various positioning techniques
•  Her ability to maintain an upright position for
pushing, which may be influenced by weakness in the
lower extremities or fatigue
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•  The fetal presentation, position, station, and degree
of descent; descent of the fetal head provides evidence
of effective pushing, and changing the maternal position
can help to align the fetus better in the maternal pelvis
Women and their partners should be encouraged to use
aids that provide support for various positions, such as
birthing balls, cushions, squat bars, birthing stools, and
foot and leg supports. You and the woman’s partner may
also provide added physical support. If the woman cannot
maintain an upright position, encourage her to use a
lateral position. The lateral position may be more
comfortable and may decrease perineal trauma
(AWHONN, 2008).
If the woman cannot maintain an upright position,
alternating left and right lateral positions is preferred. The
lateral position enhances uteroplacental circulation,
relieves back discomfort, may decrease perineal
trauma, and may be more comfortable for the woman
(AWHONN, 2008; Simpson, 2008b).
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In the semirecumbent position, gravity and pressure are
exerted, which promotes fetal descent. This position
may be convenient for providing nursing care measures
but may not be ideal for the mother if the head of the
bed is too low. The higher the angle of elevation of the
head of the bed, the greater the pressure to facilitate
descent of the fetal presenting part (Piotrowski, 2012c). If
the semirecumbent position is used, the head of the bed
ideally should be elevated at least 30 degrees. Place a
pillow or wedge under the woman’s hip to prevent vena
cava compression (AWHONN, 2008).
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As we discussed earlier in the presentation, proper
positioning during labor can facilitate labor progress and
descent of the fetus and may shorten the second stage of
labor. These same anatomic and physiologic principles
apply for positioning during the second stage of labor.
Upright positioning for the second stage of labor is
defined as follows (AWHONN, 2008; Simpson, 2008b):
•  Sitting with the head of the bed at a 45-degree angle
or greater, with the legs supported on leg and foot rests
and by the nurse or the woman’s partner when needed
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•  Squatting
•  Kneeling
•  Standing
There are many advantages to incorporating a variety of
position changes during labor. Upright positioning
promotes descent of the fetus. Helping a laboring woman
maintain an upright position whenever possible may help
increase the diameter of the pelvis by as much as 30%.
The upright position can also result in stronger
contractions, may help ease the discomfort of labor,
may reduce the duration of labor (particularly of the
second stage of labor), and may help reduce perineal
trauma (AWHONN, 2008; Simpson, 2008b).
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The “all fours” position, which is kneeling in bed and
leaning forward with support, helps to relieve back pain
during labor when the fetus is in an OP position. It may
also facilitate rotation of the fetal head from occiput
posterior (OP) to occiput anterior (OA) position
(AWHONN, 2008).
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Sitting or squatting increases the pelvic outlet diameter to
facilitate second-stage pushing and bearing-down efforts.
The squatting position may also help to minimize the pain
of second-stage labor pushing, may reduce the duration of
the second stage of labor, and may reduce perineal trauma,
assuming that the perineum is well supported (AWHONN,
2008).
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If the woman is able to elevate herself to a squatting
position, as with the use of a squatting bar as shown on
this slide, she will be able to push more forcefully (if that
is desirable or necessary) and shorten the second stage
because of enlargement of the outlet and transverse
diameters of the pelvis. The use of the squatting bar
enables women not only to bring themselves to a squatting
position, but also to rest back on the bed between
contractions. Excessive force with pushing could
contribute to perineal lacerations, so it is important for the
nurse to judge the rate of fetal descent and provide the
woman with feedback about the force she needs to exert
with pushing in a squatting position (AWHONN, 2008).
It is important to watch how the woman’s pushing goes
once she brings herself to a squat and encourage her only
to push with the urge and not add additional force unless it
seems necessary to advance the head. Resting between
contractions helps to return normal resting tone and allows
for reperfusion of the uterus and fetal reoxygenation.
Now that we have reviewed positioning for the second
stage of labor, let’s discuss delayed and nondirected
pushing. Evidence supports delayed pushing until the
active phase of the second stage unless contraindicated by
maternal or fetal conditions (AWHONN, 2008). Key to
your role in supporting and caring for women during the
second stage of labor is helping to decide when and how
pushing should begin. Ideally, this decision should be
made in collaboration with the mother and the obstetric
care provider.
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Traditionally, most practitioners use directed pushing, or
what is commonly referred to as the “Hold your breath and
count to 10” method, to help women push. Traditional
directed breath-holding and pushing for 10 seconds
should be discouraged. Evidence suggests that delaying
pushing until the woman actually feels an
uncontrollable urge to push should be promoted and can
be more effective than directed pushing. With this method,
pushing is delayed until the fetal presenting part reaches
the pelvic floor and spontaneous pushing effects are
observed (AWHONN, 2008; Roberts, 2003).
The mother should be encouraged to push for 4–6
seconds using the open glottis method, repeating for five
to six pushes per contraction. The goals of nondirected
pushing are to facilitate descent of the fetus, increase
maternal comfort, and minimize trauma.
Note to Instructor:
You may want to pause at this point and demonstrate a few
of the more commonly used breathing and relaxation
techniques. Delayed pushing will be covered in more depth
at the end of the module.
This video shows how the baby rotates during the second
stage of labor. Strong uterine contractions push the fetus
forcibly through the birth canal during labor and delivery.
The animation clearly shows the baby's head crowning and
emerging during childbirth.
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The third stage of labor begins with the birth of the
infant and ends with separation and delivery of the
placenta. After the infant is delivered the umbilical cord is
clamped. At this time cord blood specimens can be drawn
from the attached cord or the portion of the cord no longer
attached to either mother or infant. Remember that the
uterus continues to contract after delivery. These
contractions facilitate the separation of the endometrium
from the uterine surface. Once the infant is delivered,
intravenous or intramuscular oxytocin is commonly
administered to assist in this process. Signs of placental
separation may include but are not limited to a lengthening
of the umbilical cord at the perineum and a gush of blood.
Separation of the placenta may occur with the third or
fourth contraction after the birth of the infant but may take
longer. The third stage may last from about 5–7 minutes or
may continue for about 1 hour. Perineal repair may
occur during this time. As the length of the third stage
of labor increases, the risk of hemorrhage also
increases. During this period, you should observe for
physiologic signs of excessive blood loss, such as
increased heart rate, pallor, lightheadedness, decreased
urine output, and decreased level of consciousness and
orientation (Piotrowski, 2012a). If the placenta has not
delivered spontaneously within the first hour, the primary
care provider may deliver the placenta manually.
During the birth process, the perineum is stretched
significantly to accommodate the emerging fetus.
Massaging the perineum and controlling the birth of the
fetal head or other presenting part during the second stage
of labor helps to minimize the risk for perineal lacerations,
but even under controlled circumstances, lacerations may
occur.
There are four types of perineal lacerations (Simpson,
2008b):
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•  A first-degree laceration extends through the
perineal skin and vaginal mucous membrane.
•  A second-degree laceration extends through the skin
and mucous membrane plus fascia and muscle of the
perineum.
•  A third-degree laceration continues through the
muscle of perineum and extends into the anal
sphincter.
•  A fourth-degree extends into rectal mucosa to expose
lumen of rectum.
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Vaginal or peri-urethral tears may occur in combination
with other types of lacerations during birth. Vaginal
lacerations typically involve the sidewalls, or sulci, of
the vagina and are also referred to as sulcus tears. If the
tear is significant, it may extend into the levator ani
muscle or around the ischial spines. Peri-urethral
lacerations are those around the urethra or clitoris.
Both of these types of lacerations may occur with forceps
delivery, rapid fetal descent, or precipitous birth
(Piotrowski, 2012b). Cervical tears and lacerations may
also occur. This graphic image shows a laceration that
extends from the vaginal wall into the anal sphincter.
An episiotomy is a surgical incision made into the
midline or in the mediolateral area of the perineum to
enlarge the vaginal outlet. Enlarging the vaginal outlet
may be necessary to provide additional room for delivery
of the presenting part. Because episiotomy can be
associated with a higher incidence of 3rd and 4th degree
lacerations, this procedure should be performed only when
indicated (Piotrowski, 2012b). Current typical indications
for episiotomy include the need to expedite delivery in the
setting of FHR abnormalities and relief of shoulder
dystocia.
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There are two types of episiotomies: midline (median) and
mediolateral. The midline episiotomy is the most common
type performed in the United States. It is effective, usually
easy to repair, and generally less painful than the
mediolateral episiotomy. The midline episiotomy may
extend through the rectal sphincter (third-degree
laceration/extension) or even into the anal canal (fourthdegree laceration/extension) (Piotrowski, 2012b).
Therefore, the healing episiotomy may be quite painful.
The mediolateral episiotomy is usually used when the need
for posterior extension is likely, as may be the case during
operative birth. Opting for a mediolateral episiotomy may
prevent a fourth-degree laceration; however, a third-degree
laceration may occur. Mediolateral episiotomy usually
involves greater blood loss, is typically more difficult to
repair, and can be more painful when compared with pain
associated with midline episiotomy (Piotrowski, 2012b).
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The fourth stage of labor is the immediate recovery period.
It begins after the delivery of the placenta and lasts for
approximately 2 hours after birth or until the mother’s
condition is stabilized. Some define the fourth stage of
labor as the time of discharge from the hospital while
others define it as the time to full recovery (6 weeks). This
stage includes assessment and observation of the
mother for signs of normal recovery and for
complications (Lowdermilk, 2012b). Nursing physical
assessment and interventions include fundal assessment
and massage to ensure the uterus has begun to contract and
is firm, assessment of vaginal bleeding, assessment for
urinary retention, and frequent assessment of vital signs.
Now that we have discussed normal physiologic labor, we
are going to present common labour situations that require
intervention.
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When the newborn stays with the mother during this
period, newborn assessment and stabilization are also
initiated. If mother and baby are stable, this stage is a
good time to facilitate maternal (and family)–infant
attachment. Assisting the breastfeeding woman to begin
nursing is also encouraged within the first hour of life,
assuming that there are no maternal or neonatal
complications that would preclude breastfeeding initiation.
Now that we have discussed normal physiologic labor, we
are going to explore common labor situations that require
intervention. We will begin by discussing induction and
augmentation of labor.
Note to Instructor:
Details about postpartum and newborn assessment are
covered in Module VI: Postpartum Assessment and
Nursing Care and Module VII: Newborn Assessment and
Nursing Care. You may want to pause at this time to
answer questions.
When labor has not begun spontaneously, or when there
are medical or other indications for delivering the fetus, a
variety of methods are available to initiate labor. Under
other circumstances, spontaneous labor may not be
progressing well or normally, necessitating further
stimulation of the labor process. In the next series of slides,
we’ll be discussing principles of and nursing management
for cervical ripening, induction of labor, and augmentation
of labor. We will also discuss dysfunctional labor and
indications for assisted vaginal birth.
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First, let’s define a few key terms (ACOG, 2003a, 2009):
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•  Cervical ripening is the process of effecting physical
softening and distensibility of the cervix in
preparation for labor and birth.
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•  Induction of labor is the stimulation of uterine
contractions before the spontaneous onset of labor
for the purpose of accomplishing vaginal birth.
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•  Augmentation of labor is the stimulation of
ineffective uterine contractions after the
spontaneous onset of labor to manage labor dystocia.
In 2011, the National Center for Health Statistics reported
that the overall induction rate for 2009 was 23.2%. This
figure represents a slight increase over the induction rates
for previous years. Induction rates have doubled since
1990 (Martin et al., 2011).
Indications for induction of labor are not absolute.
Decisions regarding induction of labor should be made
with consideration of maternal and fetal condition,
gestational age, and other individual patient factors. The
following are examples of maternal and fetal conditions
that may be indications for labor induction (ACOG, 2009;
Simpson, 2008a; Society of Obstetricians and
Gynaecologists of Canada [SOGC], 2001):
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•  Abruptio placentae (depending on the severity of the
abruption, e.g., partial vs. complete abruption, with
evaluation of the extent of maternal and fetal
compromise)
•  Chorioamnionitis
•  Fetal demise
•  Gestational hypertension
•  Preeclampsia or eclampsia
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•  Premature rupture of the membranes
•  Postterm pregnancy
•  Some maternal medical conditions (e.g., diabetes,
renal disease, chronic pulmonary disease, chronic
hypertension)
•  Fetal compromise (e.g., intrauterine growth
restriction or Rh isoimmunization)
Logistical reasons for induction of labor may include the
risk of a rapid labor (e.g., women with history of rapid
labor or precipitous birth), distance from the hospital, and
psychosocial reasons. When labor is induced for logistical
reasons, gestational age of at least 39 weeks or fetal lung
maturity should be established before induction (ACOG,
2009; Simpson, 2008b).
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It is important for the nurse to recognize the absolute and
relative contraindications for induction of labor. The
absolute contraindications are prior classical uterine
incision or fundal uterine surgery; active genital
herpes; placenta or vasa previa, cord prolapse;
transverse or oblique lie; and absolute pelvic
disproportion (e.g. a woman with a pelvic deformity).
The relative contraindications are cervical cancer and a
malpresentation, such as breech presentation, and
abnormal fetal heart tracing. A funic cord, that is a cord
presenting in front of the fetal head, may also be a relative
contraindication, depending on the station of the fetal head
(Wing & Farinelli, 2012). Individual patient circumstances
should also be evaluated to determine when induction may
be contraindicated (Simpson, 2008a).
Several obstetric conditions exist that are not
necessarily contraindications but do necessitate special
attention and assessment. Theses include but are not
limited to the following (ACOG, 2009; AWHONN, 2008;
Simpson, 2008a):
•  One or more previous low transverse cesarean births
•  Breech presentation
•  Maternal chronic medical condition or maternal
heart disease
•  Multiple gestation
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•  Polyhydramnios
•  Presenting part above pelvic inlet
•  Severe hypertension
•  Abnormal fetal heart patterns not requiring
emergent birth
•  Trial of labor after cesarean birth
•  History of prior uterine scar
Before initiation of induction, the following should be
assessed (Simpson, 2008a; SOGC, 2001):
•  Indication for induction or any contraindications
•  Gestational age
•  Cervical favorability
•  Assessment of pelvis and fetal size, as well as
presentation
•  Membrane status (intact or ruptured)
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•  Fetal well-being/FHR monitoring before labor
induction
•  Documentation of discussion with the woman,
including indication for induction and disclosure of
risk factors
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Before cervical ripening or induction of labor is initiated,
an assessment of cervical status is done to determine
whether the condition of the cervix is favorable or
unfavorable for induction. The Bishop score is a widely
used assessment of cervical status that has predictive value
for successful induction. This slide shows the factors that
are evaluated and corresponding scores. Cervical
effacement, dilation, consistency, and position are
assessed, along with determination of fetal station.
When the Bishop score is eight or greater, the probability
of vaginal birth after induction of labor is similar to that
for vaginal birth following spontaneous labor (ACOG,
2009; Simpson, 2008a).
For example, a women whose cervix is 80% effaced, 2 cm
dilated, soft, and midposition with the fetus at -1 station
has a Bishop score of nine; therefore, she is likely to have
a successful induction (Cunningham et al., 2010) barring
other maternal or fetal impediments to labor progress. In
contrast, a women whose cervix is 1 cm dilated, 40%
effaced, soft, and in posterior position with the fetus at -2
station has a Bishop score of five; therefore, she is less
likely to have a successful induction.
Ultimately, a variety of individual maternal and fetal
factors, such as parity, pelvic architecture, fetal lie,
presentation and position, effectiveness of uterine
contractions, and maternal or fetal condition, can influence
the progress and success of induction of labor. Some
women may have an indication for labor induction but
have a low Bishop score. Under these circumstances,
cervical ripening may be needed.
Note to Instructor:
You may want to have participants do an exercise using
additional examples of cervical status assessment to
reinforce the implications of high and low Bishop scores.
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Both mechanical and pharmacologic methods are used to
ripen the cervix to make it favorable for induction of labor.
Mechanical methods of cervical ripening include the use
of laminaria, a natural sterilized seaweed dilator;
synthetic hygroscopic dilators; and balloon catheters.
Dilation of the cervix by mechanical means may be an
effective method of cervical ripening for patients who have
an increased risk of uterine rupture because of previous
uterine scarring or for whom pharmacologic methods are
contraindicated. Laminaria and synthetic dilators absorb
fluid from the surrounding tissues, causing them to
enlarge, resulting in mechanical dilation of the cervix and
release of local endogenous prostaglandins (Simpson,
2008a).
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Balloon catheters can be as effective as pharmacologic
agents in ripening the cervix as demonstrated on the slide.
Balloon catheters are inserted into the extra-amniotic
space. The balloon is inflated with approximately 30 mL of
0.9% normal saline and left in place. The balloon causes
direct pressure on the cervix and stretches the lower
uterine segment. Local endogenous prostaglandins are
released that stimulate ripening of the cervix (Simpson,
2008a). The use of laminaria has been associated with a
slightly increased risk of peripartum infections; therefore,
it is important to monitor these patients more closely for
signs and symptoms of uterine infections (ACOG, 2009).
The obstetrical care provider will usually place and remove
mechanical dilators. They are usually left in place for
about 6–12 hours. Following placement, documentation
should include the number of dilators placed in the
cervix (and sponges placed in the vagina). When a
balloon catheter is inserted, the type and size of
catheter should be noted, along with the amount of
fluid instilled (Simpson, 2008a).
Note to Instructor:
Please review your facility guidelines for assessment of
uterine contractions and maternal and fetal status during
administration of mechanical dilators.
Dinoprostone is a prostaglandin E2 agent that is most
frequently used for cervical ripening. Dinoprostone softens
the cervix, relaxes cervical smooth muscle, and
produces uterine contractions. It is available as a
vaginal insert or in gel form. Dinoprostone gel (Prepidil)
and vaginal insert (Cervidil) are FDA-approved agents for
cervical ripening. Some hospital pharmacies may opt to
compound the preparation in their own facilities. Side
effects of prostaglandins may include the following
(Simpson, 2008a):
•  Nausea
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•  Vomiting
•  Diarrhea
•  Tachysystole
With any of the prostaglandin agents, tachysystole is a
possibility. Terbutaline, 0.25 mg, subcutaneously, should
be available to treat tachysystole according to facility
guidelines and the orders of the primary obstetric care
provider.
Note to Instructor:
Please make participants aware of the prostaglandin
preparations used for cervical ripening in your facility.
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Commercially manufactured prostaglandin E2 gel contains
0.5 mg of dinoprostone in a 2.5-mL syringe. The gel is
inserted into the cervical canal below the internal os
using a plastic catheter applicator. Women should
remain recumbent for at least 30 minutes after
administration, ideally in a lateral position. ACOG
(2009) recommends continuous FHR and uterine
monitoring for 30 minutes to 2 hours after insertion of the
gel. FHR and uterine monitoring should continue beyond
the initial assessment period if uterine contractions persist.
Maternal vital signs should also be assessed according to
your facility’s guidelines.
If there is no cervical change with the initial dose, a repeat
dose may be given 6–12 hours later. Up to three doses
may be given over a 24 hour period, for a total
cumulative dose of 1.5 mg in 24 hours (ACOG, 2009).
Oxytocin administration should be delayed until 6–12
hours after the last dose of gel is inserted (ACOG, 2009;
Simpson, 2008a).
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The commercial preparation of the prostaglandin E2
vaginal insert contains 10 mg of dinoprostone in a timereleased form that delivers prostaglandin at
approximately 0.3 mg per hour. The insert absorbs
moisture from the vagina, which activates the release of
the medication. Women should remain recumbent for 2
hours after insertion, ideally in a lateral position, and
then may ambulate if EFM telemetry is used. If
tachysystole occurs, the insert should be removed. The
insert should also be removed in the presence of an
abnormal FHR pattern, with or without tachysystole
(Simpson, 2008a).
Tachysystole will usually subside within about 15 minutes
of removal (Simpson, 2008a). Otherwise, the insert is
usually removed after 12 hours or when active labor
begins. Oxytocin administration should be delayed 30–
60 minutes after removal of the insert (ACOG, 2009).
Because the risk of tachysystole is higher with the vaginal
insert than with the prostaglandin gel, continuous FHR and
uterine monitoring is indicated from the time it is inserted
until at least 15 minutes after its removal. Prostaglandins
should be used with caution in women who have a history
of glaucoma, asthma, chronic lung disease, or hepatic,
renal, or cardiac disease (ACOG, 2009).
Misoprostol is a synthetic prostaglandin analog (PGE1)
that is indicated for the prevention of gastric ulcers in
patients at high risk of complications from gastric ulcer.
The FDA has removed the contraindication for the use of
Misoprostol for women during pregnancy because it is
widely used in induction of labor. However, the FDA has
included warnings about the potential adverse effects of
this medication during pregnancy.
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The dose for cervical ripening is usually 25 micrograms
(mcg) (one quarter of a 100 mcg tablet) inserted
intravaginally in the posterior fornix of the vagina. The
peak action usually occurs within 1–2 hours. Dosing
should not be repeated more frequently than every 3–6
hours. Oxytocin administration should be delayed until
4 hours after administration of the last dose (ACOG,
2003b). Misoprostol is contraindicated in patients with
previous cesarean birth or uterine surgery (ACOG,
2010; Simpson, 2008a).
Labor can be induced by mechanical methods,
pharmacologic methods, or a combination of both. Let’s
talk first about mechanical methods. Labor may be
stimulated by stripping the membranes or performing an
amniotomy. During the examination, a finger is inserted
into the internal cervical os and rotated 360 degrees. When
the membranes are stripped, or swept, the chorionic
fetal membrane is separated from the wall of the cervix
and the lower uterine segment digitally during a cervical
examination (Simpson, 2008a).
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Significant increases in phospholipase A2 activity and
prostaglandin F2-alpha occur as a result of this procedure.
Release of oxytocin from the maternal posterior pituitary
gland may also be stimulated with membrane stripping.
Stripping of the membranes is associated with a greater
frequency of spontaneous onset of labor and fewer
postdate inductions. Risks associated with membrane
stripping are intrauterine infection, premature rupture
of the membranes, bleeding from an undiagnosed
previa, and precipitous labor and birth (ACOG, 2009;
Gilbert, 2011; Kilpatrick & Garrison, 2012; Simpson,
2008a).
Amniotic membranes may be artificially ruptured if the
cervix is ripe, or favorable, and the presenting part is
engaged. Artificial rupture of the membranes (AROM)
causes arachidonic acid release that converts into
prostaglandins (Gilbert, 2011). For some women,
amniotomy may reduce or eliminate the need for oxytocin;
however, some research indicates that amniotomy plus
oxytocin tends to shorten labor better than amniotomy
alone (ACOG, 2009; Simpson, 2008a).
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Early amniotomy is contraindicated in the presence of
maternal infection, such as HIV, active genital herpes
simplex, and possibly viral hepatitis (Kilpatrick &
Garrison, 2012). Routine amniotomy is not
recommended, and the adverse effects of increased
abnormal FHR patterns with cesarean delivery can best be
avoided if amniotomy is avoided until the cervix is dilated
(Simpson, 2008a). The graphic shows the process of
AROM by the healthcare provider using an amniotomy
hook.
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Oxytocin is the most commonly used induction agent.
Endogenous oxytocin is released via the posterior pituitary
gland in response to vaginal and cervical stretching, breast
stimulation, and sensory stimulation of the lower genital
tract. The release of oxytocin results in uterine
contractions. Synthetic oxytocin is chemically and
physiologically the same as endogenous oxytocin
(Simpson, 2008a). It is important to recognize that the
Institute for Safe Medication Practices (ISMP) has
identified oxytocin as a high-risk medication (ISMP,
2007). Many practitioners are comfortable administering
IV oxytocin. However, many errors have occurred which
may lead to long term consequences to the mother or baby.
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Note to Instructor:
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There is a section on high-risk medications and oxytocin
safety in Module IX: Perinatal Safety and Risk
Management.
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Oxytocin is administered IV via a controlled infusion
pump and piggybacked into the mainline solution at the
port most proximal to the venous site. There are many
variations in the dilution rate. Some protocols suggest
adding 10 units of oxytocin to 1,000 mL of an isotonic
electrolyte IV solution, resulting in an infusion dosage rate
of 1 milliunit per minute at 6 milliliters per hour. However,
other dilutions, such as the following, may also be used:
•  20 units of oxytocin to 1,000 mL IV fluid
(1 milliunit/minute = 3 mL/hour)
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•  30 units of oxytocin in 500 mL (1 milliunit/minute =
1 mL/hour)
•  60 units of oxytocin to 1,000 mL IV fluid
(1 milliunit/minute = 1 mL/hour)
There are no clear advantages for any one dilution rate; the
key issues are knowledge of how many milliunits per
minute are administered and consistency in clinical
practice within each institution. To enhance
communication among members of the perinatal healthcare
team, avoid confusion, and reduce the risk of medication
errors, oxytocin administration rates should always be
ordered by the healthcare provider as milliunits per minute
and documented in the medical record in milliunits per
minute (ACOG, 2009; Simpson, 2008a).
Typically, oxytocin infusions are started at 0.5–1
milliunits per minute and increased by 1–2 milliunits
every 30–60 minutes. Shorter intervals for increasing
doses, such as every 15–30 minutes, and higher dosing
protocols have been used, but such regimens are also
associated with a higher risk of tachysystole and alterations
in FHR patterns (Simpson, 2008a).
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During oxytocin administration, the FHR tracing should
be evaluated every 15 minutes when continuous
monitoring is in use or auscultated and documented
every 15 minutes if auscultation is being used for fetal
assessment (AAP & ACOG, 2012). Patient education is
important for women and their partners undergoing
induction of labor, particularly because the contractions
produced by oxytocin may be perceived as stronger than
those occurring naturally. Procedures should be explained
to the woman and her partner, and support and comfort
measures should be provided.
Note to Instructor:
Please explain that milliunits should be spelled out rather
than using the abbreviation “mU” in documentation,
particularly in physician and certified nurse-midwife
orders, to minimize the risk of errors. You may also want to
emphasize your facility’s guideline for mixing oxytocin, as
well as the ranges for starting and increasing doses.
Whether oxytocin is used for induction or augmentation of
labor, nursing responsibilities include titrating the drug
according to the maternal and fetal response (Simpson,
2008a, 2009):
•  Decrease the dosage or discontinue the medication
when contractions are too frequent.
•  Discontinue the medication if indeterminate or
abnormal FHR patterns occur.
•  Increase the dosage when uterine activity and labor
progress are inadequate.
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The primary obstetric care provider should be notified
and oxytocin infusion stopped in the following situations
(Piotrowski, 2012b):
•  Tachysystole
•  Abnormal FHR pattern
•  Suspected uterine rupture
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Corrective measures should be initiated. For example,
measures such as positioning the patient on her side,
increasing the IV rate, and administering oxygen by face
mask may be needed to address decreases in the FHR
pattern. Terbutaline, 0.25 mg or another drug that has a
tocolytic effect, may be administered subcutaneously for
tachysystole according to healthcare provider orders or
facility guidelines (ACOG, 2009; Simhan & Caritis, 2007).
Note to Instructor:
There is scientific evidence that supports the use of
terbutaline and magnesium sulphate tocolysis for the
purpose of preventing preterm birth (Simhan & Caritis,
2007). Some providers are using these same drugs for
tocolysis during labor. The administration of terbutaline
and magnesium sulfate for tocolysis is an off-label usage.
There are several ways to ensure patient safety during
oxytocin administration (Simpson, 2008a):
•  Implement one unit policy or protocol that everyone
is expected to follow and that reflects current
knowledge about physiology and pharmacology.
•  Develop a system for monitoring clinical practice
that includes professional accountability to ensure that
tachysystole is not part of routine care.
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•  Support nursing assertiveness to allow nurses to
fulfill their independent professional duty to care for
patients using current evidence, standards, and
guidelines. For example, nurses should be able to
independently assess and respond to changes in
patient status.
The goal of induction and use of oxytocin is to deliver a
well-oxygenated baby vaginally in a timely manner
with optimal outcome for the mother. There is no clear
evidence to support that high rates of oxytocin infusion
decrease the length of labor (Simpson, 2008a). Nursing
practice should be based on the best evidence, standards,
and guidelines.
Note to Instructor:
Your facility guidelines for oxytocin administration should
be reviewed with participants.
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Augmentation of labor is defined as the stimulation of
contractions when labor has started but has not
resulted in progressive cervical dilation or descent of
the fetus (ACOG, 2003a). Augmentation may be
considered if contractions are greater than 3 minutes apart
or less than 25 mm Hg during the active stage of labor and
without evidence of dilation and fetal descent. Labor may
be augmented by amniotomy or oxytocin
administration. If oxytocin is used to augment labor,
the protocols are usually similar to that for induction of
labor and may also vary widely. Either low- or high-dose
oxytocin regimens may be acceptable for augmentation of
labor. High-dose regimens may be used for multiparous
women, but, according to ACOG (2003a), there is
insufficient evidence to support the use of high-dose
oxytocin regimens for augmentation of labor in a woman
with a previously scarred uterus.
What you are likely to find in the clinical setting is
variation in oxytocin protocols based on the woman’s
individual circumstances. For example, a low-dose
regimen may be all that is needed to stimulate contractions
that are not strong enough and are not occurring frequently
enough. Conversely, a higher dose regimen using up to 6
milliunits per minute may be needed for a women whose
labor has slowed significantly.
Note to Instructor:
This is a good time to review your facility’s guidelines
related to augmentation of labor.
The current indications for augmentation are labor
dystocia and uterine hypocontractility. Before
beginning augmentation of labor, the adequacy of
maternal pelvis and fetal position, station, and wellbeing should be assessed. Ultimately, the goal of labor
augmentation should be to enhance uterine activity to
produce cervical change and fetal descent, while avoiding
tachysystole and fetal compromise (ACOG, 2003a;
Simpson, 2008a).
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The contraindications for augmentation of labor are
similar to those for labor induction and may include the
following (ACOG, 2003a; Simpson, 2008a):
•  Transverse fetal lie
•  Prolapsed cord
•  Placenta previa or vasa previa
•  Active genital herpes infection
•  Invasive cervical cancer
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•  History of previous uterine surgery, particularly with
a prior classical (vertical) uterine incision
•  Pelvic structural abnormalities
The relative contraindications for labor augmentation or
conditions that require special attention and assessment are
also similar to those we’ve already discussed for induction
of labor.
We will now return to our discussion about issues related
to the second stage of labor.
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To review from earlier in the presentation, maternal
bearing-down or expulsive efforts are referred to as
secondary powers. During the second stage of labor, a
variety of conditions can inhibit the mother’s ability to
push. Regional anesthesia and large amounts of
analgesic medication (for example, repeated doses of
meperidine during the first stage of labor) may decrease
the strength or frequency of uterine contractions and may
also decrease the perception of pressure, impeding or
blocking the pushing effort and prolonging the second
stage of labor (ACOG, 2003a; Piotrowski, 2012b). How
profound this effect is may vary depending on the timing,
route, and doses of medications administered via epidural
or parenterally and the type of regional anesthesia or
analgesia given (AWHONN, 2011b). For example,
combined spinal-epidural analgesia may not inhibit the
mother’s pushing reflex as much as intermittent-dose
epidural anesthesia, which can produce a more profound
anesthetic effect and sometime obliterate the mother’s urge
to push. The practice of allowing the woman to “labor
down” and delay active pushing until the fetus has
descended in the pelvis has been found to result in less
maternal fatigue and higher rates of unassisted vaginal
births than directing the woman with an effective epidural
to start pushing when she reaches complete cervical
dilation (Roberts & Hanson, 2007). That is, directions to
push can be deferred until the fetus has rotated and
descended in the pelvis to a +1 or +2 station (ideally, the
fetus has reached the perineal floor) or the woman has a
strong urge to push with contractions (AWHONN, 2008).
Exhaustion from lack of sleep, prolonged labor, or
inadequate intake of food or fluids can inhibit or prohibit
the mother’s pushing efforts (Piotrowski, 2012b).
Maternal positioning, particularly in the recumbent or
lithotomy position, can work against gravity and impede
pushing efforts (AWHONN, 2008). Directed pushing,
particularly before the presenting part is at +1 station and
the fetus in OA position or without strong contractions can
hinder the mother’s bearing-down efforts and impede
progress (Roberts, 2003).
Ineffective contractions during the second stage of labor
(from medications or other causes of uterine dystocia) can
compromise the mother’s ability to push and, ultimately,
slow fetal descent through the pelvic outlet (Piotrowski,
2012b).
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Pelvic dystocia may be caused by contracted pelvic
diameters that result in reduced capacity of the pelvic
inlet, midpelvis, or outlet. Smaller-than-normal pelvic
diameters may be the result of heredity, pelvic fractures, or
diseases, such as cancers, that alter pelvic anatomy.
Immature pelvic size in some adolescents is also a risk
factor for pelvic dystocia. You may suspect contracted
pelvic diameter if you feel prominent ischial spines or
converging vaginal sidewalls during a vaginal
examination. External measurement of the distance in
centimeters between the ischial tuberosities (the bones you
sit on) can also give you an idea of the size of the pelvic
outlet. If the distance between the inner portion of the
ischial tuberosities is less than 8 cm, the pelvic outlet may
be contracted (Gilbert, 2011). If the pelvis is too small for
the fetus to pass through or the fetus is too large to fit
through the pelvis, this condition is commonly referred to
as CPD or fetopelvic disproportion (Gilbert, 2011).
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Soft tissue dystocia refers to conditions that cause
obstruction of the birth canal by an anatomic abnormality
other than that of the bony pelvis. Obstruction of the
birth canal may be caused by a placenta previa that
partially obstructs the internal cervical os; uterine
fibroids, particularly those occurring in the lower uterine
segment; ovarian tumors; a full bladder or rectum, or fat
dystocia related to maternal morbid obesity. Any of these
conditions can prevent the fetus from entering the pelvis
(Piotrowski, 2012b). Cervical edema occasionally can
inhibit complete dilation. Bandl’s ring is a pathologic
retraction ring associated with protracted labor. Bandl’s
ring may form between the upper and lower uterine
segment because of abnormal thinning of the lower uterine
segment, as may be the case when there is pronounced
disproportion between the fetal presenting part and the
pelvis. The formation of Bandl’s ring may then further
prohibit descent into the pelvis (Cunningham et al., 2010).
With extreme forms of female genital mutilation, soft
tissue obstruction of the birth canal may occur.
Labor dystocia may be caused by conditions that affect the
passenger, the fetus. These conditions are usually
categorized as fetal anomalies, malpresentation,
malposition, multiple gestation, and large fetal size. Some
fetal anomalies may significantly impair labor progress or
make labor impossible because of physical deformities that
make the fetus too large to safely enter or pass through the
birth canal, such as the following (Gilbert, 2011):
•  Hydrocephalus, with gross enlargement of the fetal
head
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•  Anomalies that result in abdominal enlargement,
such as hydrops fetalis
•  Abdominal tumors
•  Conjoined twins
Abnormal fetal presentation or position can make
vaginal birth impossible or make the diameter of the
presenting part too wide to fit through the birth canal.
Breech presentation poses two primary problems
associated with progressive cervical dilation and descent.
First, the fetal buttocks or the feet are softer than the fetal
head. When the fetus is in a cephalic, or head-first,
presentation, the pressure exerted by the head on the cervix
helps the cervix dilate. The softer presenting part of the
breech tends to exert less pressure on the cervix and,
therefore, may not promote cervical dilation in the same
way the fetal head would. Second, although the breech
may be able to pass through the birth canal normally, if the
after-coming head is not well flexed, the dilated cervix
may retract around the smaller-diameter fetal neck
(Gilbert, 2011).
The next slide addresses interventions for posterior fetal
position.
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Problems associated with abnormal fetal positions relate
primarily to the diameter of the presenting part in
relationship to the diameters of the pelvic inlet, midplane,
or outlet. Here’s an example. On the slide, you see the
baby’s head in a occiput posterior position. When the fetal
head is in this position, rotation of the fetal head may be
slower and tends to be more difficult than when the fetal
occiput is in anterior position, because the degree of
rotation needed (approximately 135 degrees) is greater
than that of a fetus in OA position, and the head cannot
flex as much as is desirable because it is facing the
symphysis pubic rather than facing the hollow of the
sacrum. Therefore, rotation and descent are slow and may
be impeded. If the fetal brow presents, labor progress may
be prolonged or arrested, because the fetal brow is the
largest diameter of the fetal head to engage in the pelvis
(Gilbert, 2011).
Fetal size estimated at greater than 4,000 grams (9 lb) may
cause protracted labor or arrest of labor progress (Gilbert,
2011) unless the pelvic dimensions can accommodate a
fetus this large.
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Fetal descent may be delayed in the first or second stage of
labor if the presenting part is OP which is the most
common of fetal malpositions and occurs in about 25% of
labors. Your first clue that the fetus is in OP may be the
mother’s complaint of back pain. The pain is typically the
result of the occiput exerting pressure on the mother’s
sacrum. Comfort measures to relieve pain include
applying counterpressure at the small of the back with
your hand or a firm object, such as a tennis ball, during
contractions and applying heat to the sacral area.
Helping the woman into hands-and-knees position
(Stremler et al., 2005) or standing position (when
possible) can also relieve pain and pressure (Piotrowski,
2012a).
While the use of positional techniques, such as handsand-knees with pelvic rocking, before labor have not been
found to prevent posterior fetal position during labor
(Ridley, 2007), a number of interventions can help rotation
of the OA during labor and pushing. The side-lying,
squatting, and all fours positions and pelvic rocking can
help rotate the fetal head. Specifically, lying in Sims’
position on the same side as the fetal back is recommended
to enhance rotation from OP to OA (Ridley, 2007).
During labor, helping the woman into one of these
positions, particularly the hands-and-knees (Stremler et al.,
2005), has been found to provide relief from back pain.
You may also instruct and help the woman push in a sidelying position with one leg elevated; this position may be
preferred for women with epidural analgesia. You may also
support her to push on her hands and knees or in a
squatting position if she is able. Any of these positions help
to widen pelvic diameters enough to help the OP rotate
around to the anterior position and descend further into the
pelvis (Roberts, 2003; Roberts & Hanson, 2007).
Decisions regarding optimal pushing positions should be
made in consultation with the mother and healthcare
provider. Physical support measures should be employed to
help women maintain alternative positions. For example,
you or the support person can help support the mother in
hands-and-knees position by using pillows or a birthing
ball to provide additional support. Assisting the mother to
sit on a stool or toilet or using a squat bar helps support the
squatting position. When your patient pushes in side-lying
position, you may use pillows to help support her back;
you’ll also need to ensure support of her elevated leg.
Care of the women experiencing labor dystocia should
be guided by the nursing process and really begins when
she enters the obstetric care setting. Your ability to provide
or ensure supportive care, ongoing assessment, and timely
intervention can help influence the progress and outcome
of labor.
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As we have discussed throughout this presentation,
providing women with continuous support during labor
may decrease the need for pain medication, shorten labor,
reduce the rate of operative or assisted vaginal and
cesarean birth, decrease the use of oxytocin, and promote
satisfaction with the birth experience (ACOG, 2003a;
AWHONN, 2008). Physical and emotionally supportive
care can be particularly important when labor is not
progressing normally. Helping the mother focus on
breathing and relaxation techniques and providing
comfort measures may be as important as more high-tech
interventions. We’ll talk more about comfort measures in
the next few slides. You may be providing supportive care
yourself, or you may need to work with the woman’s
partner or doula to help them understand the nature of
problems with the labor and assist with some of the
support measures needed.
On admission to the obstetric care setting, your initial
physical assessment; review of the woman’s prenatal, past
pregnancy, and medical history; and communication with
the healthcare provider should help you identify relevant
pre-existing risk factors for dysfunctional labor. Ongoing
assessment of cervical effacement, dilation, and fetal
position and descent during labor help you determine
whether labor is progressing normally and anticipate the
need for specialized intervention if labor dystocia is
identified. Your assessments should also include
evaluation of the woman’s ability to cope with labor,
need for pain relief, level of fatigue, and hydration.
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Labor is clearly a time of physical and emotional stress for
the woman and her support persons. As we discussed
earlier in the presentation, the presence of support persons
(professional or nonprofessional) to facilitate the labor
process is crucial. Support persons can explain processes,
assist the woman to cope with pain, focus on the work of
labor, and facilitate rest and relaxation between
contractions which can promote normal labor progress.
Fear, intense or uncontrolled pain, fatigue, and lack of
support are all negative stressors that can slow labor
progress. The stress produced by one or more of these
factors may result in increased catecholamine levels and
sympathetic nervous system activity that can decrease
uteroplacental perfusion and impede normal uterine
contractility (Piotrowski, 2012b; Roberts, 2003).
As much as many women desire and are committed to
having an unmedicated birthing experience, there are times
when shear exhaustion and the intensity of the pain may
hinder labor progress. Similarly, a woman who perhaps has
had a previously negative experience, such as a previous
stillbirth or inadequate or poor support, may have fears
about the present labor that may not allow her to use
breathing or relaxation techniques effectively without help
and reassurance about the well-being of her fetus
(Simpson, 2008b).
Note to Instructor:
You may want to include a case example based on a patient
you’ve cared for whose labor was protracted or prolonged
due to one of more of the factors identified above.
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Communication with the woman and her partner about
labor progress is another important part of your role.
Providing information and encouragement about labor
progress and supporting the woman’s needs and desires
whenever it’s possible can help empower her to continue
the work of labor and childbirth (AWHONN, 2008;
Simpson, 2008b). As labor continues, communicating your
assessments with the primary obstetric care provider is
necessary to ensure that she or he is aware of labor
progress and issues that may require further medical
evaluation and intervention. You’ll see in the next few
slides that when labor dystocia is identified, a variety of
interventions may be implemented to address protracted
labor or arrest of progress during the first or second stage
of labor.
As interventions are implemented, ongoing evaluation of
their effect is important. For example, a cervical
examination may confirm that changing the maternal
position has helped rotation of the fetal head from OP to
OA position or that labor progress has resumed with
further dilation and descent. Evaluation of the strength and
quality of uterine contractions on a continuum following
augmentation can help you identify whether labor is
progressing normally or whether further intervention may
be needed.
Note to Instructor:
Interventions for hypertonic and hypotonic uterine
dystocia, OP position, and prolonged second stage of labor
are presented in the next series of slides. You may want to
pause at this point to answer questions about the content
covered thus far.
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You’ll recall from our earlier discussion that conditions
such as overstimulation with oxytocin, fatigue, maternal
anxiety, and dehydration may cause uterine irritability or
uncoordinated, hypertonic contractions. If the woman has
tachysystole while receiving oxytocin, you’ll need to
discontinue the oxytocin and notify the healthcare
provider once you’ve evaluated the FHR and contraction
pattern. To review, your interventions may include
repositioning the woman on her side and increasing the
IV rate to help maximize uteroplacental blood flow and
decrease uterine activity. You may also need to
administer oxygen by nonrebreather face mask (usually
at 8–10 L/min) to help correct abnormal or indeterminate
FHR patterns (Simpson, 2009).
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If the woman’s contractions have slowed or stopped, your
interventions are aimed at helping to identify possible
causes, such as fetal malposition, and taking corrective
action within your role or as ordered. The potential for
CPD and maternal–fetal well-being should be evaluated. If
the mother and fetus are otherwise doing well,
management may include interventions to promote labor
progress, such as amniotomy, stripping the membranes,
ambulation, or possibly oxytocin augmentation (ACOG,
2003a; Piotrowski, 2012a). Position changes may also
help to rotate the fetus that is in a malposition, as we will
discuss in a few minutes. Regardless of the cause of
uterine dystocia, you should assess hydration by
evaluating intake — either the volume of fluid infused or
taken by mouth — and assessing output to ensure the
woman is not becoming dehydrated.
Some women may have hypotonic uterine dystocia
because of exhaustion and inability to cope with the pain
of contractions, particularly during the latent phase of the
first stage of labor. Therapeutic rest measures may be
ordered to help the woman regain her strength and resume
normal labor progress with better coordinated, regular
contractions (Piotrowski, 2012a). Therapeutic rest
measures may include administration of sedatives or
narcotic analgesics to help promote sleep and relieve pain.
Hydrotherapy, which may include a warm shower or
whirlpool bath, is used in many facilities to reduce
discomfort and anxiety. The sensation of warm water on
the skin and buoyancy felt in a warm bath or shower
promotes vasodilation, reversal of the sympathetic nervous
system response, and reduction in catecholamines. These
responses can reduce muscle tension, decrease pain, and
facilitate relaxation (Florence & Palmer, 2003).
Hydrotherapy has been shown to be beneficial for pregnant
women with low risk pregnancies, with or without
ruptured membranes. Since it can potentially produce
hyperthermia, hypothermia, or cardiovascular changes,
water temperatures of 96–98° F (36–38° C) have been
proposed to avoid these effects (Florence & Palmer, 2003).
If whirlpools and showers are not available, you can
provide or help the woman’s support person provide
comfort measures, such as warm blankets, warm
compresses, massage therapy, music, and a quiet
atmosphere, all of which can help promote rest.
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Let’s talk now about delay of descent during the second
stage of labor. We’ve already touched on a variety of
factors that may impede labor progress, and a key feature
of your assessment of the woman’s bearing-down efforts is
the degree of descent and rotation of the fetal head
(Roberts, 2003). As we’ve just discussed, inadequate
contractions and exhaustion may make it more difficult for
the woman to push effectively. The woman’s inability to
push may also be the result of encouraging her to push
before she feels a natural urge. Initiation of this natural,
spontaneous urge to push is known as Ferguson’s
reflex, a physiologic response that occurs with stretching
of the pelvic floor muscles, typically when the fetal
presenting part is at +1 station or greater. Delaying pushing
until the mother feels the urge to push is also referred to as
“laboring down” or “rest and descend” (AWHONN, 2008;
Roberts, 2003).
Delaying pushing offers you the opportunity to encourage
the woman to push in response to her natural urges.
Initially, you may coach her through gentle, open glottis
pushing until adequate fetal descent occurs and help her
rest and breathe deeply between and through milder
contractions. This strategy can be effective, particularly
when epidural anesthesia has blunted the woman’s
perception of pressure. More directed pushing may be
initiated based on your assessment that progress in descent
is occurring. During the second stage of labor, following
the woman’s cues and palpating contractions to determine
peak intensity help you assist the mother to push when the
force of the contraction is strong and most effective
(AWHONN, 2008; Roberts, 2003). You can help her take a
few slow, cleansing breaths as the contraction begins, take
another few breaths between pushes to promote
reoxygenation of her blood, and then help her relax as the
contraction subsides.
(Continued on the next slide.)
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Initially, you may coach her through gentle, open glottis
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rest and breathe deeply between and through milder
contractions. This strategy can be effective, particularly
when epidural anesthesia has blunted the woman’s
perception of pressure. More directed pushing may be
initiated based on your assessment that progress in descent
is occurring. During the second stage of labor, following
the woman’s cues and palpating contractions to determine
peak intensity help you assist the mother to push when the
force of the contraction is strong and most effective
(AWHONN, 2008; Roberts, 2003). You can help her take a
few slow, cleansing breaths as the contraction begins, take
another few breaths between pushes to promote
reoxygenation of her blood, and then help her relax as the
contraction subsides.
(Continued on the next slide.)
Your interactions should be based on communication with
the healthcare provider and may include helping the
woman breathe and rest through contractions, changing her
position, increasing the IV rate, and administering
supplemental oxygen when indicated, as well as
Your assessment should also include evaluation of the
FHR response to pushing. The presence of a normal FHR
baseline between contractions and accelerations is a
reassuring sign. A rising or decreasing baseline (above or
below the normal FHR baseline) and loss of baseline
variability may indicate that the fetus isn’t tolerating
forceful pushing (Roberts, 2003).
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While current research endorses primarily supporting
women’s involuntary bearing-down efforts, there are
occasions when women need assistance and direction with
their bearing-down efforts. Try to identify what may be
inhibiting the mother from effective pushing, such as
pain, fear of tearing, her feeling that she is “not ready”
to have a baby, exhaustion, or uncoordinated efforts
(Roberts, Gonzalez, & Sampselle, 2007).
Note to Instructor:
You may want to demonstrate pushing techniques as
described in the script and field questions at this time.
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On the other side of the birth spectrum, labor may progress
too quickly. This condition is called precipitous labor and
is defined as a labor duration of less than 3 hours from
onset to the birth of the baby (Wing & Farinelli, 2012).
Labor may be characterized by abnormally strong
uterine and abdominal contractions; poor soft tissue
resistance from a firm, thick cervix; or, in rarer
instances, the absence or lack of awareness of the
sensations of labor pain. In the latter instance, you may
encounter a woman — typically a multipara — who
presents with only the complaint of mild pain or no pain
but a feeling of pressure. You may be surprised that she is
completely dilated when you examine her.
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Conversely, you may admit a woman who states that she’s
only been in labor a few hours but has been having
extremely strong contractions and says that it “feels like
the baby is coming out.” Trust the cues from your patient.
Frequently, if the mother says she feels like she’s ready to
deliver, she’s probably correct. There may be few maternal
or fetal complications if the cervix is well-effaced and
dilating easily, the vagina has been stretched previously (as
in a multipara), and the perineum is relaxed. However,
vigorous contractions in the absence of these conditions
has been associated with lacerations of the cervix,
vagina, vulva, and perineum and uterine rupture
(Cunningham et al., 2010).
Precipitous labor and birth with lacerations of the cervix,
pelvic floor, and vulva also poses a risk for amniotic
fluid embolism, which is release of fluid or particulate
matter from the amniotic sac into the maternal circulation.
Postpartum hemorrhage from the abnormally strong
contractions with subsequent uterine atony is a significant
risk (Cunningham et al., 2010). Be alert for potentially
serious sequelae, such as placental abruption and
shoulder dystocia, because the fetus does not have time to
accommodate — that is, rotate — through the pelvis. It is
important to assess all women during pregnancy and on
admission to the obstetric care unit for the use of street
drugs. Precipitous birth may be associated with the use of
cocaine (Wing & Farinelli, 2012).
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Potential adverse fetal effects may result from inadequate
uterine blood flow and fetal oxygenation characteristic of
intense uterine activity without sufficient intervals of
relaxation between contractions. Cephalohematoma is a
risk potentially from unusually rapid fetal descent,
sometimes with resistance on the fetal head from the birth
canal (Cunningham et al., 2010). When birth is
imminent, preparation for the birth should include
assessing maternal and fetal status, notifying the
healthcare provider, seeking help to deliver the baby,
and alerting the neonatal team in accordance with
your facility’s guidelines. If birth is not imminent,
oxytocin should be discontinued if it’s in use, the primary
obstetric care provider notified, and maternal and fetal
status assessed. The side-lying position may help
contractions diminish; tocolytic agents such as terbutaline
or magnesium sulfate may be used.
Now let’s discuss some of the emergencies that you may
encounter in the obstetric care setting.
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Under normal circumstances, following the birth of the
baby’s head, the anterior shoulder is delivered with gentle
downward pressure placed on the head. When gentle
pressure on the fetal head does not result in delivery of the
shoulder, you should suspect shoulder dystocia. Shoulder
dystocia is defined as an impaction (or trapping) of the
fetal anterior shoulder behind the maternal symphysis
pubis (pubic bone). Retraction of the fetal head against
the maternal pelvis, called turtle sign, may help in the
diagnosis of shoulder dystocia. Occasionally, shoulder
dystocia may also occur as a result of impaction of the
posterior shoulder on the sacral promontory (ACOG,
2002b). In either case, additional maneuvers are needed to
disimpact the shoulder and deliver the baby.
The primary risks associated with shoulder dystocia
are fetal macrosomia of 4,000 grams (9 lb) or more,
maternal diabetes, and maternal obesity. However,
many women who have diabetes or are obese never have
shoulder dystocia. Obese women are at risk for shoulder
dystocia because they tend to have larger babies. A number
of other factors, such as the following, have been
associated with shoulder dystocia, but their predictive
values are too low to establish a direct cause-and-effect
relationship (Simpson, 2008b):
•  Previous shoulder dystocia
•  Multiparity
•  Postterm pregnancy
•  Previous macrosomia
•  Labor induction
•  Epidural anesthesia for labor
Note to Instructor:
You may want to use an anatomic model or chart to
demonstrate how the fetal shoulder becomes lodged behind
the pubic bone. Illustrations of suprapubic pressure and
McRoberts maneuver are included with this series of
slides.
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Shoulder dystocia is an unpredictable and urgent event that
requires teamwork and expeditious care. You’ll likely
need to call for additional help, explain to the mother
and her partner what has taken place, and provide
supportive care. The focus of your care of the mother will
be to help her into the positions for the maneuvers needed
to free the entrapped shoulder and reassure her and her
partner that you and the team are doing everything needed
to help deliver the baby. Fetal status should be evaluated.
You’ll also be working with the healthcare provider to
help with the maneuvers and other interventions
(Simpson, 2008b). You may also need to mobilize plans to
ensure neonatal staff are available for the birth. As always,
neonatal resuscitation equipment should be ready. As the
events conclude, you’ll want to ensure documentation of
the circumstances and the steps taken by the healthcare
team to manage the shoulder dystocia (Simpson, 2008b).
The primary interventions for shoulder dystocia are
application of suprapubic pressure and the McRoberts
maneuver. Let’s take a look at these on the next two
slides.
Suprapubic pressure is usually one of the first
interventions attempted to help dislodge the impacted
shoulder. As you can see in this illustration, suprapubic
pressure involves applying firm pressure to the area around
the pubic bone using a closed fist. The pressure applied
should be directed away from and to the left or right side
of the fetal back so that the shoulders might be dislodged
from under the symphysis into the oblique diameter of the
pelvis (Simpson, 2008b).
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Applying suprapubic pressure from the side of the fetal
back may also cause abduction of the shoulder towards the
fetus’ midline, thus reducing the diameter of the shoulders
and enabling them to fit into the pelvis (Gurewitsch &
Allen, 2006). At the same time the healthcare provider will
help guide the delivery in one or more different ways. The
healthcare provider may slide a hand under the occiput into
the vagina to help deliver the posterior shoulder. Some
practitioners will exert gentle downward pressure on the
fetal head while suprapubic pressure is being applied to
dislodge the trapped anterior shoulder. Fundal pressure
should not be applied because it will further impact the
fetal shoulder(Simpson, 2008b).
The interventions to be performed by the team for shoulder
dystocia should be organized and communicated so that
everyone is aware of the steps involved and their
responsibilities.
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The McRoberts maneuver may be used before, after,
or in conjunction with suprapubic pressure (ACOG,
2002b; Simpson, 2008b). Performing the maneuver
involves helping the mother hyperflex her thighs
against her abdomen to facilitate delivery of the
shoulder. You may want to summon additional help for
this maneuver, because suprapubic pressure may also be
needed in addition to the McRoberts maneuver, and you
may need another pair of hands to help you support the
mother’s legs, particularly if she has had an epidural or is
very uncomfortable. The McRoberts maneuver may help
reduce potential complications of shoulder dystocia, such
as fetal clavicular fractures and brachial plexus injury
(Simpson, 2008b).
The video shows the baby’s shoulder trapped behind the
mother’s symphysis pubis at the front of her pelvic bones,
preventing a normal vaginal delivery. An inside view of the
mother’s pelvis shows the baby’s shoulder releasing from
the pelvic bone.
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The primary maternal complications associated with
shoulder dystocia are postpartum hemorrhage and
fourth-degree lacerations (ACOG, 2002b).
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The incidence of these complications is similar for women
who have had both suprapubic pressure and McRoberts
maneuvers (ACOG, 2002b). Postpartum hemorrhage may
be associated with a number of factors, such as the
additional manipulation of the fetus in utero or the
presence of a large fetus, which, in turn, contributes to
overdistention of the uterus and, therefore, risk of
hemorrhage.
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Neonatal complications associated with shoulder
dystocia are brachial plexus injuries and fractures of
the clavicle and humerus (ACOG, 2002b). The incidence
of these types of injuries varies widely, from about 4–40%.
However, fewer than 10% of shoulder dystocia cases are
associated with persistent brachial plexus injuries. Some
severe cases of shoulder dystocia may result in hypoxic–
ischemic neonatal injury (ACOG, 2002b). The video
shows the location of the brachial plexus in the neck of the
fetus. When the infant’s shoulder is trapped in the maternal
pelvis, the nerves of the brachial plexus may be stretched
and injured. This video shows the potential stress to the
brachial plexus area on the infant during a shoulder
dystocia delivery.
Note to Instructor:
Current recommendations for patient safety suggest
incorporating shoulder dystocia simulation drills into
routine emergency planning exercises. You may want to
discuss your facility’s guidelines in the context of this
discussion.
Now let’s discuss assisted vaginal births. Assisted, or
operative, vaginal birth may be indicated when other
interventions to promote fetal descent have failed or when
the maternal or fetal condition influences decisions about
the method of delivery. We will be discussing forceps- and
vacuum-assisted birth in the next few slides. Indications
for either of these methods may be the same and may
include but are not limited to the following (ACOG,
2000):
•  Prolonged second stage of labor (may be caused by
protracted descent of the fetal head or other factors)
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•  Suspected immediate or potential fetal compromise
(such as certain abnormal FHR patterns with absent
short-term variability and with conditions amenable to
vaginal birth)
•  Maternal condition necessitating shortening of the
second stage
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According to ACOG (2000) (as reaffirmed in 2012) there
are no absolute indications for operative vaginal birth.
That is, each woman’s condition and circumstances should
be evaluated as the obstetric care provider decides which
method of delivery is appropriate.
Note to Instructor:
Because specific circumstances may vary widely, you may
want to include a case example you’ve encountered in
which one or more of the indications listed applies.
The forceps is an instrument with two curved blades
used to assist in the birth of the fetal head either from a
cephalic or breech presentation. A variety of forceps
designs are available to accommodate variations in the
contours of the fetal head and maternal pelvis. The blades
of the forceps are joined by a screw or pin which lock to
prevent compression of the fetal skull.
Different types of forceps-assisted birth are initiated
depending on fetal-pelvic conditions (ACOG, 2000):
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•  The criteria for using outlet forceps are that the fetal
scalp is seen at the introitus without separating the
labia, the fetal skull has reached the pelvic floor, the
position of the fetal head is favorable, the fetal head is
in the perineum, and the degree of rotation needed does
not exceed 45 degrees.
•  Low forceps are used when the leading point of the fetal
skull is at +2 station or greater and not on the pelvic
floor.
•  Midforceps refers to the application of forceps when the
fetal head is engaged but the leading point of the skull
is above +2 station.
Generally, the lower the fetal head and the less rotation
required, the lower the likelihood of maternal or fetal
injury (ACOG, 2000). Your nursing care includes helping
to explain the procedure to the woman and her partner,
obtaining the forceps requested by the obstetric care
provider, instructing the woman about when and how to
push during the procedure and helping her to do so, and
monitoring maternal and fetal status. When the anesthesia
care provider is present for the procedure, she or he will
usually monitor maternal vital signs. This graphic image
shows the placement of forceps for forceps-assisted birth.
Note to Instructor:
It is important to convey to participants that the neonatal
staff may be present depending on individual patient
circumstances and your facility’s guidelines related to
forceps-assisted birth.
Vacuum-assisted birth is an operative delivery in which
a vacuum cup is applied to the fetal head using negative
pressure. Caput or mild swelling may develop inside the
cup as pressure is initiated. Traction is then applied by the
obstetrician to facilitate descent of the fetal head. Because
there is variation in the kind of vacuum devices available,
it is important to follow the manufacturer’s guidelines and
your facility’s guidelines for use of the vacuum and
vacuum suction settings (ACOG, 2000). This graphic
image demonstrates proper placement of the vacuum to
assist with the delivery of the infant.
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There is no consensus about what constitutes an
appropriate total number of pulls, maximum number of
cup detachments, or total duration of the procedure
(ACOG, 2000). The procedure of performing three pulls
has generally become accepted as a safety measure for
limiting the amount of traction on the fetal head. Evidence
does support that the use of no more than 600 mm Hg
pressure, three detachments (pop-offs), and total time of no
longer than 20 minutes is associated with a decrease in
fetal injuries (Simpson, 2008b). Documentation of the
procedure should include the numerical amount of pressure
used, number of pop-offs, and total length of time the
vacuum is applied to the fetal head. As with forceps, there
should be a willingness to abandon attempts if satisfactory
progress is not made (ACOG, 2000).
Note to Instructor:
At this time, your facility guidelines for the use of the
vacuum device should be reviewed.
The traction achieved with vacuum devices is significant
and can result in fetal injury if it is not used properly
(ACOG, 2000). Potential vacuum-device-related
injuries include but may not be limited to the following:
•  Scalp lacerations (with excessive torsion)
•  Cephalohematoma (more common with vacuum
extraction than with forceps and may resolve without
neonatal complications)
•  Subgaleal hemorrhage (collection of blood between
the cranial periosteum and the scalp)
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•  Intracranial hemorrhage
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•  Hyperbilirubinemia (from increased lysis of red blood
cells)
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•  Retinal hemorrhage (rare, more often seen following
forceps delivery)
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On the slide, you can see the deeper colored marking
where the vacuum cup was applied. This is a baby who
should be observed closely for the development of any of
the listed complications.
Now let’s expand on subgaleal hemorrhage. The swelling
associated with subgaleal hemorrhage can be diffuse and
may extend from the orbital ridges to the nape of the neck.
The infant may develop hypotension and pallor without
significant cranial findings. Signs of intracranial and
subgaleal hemorrhage may not appear for hours after birth.
These may include lethargy, seizures, tachypnea, bulging
fontanels, poor feeding, tachycardia, and shock. You and
the neonatal staff should be aware of and assess for
potential complications. The mother and her partner should
also be taught to be alert for and report signs that may
indicate a problem, particularly if subgaleal or intracranial
hemorrhage has been identified (Dwyer, 2002).
Note to Instructor:
Some of these neonatal conditions will be further discussed
in Module VII: Newborn Assessment and Nursing Care.
Nursing care for assisted vaginal birth includes
explaining the procedures to the mother and her
partner about the procedure and helping to ensure that
their questions are answered, assessing the mother and
fetus, assisting the obstetric care provider with the
procedure, and making the neonatal staff aware when a
vacuum device is used so that the team may assess for
potential neonatal device-related injury (ACOG, 2000).
Note to Instructor:
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Please review your facility guidelines for notifying the
neonatal staff when their presence is needed at forceps- or
vacuum-assisted births. Consider having a few kinds of
forceps and a vacuum extractor available to show
participants. Alternatively, this kind of demonstration can
be done in the clinical area.
Let’s briefly discuss fundal pressure. Fundal pressure
refers to the application of steady pressure with one hand
on the fundus of the uterus at an angle of 30–45 degrees to
the maternal spine in the direction of the pelvis (Rommal,
as cited in Simpson, 2008b). There is no evidence to
support the use of fundal pressure to shorten an otherwise
normal second stage of labor. There are studies that
identify potential injury to the mother and baby with the
use of fundal pressure. As we have discussed previously,
fundal pressure should not be used in the management of
shoulder dystocia (ACOG, 2002b; Simpson, 2008b).
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Maternal injuries associated with the use of fundal
pressure may include the following (Simpson, 2008b):
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•  Third- and fourth-degree lacerations and anal
sphincter tears
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•  Uterine rupture
•  Uterine inversion
•  Abdominal bruising
•  Fractured ribs
•  Liver lacerations
Injuries to the fetus associated with the use of fundal
pressure may include the following (Simpson, 2008b):
•  Cord compression
•  Abnormal or indeterminate FHR patterns
Fundal pressure is not an appropriate intervention for
shoulder dystocia and, in fact, may worsen the
impaction of the shoulder, increase the risk of uterine
rupture, and increase the risk of fetal injury (ACOG,
2002b; Simpson, 2008b). Some studies suggest that fundal
pressure may actually cause shoulder dystocia if applied
concurrently with vacuum extraction, because the head of
the fetus does not descend on its own (Simpson, 2008b).
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When neither suprapubic pressure nor the McRoberts
maneuver is successful to free the impacted shoulder,
additional maneuvers may be attempted, such as
positioning the woman on all-fours (the Gaskin maneuver),
which, by itself, may be successful to dislodge the
shoulder and is noninvasive. However, it may be difficult
or impossible for a woman with an epidural to assume or
maintain this position (Simpson, 2008b).
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It is important to recognize that fundal pressure may be
appropriate in limited situations. For example,
sometimes fundal pressure is used to guide the fetal head
against the cervix when AROM is used. In this instance,
fundal pressure may decrease the risk of an umbilical cord
prolapse. In some cases, gentle fundal pressure is used to
guide the application of an internal fetal scalp electrode.
The use of fundal pressure in limited clinical situations
should be supported by clear, evidence-based guidelines.
Each facility should have descriptions of techniques,
indications, and contraindications for the use of fundal
pressure, as well as criteria for documentation of the
procedure (Simpson, 2008b).
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Note to Instructor:
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Please take the time to discuss your facility guidelines for
and the nurse’s role in the use of fundal pressure in the
clinical setting. You may want to pause and field questions
about content covered thus far before moving on to the
next series of slides addressing cesarean birth, vaginal
birth after cesarean (VBAC), and postpartum hemorrhage.
The Process of Labor and Birth
In this last series of slides, we will discuss cesarean birth,
vaginal birth after cesarean, or VBAC, and postpartum
hemorrhage.
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We don’t know precisely what has contributed to the
significant rise in the primary cesarean birth rate, but a
number of factors have been identified in the literature. For
example, pregnant women over age 40 are more likely to
have chronic medical conditions, such as diabetes, chronic
hypertension, and cardiac disease, that may necessitate
cesarean birth. The use of continuous electronic fetal
monitoring (EFM) has also been associated with a higher
primary cesarean birth rate when compared with
intermittent EFM or auscultation (Martin et al., 2011).
Nulliparous women tend to have a higher rate of primary
cesarean births than multiparous women (Cunningham et
al., 2010), perhaps because the adequacy of the pelvis of
the woman giving birth for the first time has not been
tested.
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In 2009, the total cesarean birth rate in the United
States was 32.9% of all live births. This represents an
increase of greater than 60% since 1996. This increase is
influenced by an increase in the primary cesarean birth rate
and a decline in the rate of VBAC (Hamilton, Martin, &
Ventura, 2011; Martin et al., 2011). It is also important to
note that the pace of the increase in these rates has slowed
in recent years. The reasons for cesarean birth may vary
widely depending on an individual woman’s medical and
obstetric history and course of pregnancy or labor.
Generally, cesarean birth is performed when there is
concern about maternal or fetal well-being and vaginal
birth is not possible or appropriate. The cesarean birth rate
slightly declined to 32.8% for the first year in more than a
decade in 2010 which is not captured on this graph
(Hamilton et al., 2011; Martin et al., 2011).
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There are multiple reasons a patient might need to have a
cesarean birth. In 2002, the National Center for Health
Statistics categorized rates of cesarean birth according to
medical risk factors and complications of labor and
delivery (Martin et al., 2009). CPD, breech presentation,
dysfunctional labor, and placenta previa were the most
frequently identified complications of labor and delivery.
Prolapsed umbilical cord, prolonged labor, and cardiac
disease are just a few examples of the other complications
of labor and birth and medical risk factors associated with
high rates of cesarean birth. Among the most commonly
noted medical risk factors were chronic and pregnancyinduced hypertension and diabetes (Martin et al., 2009).
Each patient case is individualized, these reasons are only
a few of the most common.
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The incidence of multiple gestation increased 4% in the
United States from 1998 to 2009 (Martin et al., 2011).
Some patients may opt for a vaginal delivery with twins,
especially if the presenting twin is vertex and they have a
dichorionic, diamniotic presentation. However, in the case
of monochorionic, monoamniotic twins (or higher order)
the risk of cord entanglement or twin-to-twin transfusion
syndrome is much higher and will usually require a
cesarean section. This slide shows the cords of mono/mono
twins delivered at 32 weeks. Twin A weighed 3lbs 6 oz and
Twin B weighed 3lbs 2 oz. Both baby girls went to NICU
and progressed well, and the mother was discharged on
postpartum day 4 after 6 weeks of bedrest on the high risk
antepartum unit.
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Women in the United States are now able to opt for a
cesarean birth by choice rather than experience the labor
process. Cesarean birth on maternal request is defined as a
primary cesarean delivery at maternal request in the
absence of any medical or obstetric indication (ACOG,
2007a). The available data on cesarean birth on maternal
request are limited and mostly based on indirect
comparisons. There are, however, two maternal outcomes
that favor vaginal birth: decreased incidence of postpartum
hemorrhage and decreased maternal length of stay. The
strongest evidence in support of vaginal birth is decreased
respiratory morbidity in the neonate. Studies have shown
that infants born via cesarean delivery have a higher
incidence of respiratory distress than those born via
vaginal delivery (ACOG, 2007a). There are no maternal or
neonatal outcomes with strong evidence that favor
cesarean birth over vaginal birth (Simpson, 2008b).
However, more studies are needed in this area.
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Current recommendations specify that cesarean delivery
on maternal request (ACOG, 2007a):
•  Should not be performed before 39 weeks of
gestation unless there is documentation of fetal lung
maturity
•  Should not be motivated by the lack of available
effective pain management
•  Is not recommended for women desiring several
children
Repeat cesarean deliveries have the risk of increased
placenta previa, placenta accreta, and hysterectomy with
each subsequent delivery.
Cesarean birth refers to delivery of the fetus through
incisions made into the abdomen, through the
subcutaneous tissue, abdominal fascia layer, and
peritoneum, and then into the uterus. Let’s look at the slide
as we discuss the types of uterine incisions.
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Abdominal incisions are made either vertically or
horizontally, as you can see in the upper panel of this
illustration. The horizontal incision is also known as
Pfannenstiel’s incision and is commonly referred to as the
bikini incision. The incision into the uterus is usually a
lower uterine segment transverse incision, as you can see
in the lower panel of the illustration. The lower uterine
segment transverse incision is generally easier to repair, is
less likely to rupture in a subsequent pregnancy, and
generally does not promote the formation of adhesions to
the incision line (Cunningham et al., 2010).
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The vertical uterine incision may be made into the upper
body of the uterus, or the upper uterine segment. This type
of incision is referred to as a classical cesarean incision
and is seldom used for cesarean birth. A lower uterine
segment vertical incision may be used, though less often
than the transverse uterine incision. Occasionally, a lower
uterine segment vertical incision may need to be extended
when more room is needed to deliver the fetus. A vertical
uterine incision that extends into the upper uterine segment
is more likely to rupture during a subsequent labor than a
transverse uterine incision (Cunningham et al., 2010).
Therefore, women who have had a classical uterine
incision or an extended vertical lower uterine segment
incision are not candidates for VBAC (ACOG, 2010).
Note to Instructor:
Nursing care of the woman having cesarean birth is
addressed in the next few slides. Be prepared to discuss
your facility guidelines related to planned and unplanned
cesarean births, including notification of pediatric or
neonatal staff and responsibilities for maternal, fetal, and
neonatal care before during and after the procedure.
Whether cesarean birth is planned or unplanned, some
women may feel a sense of loss or unmet expectations over
not having a desired vaginal birth. Your care of the woman
who requires cesarean birth should be based on principles
of woman and family-centered care, including involving
the woman’s partner in the birth process and promoting
family–infant attachment following the birth whenever
possible.
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When cesarean birth is a scheduled event, your admission
assessment is similar to the assessment you’d conduct
for any woman admitted for labor and birth. You’ll also
want to verify that the woman has had nothing by mouth in
preparation for surgery according to physician orders and
facility guidelines. As you would do for women in labor,
explaining procedures and answering questions is an
important part of your nursing care. As part of the
admission process, you may be witnessing the consent for
surgery; this may be a good opportunity to assess the
woman’s and her partner's understanding of cesarean
birth and address questions regarding the events about to
take place. When the primary support person is able to
be present at the birth, you’ll need to explain labor and
delivery routines and what to expect in the operating
room (OR), including information about appropriate attire
and orientation to sterile areas in the OR.
Preparation for cesarean birth may include obtaining
additional preoperative laboratory or other studies,
such as an electrocardiography or chest x-ray, if these were
not done before admission.
Fetal well-being and uterine activity should be assessed
on admission and before initiation of anesthesia. A
suggested routine is to obtain a 20–30 minute baseline
FHR and uterine activity tracing (Simpson, 2008b). If the
woman is in labor, the frequency of fetal and uterine
assessment should be determined based on maternal and
fetal status and your facility guidelines.
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IV fluids should be initiated, and the abdomen should
be prepped. An indwelling urinary catheter should be
placed prior to surgery. Delaying catheter insertion until
after regional anesthesia is in place, when possible, is more
comfortable for the woman (Simpson, 2008b).
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The woman should be positioned on the operating table
with a hip wedge to provide uterine displacement to
promote uteroplacental perfusion. Once the woman is
positioned properly, you’ll begin the abdominal
preparation. It is important to note maternal vital signs,
FHR, condition of the skin, and maternal emotional status
prior to the incision. At the appropriate time, you or
another staff member should ensure that the woman’s
partner is escorted to his or her position at the head of
the surgical table and understands which areas of the
room are considered sterile. Circulating duties usually
include ensuring that additional equipment and supplies
needed for the surgery are available and conducting
instrument, needle, and sponge counts. Be prepared to
assist the newborn staff as needed and to facilitate
interaction with the mother, support person, and the
newborn whenever possible. Maternal and neonatal
conditions should be noted prior to leaving the OR
(Simpson, 2008b).
During surgery, the minimum registered nurse-topatient ratio is 1:1 (Association of periOperative
Registered Nurses [AORN], 2011). This guideline is
usually met by having one registered nurse act as the
circulator and at least one additional person whose sole
responsibility is to care for the newborn. Either this person
or someone who is immediately available should have the
skills required to perform complete resuscitation, including
endotracheal intubation and medication administration
(AAP & ACOG, 2012). Let’s pause and take a look at an
animation of a cesarean birth on this slide.
We will now review the care required for women and
newborns in the post-anesthesia care setting after cesarean
birth.
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Cesarean births are performed for emergent and elective
reasons. It is a surgical procedure which is generally
associated with a higher incidence of complications than
vaginal birth. Risks for morbidity from cesarean birth
complications are influenced by the number of prior
cesarean births and the nature and severity of the medical
or pregnancy complications preceding delivery (Thorpe,
2009). Post anesthesia recovery after cesarean delivery
may be complicated by hypotension, airway obstruction, or
hemorrhage, among other physiological problems. Safe
post anesthesia recovery depends on vigilant, continuous
surveillance as well as timely assessments, recognition of
postoperative complications, and performing appropriate
interventions to support women in the immediate
postoperative period.
Postoperative assessments are performed consistent with
post anesthesia care unit (PACU) guidelines. If recovery
takes place in the obstetric care setting, care should be
comparable to care provided in the main hospital
operating room. Nurse-to-patient ratios during the
recovery phase should be comparable to the main hospital
recovery suite.
We will review the PACU recommendations provided from
some national credentialing and professional associations.
The following national credentialing organizations and
professional associations support the concept that
standards should be uniformly applied throughout a care
facility regardless of their recovery locations:
•  The Association of Women’s Health, Obstetric and
Neonatal Nurses (AWHONN) (2010a, 2010b) and
ASPAN (2010) both provide recommendations for life
support training required for nurses working in the postanesthesia care units (PACU) and staffing guidelines for
this area. Let’s continue by discussing these
recommendations.
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•  American Society of PeriAnesthesia Nurses
(ASPAN) (2010) provides Standards of PeriAnesthesia
Nursing Practice to help guide post anesthesia care.
These guidelines are intended to assure patient safety
and consistent quality of care during post anesthesia
recovery in all locations.
•  The Joint Commission (TJC) (2010a) requires that
patients with comparable needs receive the consistent
standard of care, treatment, and services throughout the
institution.
•  The American Society of Anesthesiologists (ASA)
(2007) Task Force on Post Anesthetic Care Guidelines
apply to all patients, who are recovering from general
anesthesia, neuraxial anesthesia, or moderate to deep
sedation, regardless of the location of their recovery.
•  A joint statement from the ASA Task Force on Postanesthetic Care and the American College of
Obstetricians and Gynecologists (ACOG)
recommends that the equipment, facilities, support
personnel, and care provided in the obstetric operating
rooms and recovery areas be equivalent to that provided
in main surgical areas (ASA & ACOG, 2010). This
recommendation was reiterated in the ASA Practice
Guidelines for Obstetrical Anesthesia (ASA, 2007).
AWHONN and American Society of PeriAnesthesia
Nurses (ASPAN, 2010) have similar requirements for
PACU nurse competency validation as shown on this table.
These organizations differ in their recommendations
related to life support standards. We will now review
AWHONN’s position statement related to advanced
cardiac life support training for obstetrical nurses working
in the PACU.
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AWHONN does not mandate advanced cardiac life
support (ACLS) competence validation for perinatal
nurses who provide post analgesia and post anesthesia care
for obstetric patients. It is important to remember that
maintaining ACLS competence can be a challenge because
the need to apply and implement these skills during the
care of obstetric patients is usually rare. Perioperative
nurses who are exclusively assigned to the care of general
surgical patients may have the opportunity to apply ACLS
knowledge and skills with greater frequency than obstetric
nurses. Given the general lack of opportunity for obstetric
nurses to use ACLS knowledge and skills, it may be more
appropriate to mobilize the code team when maternal
resuscitation requiring ACLS care is needed during the
perioperative period (AWHONN, 2010a). However, as a
broader issue of appropriate facility standards and patient
care, each hospital must ensure that teams are capable of
providing ACLS care (e.g., a code team) and the means to
provide invasive monitoring or extensive ventilatory
support to obstetric patients are available at all times
(AWHONN, 2010a).
Note to Instructor:
Refer to your facility’s guidelines, policies or protocols
regarding recommendations for ACLS.
Let’s review the AWHONN staffing guidelines for PACU
outlined on this slide. On admission to the OB PACU both
the mother and infant require ongoing assessment and
stabilization. Perinatal units should maintain staffing at
comparable levels to the main hospital PACU for obstetric
patients recovering from neuraxial or general anesthesia
(AWHONN, 2011b). Nursing staff assigned to the
immediate recovery of a woman should have no other
obligations until the critical elements for the mother are
met (AAP & ACOG, 2012; AWHONN, 2011b).
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Upon initial admission to the OB PACU two nurses
should be in attendance. One RN should be assigned
only to the care for the mother until the critical
elements for the mother have been met. The second RN
should be assigned to the care only for the newborn
until the critical elements for the newborn have been
met.
When there are multiple infants, there should be one
nurse for each newborn (AWHONN, 2010b).
Once critical elements have been met for the newborn
and mother, one RN can assume care for the couplet.
The “critical elements” for care provided to the mother and
her newborn will be further defined on the next slide.
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The critical elements for the mother’s postanesthesia care
after cesarean birth before the nurse accepts the baby as
part of the patient care assignment include (AWHONN,
2011b):
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•  The anesthesia provider’s report may include but is
not limited to the patient’s history, mental status,
anesthesia and or sedation provided, current status,
urinary output, estimated blood loss, vital signs and
other relevant events that transpired during the surgery
must be received by the nurse. Any questions that the
nurses may have must be answered. The nurse caring
for the mother and newborn in the PACU must
accept the transfer of care from the anesthesia
provider.
•  The mother must be conscious with demonstration of
adequate respiratory status assessed by pulse
oximetry evaluation and other signs of adequate
oxygenation.
•  The initial assessment has been completed and
appropriately documented.
•  The woman demonstrates hemodynamic stability.
Critical elements for the newborn before the mother’s
nurse accepts the infant as part of the patient care
assignment are defined as:
•  The nurse assuming the infant’s care receives a report
from the baby nurse with the nurse’s questions
answered, and transfer of care accepted.
•  The newborn’s initial assessment has to be complete
and appropriately documented.
•  All identification bracelets have been applied.
•  The newborn condition must be stable.
ASPAN (2010) divides post-anesthesia care into 3 levels of
care that include:
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•  Phase I is the immediate postanesthesia period. In
this time period, a woman is emerging from a surgical
procedure such as a cesarean birth requiring general
anesthesia, regional anesthesia or moderate sedation.
Phase I is the level of care in which close monitoring is
required, including airway and ventilatory support,
progression towards hemodynamic stability, pain
management, fluid management, and other acute
aspects of patient care. When the woman has progressed
beyond these elements of care, they can progress to
Phase II level of care.
•  Phase II is the level of care in which plans and care are
provided to progress the woman to discharge home.
This may be in the same location as Phase I care. In
Phase II the woman has a stable airway and good
ventilatory status on room air, achieved or maintained
hemodynamic stability, satisfactory pain and nausea
management, and appropriate ambulatory ability after
the procedure. Transfer and discharge criteria should be
consistent with PACU standards determined by each
facility (ASPAN, 2010). In the obstetrical setting Phase
II care may be provided on the postpartum unit.
•  Extended care is the level of care needed for women
who have met criteria to leave Phase I, but are not able
to go to another place. Extended Care may also be done
in the same physical location as care provided to Phase
I and Phase II patients. The most common reason this
phase of care is utilized is when there is not a bed
available on the appropriate nursing unit.
During the next few slides, we will focus on the level of
care provided during phase I, the immediate postoperative period.
Note to Instructor:
Please review your facility guidelines, policies or protocols
defining each level of care, assessment and discharge
criteria for each phase. Staffing and competency
requirements are typically determined by the level of care
needed.
Phase I postanesthesia care requires constant vigilance and
intensive monitoring of woman’s status. Nursing
assessment and the primary goals of nursing care focuses
on airway and ventilatory status, cardiac and
hemodynamic stability, normothermia, pain and
comfort management, integrity of surgical site and
fluid balances. The goal of Phase I care is to transition the
woman to Phase II level of care which is an inpatient unit
(ASPAN, 2010) where routine postpartum care will
continue to be provided.
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Note to the Instructor:
Review your facility guidelines and recommendation
regarding PACU levels of care.
Prior to the patient’s arrival, the obstetrical postanesthesia
recovery care unit must have the essential equipment at the
bedside to ensure maternal-newborn safety. Additional
equipment that should be readily available and easily
accessible includes but is not limited to warming and
cooling devices, pneumatic compression devices (TJC,
2010b), medications, IV fluids/supplies, monitor to assess
hemodynamic and cardiovascular status, arterial blood
gases and malignant hyperthermia supplies.
POEP 3rd Edition • Module III
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©2013 AWHONN
During Phase I PACU, each bedside should be
equipped with the following (AWHONN, 2011b):
•  Artificial airways
•  Oxygen
•  Suction
•  Monitor for blood pressure, pulse, EKG
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•  Thermometer
•  Pulse oximetry
•  Blood glucose meter
•  Emergency crash carts for the mother and newborn
•  Maternal/newborn care supplies
There should be a defined process for communicating the
need for assistance, and designated location for emergency
equipment and supplies so they are immediately available
(ASPAN, 2010).
Note to Instructor:
This is a good time to review the equipment in the
obstetrical PACU. The location and protocol for calling a
code should be shown to participants on the unit.
Simulating a code scenario may be helpful to assess
learning.
Upon admission into the OB PACU the nurse receives a
report from the anesthesia provider (ASA, 2007).
A rapid assessment of maternal status is completed
immediately on arrival prior to the anesthesiologist leaving
the PACU. If the mother is stable the RN accepts the
transfer and assumes care of the mother. In situations in
which the mother is not stable the anesthesia provider
should remain with the mother until the RN accepts the
responsibility of the mother.
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This slide lists essential elements of a PACU admission
report provided by the anesthesia provider and given to
the receiving nurse (ASPAN, 2010). Note that some
elements may be omitted if the receiving nurse has already
cared for this patient during the intrapartum, preoperative
and/or intraoperative phases.
Note to Instructor:
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Consider enhancing the learning experience by having
attendees simulate giving and receiving report to reinforce
all the elements mentioned.
The Joint Commission (2010b) has issued a Sentinel
Event Alert which specifically identifies the leading
causes of pregnancy related maternal deaths. The most
common causes of preventable errors directly related to
postoperative care following cesarean births are failure
to recognize and act upon vital sign changes and failure
to recognize, act upon and respond to postpartum
hemorrhage. Frequent evaluation, constant vigilance and
focused attention must be paid to the postpartum woman
especially during postoperative recovery period.
POEP 3rd Edition • Module III
Note to the Instructor:
©2013 AWHONN
To enhance the learning experience, this would be a good
time to review the Joint Commission’s 2010 Sentinel Event
#44: Preventing Maternal Death which can be assessed
on the Joint Commission website http://
www.jointcommission.org/assets/1/18/sea_44.pdf
The Process of Labor and Birth
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The maternal vital signs, fundal assessment and vaginal
bleeding should also be performed every 15 minutes for
the first 2 hours (AAP & ACOG, 2012; AWHONN,
2011b). Keep in mind that more frequent monitoring may
be needed if there are any postpartum complications or
hemodynamic instability.
POEP 3rd Edition • Module III
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©2013 AWHONN
Each hospital is responsible for developing guidelines,
policies or protocols for postoperative care that address the
monitoring frequency of maternal status and assessment
parameters, conditions to notify providers and discharge
criteria. Obstetrical post anesthesia care units should
collaborate with anesthesia and surgery departments to
ensure comparable care elements are met. Remember,
guidelines reflect the minimum standard — assessment
parameters should be based on acuity and the patient’s
status.
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Note to Instructor:
Review your facility guidelines and protocols related to
PACU recovery time, monitoring frequency of maternal
status and assessment parameters.
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Postanesthesia care focuses on transitioning the woman
from an anesthetic state to one requiring less acute
interventions. It is important to recognize that
postoperative recovery is a level of care and is not defined
by a timeframe or location of care. During the
postoperative recovery phase, women should receive care
comparable to the care provided in the general PACU
(AWHONN, 2011b). Ongoing assessments include but
may not be limited to vital signs, level of consciousness,
temperature, respiratory function, circulation, obstetric
status, intake and output, and pain level. Obstetric
assessments include fundal and vaginal bleeding
evaluation. You’ll also assess the condition of the incision,
observing for signs of bleeding or other fluid drainage
(Simpson, 2008b).
There is considerable evidence that cesarean deliveries put
women at increased risk for obstetric hemorrhage,
infection, and deep vein thrombosis — the most frequent
causes of severe maternal morbidity and the leading causes
of hospital readmission in the first 30 days postpartum
(Main et al., 2012). During the next few slides we will
examine crucial maternal status assessments. Some of the
complications commonly seen during the recovery period
will also be presented. The following systems approach
and pertinent assessments will be used to guide the OB
PACU evaluation during the immediate recovery period
(AWHONN, 2011b):
•  Respiratory status
•  Cardiovascular status will include monitoring of the
woman’s intake and output
•  Mental status
•  Neuromuscular function
•  Temperature
•  Pain assessment
•  Genitourinary including reproductive system
assessment
•  Gastrointestinal
POEP 3rd Edition • Module III
The primary objective in the immediate postoperative
phase is to maintain ventilation and prevent
hypoxemia. In the PACU, providing supplemental
oxygen is especially important for patients who have
received general or spinal anesthesia because during this
initial anesthetic emergence phase there is a diminished
response to carbon dioxide as well as low lung volumes
(Odom-Forren, 2013). Abnormal respiratory status may
be the result of inhalation, regional or IV anesthetic
agents, therefore continuous assessment of respiratory
status is warranted.
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Respiratory status assessment includes inspection,
auscultation and pulse oximetry. Remember that
respiratory, cardiovascular and neurological assessment
together, will give a total picture of gas exchange and
adequacy of ventilations (Brunner, Smeltzer, Bare,
Hinkle, & Cheever, 2009). Normal respiratory rate is
16–20 breaths per minute. Lung sounds are assessed by
auscultation in the immediate postoperative period.
Breathing should be quiet with regular rate and rhythm.
Adventitious sounds indicate obstruction of the airway.
Expiratory wheezing may indicate asthma and or allergic
reaction and should be discussed with the anesthesia
provider if present. Gurgling sounds indicate secretions in
the respiratory passages, and should be removed. Hourly
use of an incentive spirometer and coughing is
encouraged to increase lung volume and assist in
expectoration of secretions in order to maintain airway
patency. Asking the mother to cough usually clears the
secretions. However, if coughing is ineffective,
suctioning may be indicated. Airway obstruction may
also be related to poor muscle tone due to muscle
relaxants used in general anesthesia. The airway may
need to be supported with repositioning of the head or use
of an artificial airway. Signs of distress or continued
depression from anesthetics include shallow breathing,
retractions, nasal flaring and use of accessory respiratory
muscles. Snoring may be a sign of sleep apnea and
further evaluation may be warranted (ASA, 2009).
(Continued on the next page.)
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185 of 218 (continued)
(Continued
from
the previous
The primary
objective
in thepage.)
immediate postoperative
phase is to maintain ventilation and prevent hypoxemia.
A pulse oximeter is used to measure oxygenation levels
In the PACU,
providing
is especially
during
the initial
phase ofsupplemental
recovery. Theoxygen
oximeter
meaimportant
for patients
who
have received
generalAdequate
or spinal
sures
the arterial
oxygen
saturation
in the blood.
anesthesia because
duringby
thishemoglobin,
initial anesthetic
emergence
oxygenation
is influenced
oxygen
saturaphaseoxygen
there isdelivery
a diminished
to the
carbon
dioxide
as
tion,
and theresponse
ability of
tissues
to utilize
well as low
lung volumes
(Odom-Forren,
Abnormal
oxygen.
Hypoxia
occurs when
the oxygen 2013).
demand
is higher
respiratory
status
may
be
the
result
of
inhalation,
regional
than the oxygen supply. Normal pulse oximetry values
are or
IV anesthetic
agents,
therefore
continuous
assessment
of
95–99%.
Oxygen
saturation
levels
below 95%
are usually
respiratory
status
is
warranted.
treated with supplemental oxygen. Refer to institution specific protocols or orders for treatment parameters (Stannard
& Krenzischek, 2012). We will now review the respiratory
Respiratory status assessment includes inspection,
complications that may occur during the immediate postopauscultation and pulse oximetry. Remember that
erative period.
respiratory, cardiovascular and neurological assessment
together, will give a total picture of gas exchange and
adequacy of ventilations (Brunner, Smeltzer, Bare, Hinkle,
& Cheever, 2009). Normal respiratory rate is 16–20
breaths per minute. Lung sounds are assessed by
auscultation in the immediate postoperative period.
Breathing should be quiet with regular rate and rhythm.
Adventitious sounds indicate obstruction of the airway.
Expiratory wheezing may indicate asthma and or allergic
reaction and should be discussed with the anesthesia
provider if present. Gurgling sounds indicate secretions in
the respiratory passages, and should be removed. Hourly use
of an incentive spirometer and coughing is encouraged to
increase lung volume and assist in expectoration of
secretions in order to maintain airway patency. Asking the
mother to cough usually clears the secretions. However, if
coughing is ineffective, suctioning may be indicated. Airway
obstruction may also be related to poor muscle tone due to
muscle relaxants used in general anesthesia. The airway may
need to be supported with repositioning of the head or use of
an artificial airway. Signs of distress or continued depression
from anesthetics include shallow breathing, retractions,
nasal flaring and use of accessory respiratory muscles.
Snoring may be a sign of sleep apnea and further evaluation
may be warranted (ASA, 2009).
(Continued on the next page.)
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As mentioned, most respiratory complications are typically
the direct result medications such as anesthesia, opioids,
and/or muscle relaxants. Pregnant women are at an
increased risk for aspiration during surgery. This is related
to a delayed gastric emptying time, decrease in tone of the
lower esophageal sphincter related to the effect of
progesterone and the anatomical changes that the gravid
uterus places on the thorax and abdomen. Aspiration
pneumonitis may occur in a woman entering labor and
delivery with a full stomach and requiring an emergency
cesarean birth. Aspiration can occur during induction of
anesthesia or in the immediate postoperative period.
Material with a pH of 2.5 can cause a chemical
pneumonitis or acid aspiration syndrome. In addition,
small particulate matter can produce hemorrhage and
edema leading to alveolar damage. Large particles can
block the airway. Acute signs of aspiration include
tachypnea, rales, cough, cyanosis, wheezing, apnea and
shock. If she begins to vomit the woman should be
positioned in a side lying position and suctioned as needed
(Mason & Dorman, 2013). Hypoxia is caused by several
different conditions. Observe the mother for restlessness,
confusion or anxiety which are early signs of hypoxemia
and require immediate attention. Skin color provides
important information about respiratory function. Cyanosis
is a late sign of hypoxia; if present immediate interventions
to correct the situation are required.
(Continued on the next page.)
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©2013 AWHONN
186 of 218 (continued)
(Continued
frommost
the previous
page.)
As mentioned,
respiratory
complications are typically
the direct result medications such as anesthesia, opioids,
Laryngeal
obstruction
laryngospasm
and/or muscle
relaxants.orPregnant
womenoccurs
are at when
an the
muscles
the for
larynx
close down
and
obstruct
theisflow
of
increasedofrisk
aspiration
during
surgery.
This
related
air
out
of
the
lungs.
The
woman
is
unable
to
ventilate
and
to a delayed gastric emptying time, decrease in tone of the
will
become
hypoxic,
hypercarbic
acidotic.
at
lower
esophageal
sphincter
relatedand
to the
effect Women
of
risk
for laryngeal
are thosechanges
that sustain
irprogesterone
and spasm
the anatomical
that airway
the gravid
ritation
from multiple
intubation
attempts, Aspiration
smokers or who
uterus places
on the thorax
and abdomen.
pneumonitis
occur in
a woman
entering labor
have
a history may
of asthma.
Signs
of laryngospasm
areand
agitadelivery
with
a
full
stomach
and
requiring
an
emergency
tion, absence of breath sounds on auscultation, crowing or
cesarean birth.
Aspiration
canincludes
occur during
induction
of
inspiratory
stridor.
Treatment
calling
for immedianesthesia
or in the
ate
help, clearing
theimmediate
airway of postoperative
secretions andperiod.
ventilatory
Material
with
a
pH
of
2.5
can
cause
support if needed. Bronchospasm isaachemical
narrowing of the
pneumonitis
or acid
aspiration
In addition,
bronchi
and may
be the
result ofsyndrome.
asthma, allergic
reaction,
small particulate
matter can
produce
and inaspiration
or pulmonary
edema.
Signshemorrhage
and symptoms
edema leading to alveolar damage. Large particles can
clude dyspnea, tachypnea, expiratory wheeze and coughing.
block the airway. Acute signs of aspiration include
Treatment for bronchospasm includes use of intravascular
tachypnea, rales, cough, cyanosis, wheezing, apnea and
or inhaled B2 adrenergic agonists and anticholinergics.
shock. If she begins to vomit the woman should be
Supportive
oxygen
may beand
necessary.
A non-cardiopositioned in
a sidetherapy
lying position
suctioned
as needed
genic
type
pulmonary
edema
can occur
in young
healthy
(Mason
& of
Dorman,
2013).
Hypoxia
is caused
by several
adults.
The
cause
is
most
often
associated
with
shock,
rapid
different conditions. Observe the mother for restlessness,
fluids
shiftsorand
unchecked
airway
that
confusion
anxiety
which partial
are early
signsobstruction
of hypoxemia
causes
the woman
to pull
negativeSkin
pressures
and require
immediate
attention.
color against
providesthe
alveolar
bed.
Classic symptoms
are pink function.
frothy sputum,
important
information
about respiratory
Cyanosis
restlessness
respiratory
distress.immediate
Pregnant women
who
is a late signand
of hypoxia;
if present
interventions
to
correct
the
situation
are
required.
develop pre-eclampsia
at risk for developing pulmonary edema. Treatment includes elevation of the head,
oxygen therapy and diuretics. Pulmonary embolism is rare
Laryngeal obstruction or laryngospasm occurs when the
but
is alsoofone
the primary
causes
maternal
muscles
the of
larynx
close down
andofobstruct
themortality.
flow of
Pulmonary
embolism
is
associated
with
obesity,
prolonged
air out of the lungs. The woman is unable to ventilate and
surgery,
endometritis,
thrombophilia.
Pulmonary
will become
hypoxic, and
hypercarbic
and acidotic.
Women at
embolism
may bespasm
causedare
bythose
prolonged
bedrest,
deep vein
risk for laryngeal
that sustain
airway
thrombosis,
fat,multiple
air or amniotic
fluid
embolus.
Pulmonary
irritation from
intubation
attempts,
smokers
or
and
result
from
of a are
whohemodynamic
have a historychanges
of asthma.
Signs
of occlusion
laryngospasm
pulmonary
artery. This
is a life-threatening
complication
agitation, absence
of breath
sounds on auscultation,
crowing or
inspiratory
stridor.ofTreatment
calling
requiring
immediate
support
respiratoryincludes
function,
correcfor immediate
help, clearing
the and
airway
of secretionsSigns
and
tion
of hemodynamic
instability
anticoagulants.
ventilatory
support
if
needed.
Bronchospasm
is
a
and symptoms include chest pain, restlessness, tachycardia,
narrowingshortness
of the bronchi
andand
mayhypotension
be the result(Stannard
of asthma,
cyanosis,
of breath
&
allergic
reaction,
aspiration
or
pulmonary
edema.
Signs
Krenzischek, 2012). Pulmonary embolism management will
andfurther
symptoms
include
dyspnea,V:tachypnea,
expiratory
be
reviewed
in Module
Complications
of Pregwheeze
and
coughing.
Treatment
for
bronchospasm
nancy, Part II.
includes use of intravascular or inhaled B2 adrenergic
agonists and anticholinergics. Supportive oxygen therapy
may be necessary. A non-cardiogenic type of pulmonary
edema can occur in young healthy adults. The cause is
most often associated with shock, rapid fluids shifts and
unchecked partial airway obstruction that causes the
woman to pull negative pressures against the alveolar bed.
POEP 3rd Edition • Module III
The Process of Labor and Birth
©2013 AWHONN
187 of 218
During the immediate postpartum period, delivery of the
fetus and placental expulsion results in dramatic maternal
hemodynamic changes that can result in cardiovascular
instability. Immediately after delivery, the maternal cardiac
output is 60–80% higher than prelabor levels. Increased
cardiac output is due to reduction of the gravid uterus
pressure and the improved venacaval blood flow,
autotransfusion of uteroplacental blood back into the
maternal circulation and decreased vascular resistance due
to the contraction of the uterine muscle and absence of
placental blood flow. Cardiac output is highest during the
first 10–15 minutes after delivery, and then quickly
declines to prelabor values by about 1 hour (Tucker, 2002).
Determination of hemodynamic stability includes frequent
monitoring of blood pressure, pulse, temperature,
oxygen saturation and urine output. Maternal blood
pressure and pulse is assessed every 15 minutes for 2 hours
or more frequently depending on maternal status. As
mentioned on the previous slide, pulse oximeter assesses
maternal oxygenation during the initial phase of recovery
(ASA, 2009).
Intake (fluid management) and output (EBL, urine)
monitoring and documentation is performed in accordance
with your facility policy. It is important to document
estimated blood loss (EBL) resulting from the cesarean as
well as close, ongoing monitoring of blood loss from
vaginal bleeding and wound drainage during the recovery
period. Normal blood loss during a cesarean delivery is
1000 mL, however women undergoing cesarean birth may
lose a significant amount of blood during the procedure
(AAP & ACOG, 2012; Simpson, 2008b). Adequate
emptying of the bladder is monitored frequently in the first
24 hours after birth. As you perform each fundal
assessment, observe for uterine displacement to the right or
the left or other indications of bladder fullness such as
palpation of a urine filled bladder above the symphysis.
Evaluate the urimeter tubing and Foley catheter for
patency.
Cardiac rhythm is monitored on admission to PACU.
Obstetrical nurses placing electrocardiogram (ECG) for
cardiac monitoring should complete an interpretation
course and maintain competency in identification of
normal and abnormal ECG rhythms.
After respiratory problems, cardiovascular problems are
the most common complications that you will see during
the postoperative recovery period.
Cardiovascular complications are usually either the result of
the surgery itself or an exacerbation of the woman’s preexisting cardiovascular problems. Consequently, women
who develop significant cardiac problems suffer from the
result of an acute, unpredicted problem. Examples are
hemorrhage, malignant hyperthermia, hypoxia or embolism.
POEP 3rd Edition • Module III
The Process of Labor and Birth
©2013 AWHONN
188 of 218
Postoperative hypotension is most often caused by
hypovolemia as a result of postpartum hemorrhage.
Postpartum hemorrhage has been associated with
significant morbidity and mortality. Timely recognition,
diagnosis and treatment of the cause is essential. Epidural
or intrathecal anesthesia, especially with an opioid, can
cause neurogenic hypotension (AWHONN, 2011a). In
addition, rapid infusion of oxytocin can cause a reflex
tachycardia and hypotension. Hypertension may be caused
by pain or new onset of preeclampsia. She must be
evaluated for oliguria. This may be indicative of
hypovolemia.
Deep vein thrombosis (DVT) is a condition in which blood
clots form in the large veins in the legs or other parts of the
body. Surgery is a risk factor for the occurrence of DVTs. It
may also be caused by increased intraabdominal pressure
resulting in venous blood stasis, prolonged immobility and
polycythemia. Obese pregnant women are twice as likely to
have postoperative DVTs. Homans’ sign is performed to
identify signs of thrombophlebitis or deep vein thrombosis.
A positive test is one in which the mother reports pain in the
calf muscles with dorsiflexion of the foot. Typically pain is
unilateral. At the same time, determine if there are red,
warm areas on either leg. Pedal pulses should be checked if
thrombophlebitis is suspected. It is important to recognize
that a positive Homans’ sign is not a definitive indicator of
thrombophlebitis, further assessment is needed. Although
routine postoperative thromboprophylaxis is a controversial
issue it has been recently recommended for postoperatively
for patients who have a cesarean birth and are considered at
risk for DVTs. The decision for thromboprophylaxis to
prevent thrombus formation is based on a previous history
of thrombosis, the presence of a diagnosed thrombophilia,
and other risk factors, such as race, age, and medical
conditions, that may contribute to clot formation. Venous
thrombosis and pulmonary embolus may be effectively
treated with IV heparin (ACOG, 2007b). Treatment options
for anticoagulant agents used during pregnancy will be
reviewed in Module V: Complications of Pregnancy: Part II.
(Continued on the next page.)
POEP 3rd Edition • Module III
The Process of Labor and Birth
©2013 AWHONN
188 of 218 (continued)
(Continued
fromcomplications
the previous page.)
Cardiovascular
are usually either the result of
the surgery itself or an exacerbation of the woman’s preProvision
of safe, qualityproblems.
nursing care
means thatwomen
you must
existing cardiovascular
Consequently,
be
attentive
recognizing
signs problems
of complications
and detewho
developtosignificant
cardiac
suffer from
the
riorating
maternal
conditions
and
communicate
these
findresult of an acute, unpredicted problem. Examples are
ings
in a timely
manner hyperthermia,
to the healthcare
team (AWHONN,
hemorrhage,
malignant
hypoxia
or embolism.
2011b). Rapid response to changes in maternal vital signs
and clinical condition are critical to promoting safe care and
Postoperative
is most
often (TJC,
caused2010b).
by
minimizing
thehypotension
risk of adverse
outcomes
hypovolemia as a result of postpartum hemorrhage.
Postpartum hemorrhage has been associated with
significant morbidity and mortality. Timely recognition,
diagnosis and treatment of the cause is essential. Epidural
or intrathecal anesthesia, especially with an opioid, can
cause neurogenic hypotension (AWHONN, 2011a). In
addition, rapid infusion of oxytocin can cause a reflex
tachycardia and hypotension. Hypertension may be caused
by pain or new onset of preeclampsia. She must be
evaluated for oliguria. This may be indicative of
hypovolemia.
Deep vein thrombosis (DVT) is a condition in which blood
clots form in the large veins in the legs or other parts of the
body. Surgery is a risk factor for the occurrence of DVTs. It
may also be caused by increased intraabdominal pressure
resulting in venous blood stasis, prolonged immobility and
polycythemia. Obese pregnant women are twice as likely to
have postoperative DVTs. Homans’ sign is performed to
identify signs of thrombophlebitis or deep vein thrombosis.
A positive test is one in which the mother reports pain in the
calf muscles with dorsiflexion of the foot. Typically pain is
unilateral. At the same time, determine if there are red,
warm areas on either leg. Pedal pulses should be checked if
thrombophlebitis is suspected. It is important to recognize
that a positive Homans’ sign is not a definitive indicator of
thrombophlebitis, further assessment is needed. Although
routine postoperative thromboprophylaxis is a controversial
issue it has been recently recommended for postoperatively
for patients who have a cesarean birth and are considered at
risk for DVTs. The decision for thromboprophylaxis to
prevent thrombus formation is based on a previous history
of thrombosis, the presence of a diagnosed thrombophilia,
and other risk factors, such as race, age, and medical
conditions, that may contribute to clot formation. Venous
thrombosis and pulmonary embolus may be effectively
treated with IV heparin (ACOG, 2007b). Treatment options
for anticoagulant agents used during pregnancy will be
reviewed in Module V: Complications of Pregnancy: Part II.
(Continued on the next page.)
POEP 3rd Edition • Module III
The Process of Labor and Birth
©2013 AWHONN
189 of 218
When assessing of level of consciousness, consider the
following: does the woman respond to verbal stimuli,
tactile simulation or painful stimuli similar to her preoperative level? Is the woman oriented to time and place?
If she displays confusion, restlessness, or somnolence,
consider delayed emergence from anesthetic agents, fear
and anxiety, impaired oxygenation or pain level. Many
women undergoing cesarean birth have short acting major
regional or spinal anesthesia so any delays in emergence to
intact consciousness must be communicated to the
anesthesia care provider who will evaluate and manage this
complication.
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The Process of Labor and Birth
©2013 AWHONN
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Initial assessment is directed at determining the extent of
sensory, motor and sympathetic blockade. Regional
anesthesia can be associated with physiological changes,
that if unrecognized can have serious consequences.
Respiratory function may be compromised with a high
spinal or epidural. Sympathetic and sensory nerves are
blocked which may cause hypotension, vasodilation, and
bradycardia. Dermatome level is an area of skin supplied
by a single spinal nerve. The dermatome level is the level
at which she has feeling with regional anesthesia.
Assessment of dermatome level helps establish
sympathetic and motor levels. Dermatome levels are
associated with anatomical landmarks, for example T4 is
nipple line, T10 is umbilicus and T12 is pubis. Duration of
the regional anesthesia is influenced by many factors,
including medications used. It is important to document
that the sensory and motor block is resolving prior to
transfer to the postpartum unit. When she is able to
successfully lift her legs off of the bed, this is a
demonstration of return of lower extremity motor
function.
With a neuraxial block there is a difference between
sympathetic, sensory, and motor block level. The
sympathetic level is generally two to six dermatome levels
higher than the sensory level. The sensory level is
approximately two dermatome levels higher than the motor
level.
Knowledge of key dermatome levels assists the anesthesia
provider in assessing the level of neuraxial blockade. An
alcohol wipe is useful to assess the level of
sympathectomy by measuring the patients’ ability to
perceive skin temperature sensation. A blunt needle is
useful in the assessment of the sensory level.
Pain assessment is considered the 5th vital sign and
should be assessed with each vital sign assessment. The
single most reliable indicator of the existence and intensity
of acute pain and any resultant affective discomfort or
distress, is the woman’s self report. A pain assessment
scale is helpful in obtaining a numerical value from the
patient’s perspective of their pain rating. Appropriate pain
management is ongoing and can be decided from this value
as well as an efficacy determination of the intervention
when a reassessment pain score is obtained (AWHONN,
2011a).
POEP 3rd Edition • Module III
The Process of Labor and Birth
©2013 AWHONN
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Both pharmacological and nonpharmacological
interventions are effective in the management of
postoperative pain. Pharmacological pain relief measures
are typically managed by the anesthesia provider in the
PACU. The combination of IV or intrathecal opioids with
nonsteroidal anti-inflammatory drugs (NSAIDs) has been
shown to be highly effective for pain management
following cesarean birth (AWHONN, 2011a).
Intramuscular, IV, patient controlled analgesia (PCA)
pump, and oral (by mouth [PO]) are acceptable routes for
administration of opioids for pain management. Patient
controlled epidural analgesia (PCEA) may also be
provided with local anesthetics. Monitoring for side effects
related to administration of IV and intrathecal opioids is
important. Side effects of opioids, such as morphine, may
include pruritus, nausea, vomiting, urinary retention, and
respiratory depression (AWHONN, 2011a).
Nonpharmacological interventions may be used to increase
comfort and decrease pain. Comfort measures include
positioning, music, distraction, promoting relaxation,
education (ASPAN, 2010) and abdominal splinting.
Remember to reassess your patient’s pain level at the
appropriate interval after both pharmacological and
nonpharmacological interventions.
Note to Instructor:
Review your institution’s policy for pain assessment and
options for pain management. When possible have
participants familiarize themselves with the anesthesia
care provider team.
POEP 3rd Edition • Module III
The Process of Labor and Birth
©2013 AWHONN
192 of 218
The most common complication of any surgery is
hypothermia which is defined as a core temperature of
less than 36°C (96.8°F). Patients who have a temperature
below 96.8 have an average length of stay that is 2–3 days
longer than the patient who is normothermic (Kurz,
Sessler, & Lenhardt, 1996). Infusion of cool IV fluids,
cool irrigation, cool operating room environment and
anesthetic agents may cause hypothermia (AORN, 2011).
Temperature assessment (core temperature is ideal)
should be monitored every 15 minutes until
normothermic, then at least every hour until
discharged from PACU (ASPAN, 2010). Measures to
prevent hypothermia include warm blankets, maintaining
the room to 26°C (78.8°F) and avoiding long periods of
skin exposure (ASPAN, 2010). Treatment for hypothermia
include administration of warmed IV fluids and active
warming devices such as forced air warmers (ASPAN,
2010). Many women experience transient postoperative
shivering after both cesarean and vaginal birth. This
trembling is generally not associated with an increase in
core body temperature. Although there are many theories,
the cause of this involuntary trembling remains unknown.
Warming therapy (as mentioned) should be provided as a
comfort measure until it resolves (Odom-Forren, 2013).
Hyperthermia is defined as a core temperature of more
than 38°C (100.4°F). Postoperative fever or hyperthermia
after cesarean birth within the first 24 hours after delivery
often resolves spontaneously and cannot be explained by
an identifiable infection. Postoperative fever can be
associated with hypovolemia that require IV fluid bolus
infusion. Fever is not an automatic indicator of puerperal
infection. A new mother may have a fever due to prior
illness — possibly related or unrelated to childbirth. Any
fever within 10 days postpartum should be aggressively
evaluated. Your patient may also have physical symptoms
which may include but are not exclusive to pain, malaise,
loss of appetite, and may indicate puerperal infection.
Puerperal infection is a term used to describe bacterial
infections after childbirth and refers to infections of the
genital canal that occur within 28 days postpartum. A
puerperal infection is characterized by a temperature of
38°C (100.4°F ) or higher on at least 2 during the first 10
days after birth, exclusive of the first 24 hours. Puerperal
(postpartum) infection would require administration of
broad spectrum IV antibiotics. Notify the healthcare
provider and follow your facility’s protocol for maternal
fever management.
POEP 3rd Edition • Module III
The Process of Labor and Birth
©2013 AWHONN
193 of 218
Malignant hyperthermia (MH) is an inherited
hypermetabolic disorder of the skeletal muscle triggered
by the administration of general anesthetic agent in
susceptible individuals. The incidence is not truly known
but has been reported to range from 1 in 5,000 to 65,000
(Malignant Hyperthermia Association of the United States
[MHAUS], 2011). Though MH once had a fatality rate of
70%, greater awareness of MH symptoms, better
diagnoses, defined treatment protocols, prompt
intervention and treatment with dantrolene (Dantrium)
have reduced the rate to less than 5% (MHAUS, 2011).
MH is life-threatening disorder that requires immediate
intervention and treatment to prevent death. Triggers are
commonly used general anesthetics such as halothane,
sevoflurane, isoflurane, desflurane and the paralyzing
agent succinylcholine. MH may occur at any point after
exposure to the triggering anesthetic, on emergence from
the anesthetic, in the OB PACU (MHAUS, 2011; OdomForren, 2013) or 36 hours after receiving the anesthetic
(Hernandez, Secrest, Hill, & McClarty, 2009). Signs and
symptoms of the MH crisis include tachycardia, an
increased end-tidal CO2 causing tachypnea (an early sign),
hyperkalemia, a greatly increased body metabolism,
muscle rigidity (this may not occur) and fever that may
exceed 43°C (110°F). It is important to note that a
temperature increase may be a late sign. Cardiac arrest,
brain damage, internal bleeding or failure of other body
systems are more severe complications. The MH victim’s
ultimate death can be due to a secondary cardiovascular
collapse and survivors might have brain damage, kidney
failure, major organ or muscle damage (MHAUS, 2011).
MH susceptible women must avoid exposure to triggering
anesthetic agents as well as anticholinergics and
phenothiazines. Current evidence no longer supports
pretreatment for MH susceptible patients with dantrolene
(Odom-Forren, 2013). Preoperative screening is the most
effective prevention for MH.
This anesthetic crisis is primarily managed by Anesthesia
care providers however OB nurses need to be prepared to
assist with crisis management by becoming familiar with
acute malignant hyperthermia signs and symptoms,
treatment interventions and the appropriate equipment for
this type of emergency (Martin, 2009; Stannard &
Krenzischek, 2012). The initial steps in managing acute
MH include but are not limited to the following
interventions (Odom-Forren, 2013):
(Continued on the next page.)
POEP 3rd Edition • Module III
The Process of Labor and Birth
©2013 AWHONN
193 of 218 (continued)
(Continued
the previous
page.)
Malignant from
hyperthermia
(MH)
is an inherited
hypermetabolic disorder of the skeletal muscle triggered
•by the
Discontinue
the administration
of the triggering
administration
of general anesthetic
agentagent.
in
susceptible
individuals.
The
incidence
is
not
truly
known
• Provide rapid O2 bag-mask ventilation or if needed
but endotracheal
has been reported
to range from 1 in 5,000 to 65,000
intubation.
(Malignant Hyperthermia Association of the United States
• Insert a central venous line and an arterial line.
[MHAUS], 2011). Though MH once had a fatality rate of
•70%,
Draw
andawareness
send labs immediately
for electrolytes
and
greater
of MH symptoms,
better
arterial defined
blood gases.
Also protocols,
send labs for
complete blood
diagnoses,
treatment
prompt
intervention
andand
treatment
dantrolene
(Dantrium)
count (CBC)
platelets,with
prothrombin
time/partial
havethromboplastin
reduced the rate
to
less
than
5%
(MHAUS,
2011).
time (PT/PTT), fibrinogen, fibrin
split
MHproducts,
is life-threatening
requires
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metabolic disorder
panel, andthat
creatine
kinase
(CK) –
intervention
andastreatment
treat results
ordered.to prevent death. Triggers are
commonly used general anesthetics such as halothane,
•sevoflurane,
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IV dantrolene
1 to 2and
mg/kg
over 1 to 2
isoflurane,
desflurane
the paralyzing
minutes,
up
to
10
mg/kg
until
core
temperature
has
agent succinylcholine. MH may occur at any point after
decreased.
exposure
to the triggering anesthetic, on emergence from
the provide
OB PACU
(MHAUS,
2011; Odom•the anesthetic,
Cool patientinand
ongoing
monitoring
of paForren,
2013)
or
36
hours
after
receiving
the
anesthetic
tient’s core temperature.
(Hernandez, Secrest, Hill, & McClarty, 2009). Signs and
•symptoms
Monitorofurinary
output
appearance.
the MH
crisisand
include
tachycardia, an
increased end-tidal CO2 causing tachypnea (an early sign),
Some
facilities arequire
emergency
containing the
hyperkalemia,
greatlyMH
increased
bodycarts
metabolism,
equipment,
supplies,
and medications
be fever
available
opermuscle rigidity
(this may
not occur) and
that in
may
ating
room
suites
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PACUs.
MH
emergency
cart
contents
exceed 43°C (110°F). It is important to note that a
and
preoperative
testing
methods
beyond
the scope
temperature
increase
may
be a latearesign.
Cardiac
arrest,of
this
however
more information
bebody
found
brainpresentation
damage, internal
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other
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are moreHyperthermia
severe complications.
The of
MH
on
the Malignant
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ultimate
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can
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States
website
http://www.mhaus.org/
collapse and survivors might have brain damage, kidney
failure, major organ or muscle damage (MHAUS, 2011).
MH susceptible women must avoid exposure to triggering
anesthetic agents as well as anticholinergics and
phenothiazines. Current evidence no longer supports
pretreatment for MH susceptible patients with dantrolene
(Odom-Forren, 2013). Preoperative screening is the most
effective prevention for MH.
This anesthetic crisis is primarily managed by Anesthesia
care providers however OB nurses need to be prepared to
assist with crisis management by becoming familiar with
acute malignant hyperthermia signs and symptoms,
treatment interventions and the appropriate equipment for
this type of emergency (Martin, 2009; Stannard &
Krenzischek, 2012). The initial steps in managing acute
MH include but are not limited to the following
interventions (Odom-Forren, 2013):
POEP 3rd Edition • Module III
The Process of Labor and Birth
©2013 AWHONN
194 of 218
Uterine assessment includes the evaluation of the fundal
height, tone and location. This is evaluated with the quality
and quantity of lochia or vaginal bleeding and should be
assessed at a minimum of every 15 minutes for 2 hours (AAP
& ACOG, 2012). When performing fundal palpation, for
position and consistency, after a cesarean birth remember that
this will cause some discomfort to your patient. Encourage
deep breathing while performing these fundal checks to help
to decrease her discomfort. Assure her that this examination is
very important to evaluate how she is doing. Fundal massage
may also be given if there is bleeding as a result of uterine
atony to ensure the uterus contracts and becomes firm. Lochia
is evaluated for amount and consistency. Often lochia tends to
be lessened after cesarean birth due to the manual cleaning or
swabbing of the uterine cavity during cesarean surgery. The
woman should be checked under her buttocks for any vaginal
bleeding that may have pooled in the vagina vault, flowed
downward and is therefore not easily visualized. These
assessments along with vital signs are critical in identifying
changes in maternal status and may assist with the early
recognition of postpartum hemorrhage (AWHONN, 2011b).
Other emergencies, such as acute placental bleeding, or injury
to the uterine arteries during an emergency cesarean birth
predispose to hemorrhage (Thorpe, 2009). The surgical
dressing covering the incision is observed for oozing or
bleeding. The obstetrical provider should be notified for
excessive bleeding, increase in uterine height, oozing or
bleeding at incision site and severe abdominal pain. We will
have a detailed discussion of the treatment and management
of early postpartum hemorrhage later in this module and late
postpartum hemorrhage will be reviewed in Module VI:
Postpartum Assessment and Nursing Care.
The renal system is critical in maintaining body homeostasis
by regulation of water and electrolyte balance, excretion of
waste products and control of arterial blood pressure (Tucker,
2002). Your patient will have an indwelling urethral catheter
with urimeter collection system to evaluate urine output.
Urinary output is an indicator of fluid status and kidney
function. It should be assessed in the immediate postoperative
period for amount and color. Primary care providers should
be notified if urine appearance is blood-tinged or bloody. This
may be indicative of a bladder perforation. Urinary tract
infections are frequently associated with urinary
catheterization. Bladder injuries are usually lacerations to
the bladder that are identified and repaired surgically.
POEP 3rd Edition • Module III
The Process of Labor and Birth
©2013 AWHONN
195 of 218
Assessment for nausea is performed on admission,
discharge and more frequently if indicated to the recovery
room (ASPAN, 2010). Nausea and vomiting are common
side effects associated with anesthetic agents and opioids.
Women may receive neuraxial opioids for postoperative
pain relief which may increase their risk for postoperative
nausea and subsequent vomiting. Both can be triggered
with sudden movements, position changes and transfers to
and from bed (AWHONN, 2011b). Serotonin receptor
antagonists such as granisetron and ondansetron
significantly reduced the incidence and severity of
postoperative nausea and vomiting and decrease the need
for rescue antiemetic therapy in women who received
intrathecal morphine for a cesarean delivery (George,
Allen, & Habib, 2009). Nausea and vomiting may also be
associated with hypotension. Intravenous fluid boluses
have been shown to decrease postoperative nausea and
vomiting. If the woman does not experience nausea and
vomiting, oral nutrition can be given within 2 hours after
delivery or as ordered (AWHONN, 2011b).
Postoperative bowel ileus is fairly common, particularly
when the bowel is manipulated during surgery (Thorpe,
2009), and with decreased bowel motility from anesthesia
and analgesia. Bowel injuries are frequently associated
with pre-existing scarring or adhesions from previous
cesarean births or other abdominal surgery.
POEP 3rd Edition • Module III
The Process of Labor and Birth
©2013 AWHONN
196 of 218
Now let’s discuss issues related to the integumentary system.
One of the most common side effects of intrathecal morphine for
pain management in women who have had a cesarean birth is
pruritus due to opioids in the epidural infusion. This pruritus, for
most women will last approximately 45 minutes after the initial
dose (Simpson, 2008b). There are many different medications to
treat pruritus. Pharmacologic therapy includes antipruritic
medications such as naloxone, nalbuphine, diphenhydramine,
ondansetron and granisetron (AWHONN, 2011b). Intravenous
naloxone (Narcan, an opioid antagonist) and nalbuphine (Nubain,
an opioid mixed agonist/antagonist) are effective in prevention of
pruritus associated with neuraxial morphine in women undergoing
cesarean birth. Research has shown nalbuphine to be more
effective than diphenhydramine in treating intrathecal morphine
related pruritus (AWHONN, 2011b).
The cesarean wound abdominal dressing condition is
evaluated for any drainage and intactness. If the dressing has
blood-stained drainage, it is helpful to outline the borders of
the drainage, and document the date and time. The surrounding
visible skin is noted for any changes. Wound hematomas are
typically associated with lack of hemostasis and trauma. Signs
of hematoma include tissue bruising that can be red,
ecchymotic or dark blue in coloring, pain, or swelling at or
around the incision site. When the abdominal dressing is
removed the wound integrity with the suture line, whether
being held together by staples or sutures, is directly and
regularly assessed according to your facility’s policy. Any sign
of suture line or wound dehiscence or separation must be
reported to the primary care provider. Wound infections are
more common among women who have cesarean birth
following the second stage of labor, with the use of
suprafascial (above the fascia layer) wound drains, and among
obese women. Moderately obese women (pregnant weight of
90–100kg [198–220 lb]) are 1.6 times more likely to have a
wound infection. Women who have severe obesity (> 120 kg [>
265 lb]) are 4.45 times more likely than nonobese women to
have skin infection (Olsen et al., 2008). Some wound
infections are caused by Staphylococcus aureus contamination
as a result of compromised sterile technique. Therefore,
attention to sterile technique and good wound care are key to
preventing postoperative infection (Thorpe, 2009). Both
planned and unplanned cesarean birth may contribute to the
overall satisfaction with the birth experience. It is important to
assess the woman’s psychological response to her birth
experience and provide emotional support and education to the
woman and her family (AWHONN, 2011b).
We will now briefly review initial newborn assessment and
maternal infant bonding in the PACU setting.
POEP 3rd Edition • Module III
The Process of Labor and Birth
©2013 AWHONN
The newborn transition period requires respiratory,
cardiovascular and thermoregulatory adaptation. Most
newborns transition to extrauterine life without difficulty.
It is important to remember that babies born by cesarean
do not experience the thoracic squeeze and therefore may
experience respiratory difficulties during their transition.
Routine assessment of the newborn which include
temperature, heart and respiratory rates, skin color,
adequacy of peripheral circulation, quality of respirations,
level of consciousness, tone and activity should be
documented every 30 minutes for 2 hours according to
facility guidelines (AAP & ACOG, 2012). In addition to
the newborn assessments listed on this slide, an initial
physical assessment and hypoglycemia screen may be
performed.
Note to the Instructor:
197 of 218
Review Module VII: Newborn Assessment and Nursing
Care for additional information on transition and care of
the newborn. This may be a good time to review your
facility’s orders or protocols for routine newborn care.
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If the mother and infant are stable, it is important to
facilitate maternal–infant contact. Whenever possible,
you should try to keep the family together in the recovery
area. Early skin-to-skin care is considered best practice
and should be initiated immediately, whenever and for as
long as possible in the OR and continued in the PACU
(Haxton, Doering, Gingras, & Kelly, 2012; Hung & Berg,
2011). Mother’s should be encouraged to breastfeed
during this time. Otherwise, the father or support person
may be brought to the nursery to see the infant. Both
planned and unplanned cesarean birth may contribute to
the overall satisfaction with the birth experience. Providing
support and information is particularly important when an
emergency has occurred to help parents understand the
nature of the events and the condition of the newborn and
to help reduce the fear and stress associated with the
emergency birth (Simpson, 2008b). It is important to
assess her psychological response to the birth experience
and provide emotional support and education to the woman
and her family (AWHONN, 2011b).
Note to Instructor:
Details of postpartum recovery and care are provided in
Module VI: Postpartum Assessment and Nursing Care.
The timing of discharge from the surgical recovery area is
determined based on the woman reaching hemodynamic
stability and successfully meeting the PACU discharge
criteria. There is no identified time frame for completion of
the recovery phase. The anesthesia care provider is
involved in the decision to discharge from the PACU.
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A scoring system such as the Aldrete Scoring System, or
the Post Anesthetic Discharge Scoring System (PADSS)
may be useful for determining the mother’s eligibility for
PACU discharge (ASPAN, 2010; AWHONN, 2011b). The
PACU discharge scoring tool as shown on the slide can
assist in conducting a systematic evaluation to determine
when the mother is ready for discharge. The maximum
score one can obtain is 12. A score of 10 or more must be
obtained before being discharged (Simpson, 2008b). The
PACU discharge criteria assessments included in this tool
are:
•  Level of consciousness
•  Neuromuscular activity
•  Level of sensation
•  Circulation
•  Respiration
•  Color
Post-anesthesia care assessments and obstetrical evaluation
of the mother continues until specific criteria are met
(AWHONN, 2011b). Once the PACU discharge criteria are
met, continue postpartum routine care according to
obstetrical care standards (Simpson, 2008b). There is
usually a requirement for a physician (typically an
anesthesia provider) to release a patient from the PACU.
Note to Instructor:
Each facility is responsible for collaborative,
interdepartmental development of policies and procedures
for obstetrical PACU patients. This is a good time to
review your facility’s PACU assessment and discharge
criteria and the requirement regarding release from the
PACU.
Now let’s discuss vaginal birth after cesarean birth or
VBAC. VBAC may also be referred to as trial of labor
after cesarean, which may be a more apt description of a
planned trial of labor after a vaginal birth. Some women
who have had a previous cesarean birth may want to try
having a vaginal birth in a subsequent pregnancy. As we
noted earlier, many women feel a sense of loss when
vaginal birth isn’t possible, and, for some women, a trial of
labor in a subsequent pregnancy may be a reasonable
option.
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When a trial of labor following vaginal birth seems
reasonable, the risks and benefits of attempting vaginal
birth should be discussed by the primary obstetric care
provider with the woman, ideally during the prenatal
period. This discussion should include advantages of
successful vaginal birth, including decreased risks for
hemorrhage and infection; shorter length of hospital
stay; and less painful, quicker recovery. The obstetric care
provider should also discuss the risk of uterine rupture,
which is approximately 1%, and the risk of both maternal
and fetal morbidity and mortality associated with uterine
rupture, which may include maternal or fetal hemorrhage,
hysterectomy, neonatal infection, neurologic impairment,
or death (ACOG, 2010; SOGC, 2005).
While this kind of discussion can cause stress, it’s
important to note that many women have successful trials
of labor after cesarean birth. The woman’s choice may be
influenced by the reason she had the first cesarean birth.
Ultimately, the decision to proceed with VBAC should be
made collaboratively between the woman and her provider.
In 1996, the VBAC rate was 28.3%, but it declined to
12.6% by 2002 (Martin et al., 2009), and has further
declined to 8.0 in 2008 (Hamilton et al., 2011; Martin et
al., 2011). This decline may be due to reports about the
risks associated with VBAC, modification of practice
guidelines (e.g., implementing guidelines that are more
conservative regarding candidate selection) and
medicolegal concerns (Martin et al., 2009).
Many women who have had one previous lower uterine
segment transverse cesarean birth without other
contraindications for labor may be candidates for a
trial of labor. Women who have had two previous lowtransverse cesarean births may also be candidates;
however, the risk of uterine rupture increases with each
cesarean birth (ACOG, 2010). ACOG has also identified
the following additional criteria for selection of potential
VBAC candidates (ACOG, 2010; SOGC, 2005):
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•  The patient should have a clinically adequate pelvis,
meaning that the size of the pelvis should be estimated
to be adequate to accommodate vaginal birth.
•  Apart from the one or two previous lower uterine
segment cesarean birth scars, there should be no
additional uterine scars nor a history of a previous
uterine rupture.
•  The physician should be immediately available to
monitor active labor and to perform an emergency
cesarean delivery, if necessary.
•  Anesthesia providers and other personnel should be
available for emergency cesarean birth.
Because uterine rupture can have serious consequences for
both the mother and the fetus, VBAC should only be
attempted in institutions equipped to respond to
emergencies with physicians and nurses immediately
available to provide emergency care (ACOG, 2010).
Epidural anesthesia may be used for VBAC, because
epidural anesthesia rarely masks signs of impending
rupture and the knowledge that pain relief options are
available may help an eligible woman make the choice for
VBAC (AAP & ACOG, 2012). Oxytocin may be used
when there is an indication for induction or augmentation.
However, the use of prostaglandin gel insert for cervical
ripening in a woman attempting VBAC is discouraged, and
the use of misoprostol is contraindicated, because of the
increased risk of uterine rupture associated with these
agents in women attempting VBAC (ACOG 2003a, 2010).
VBAC should not be undertaken in women who have risks
for uterine rupture. A trial of labor after cesarean birth is
contraindicated in the following circumstances and
conditions (ACOG, 2010; SOGC, 2005):
•  History of a previous classic or T-shaped incision or
other transfundal uterine surgery
•  Previous uterine rupture
•  Medical or obstetric complication that precludes
vaginal delivery
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•  Two prior uterine scars and no vaginal deliveries
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Women who are attempting VBAC and their partners should
have support and education throughout labor — perhaps
in a different way than women experiencing spontaneous
labor without a previous uterine scar. You’ll want to ensure
that the woman understands what is involved in the labor
and birthing process and what kind of assessment and
monitoring is needed because she is attempting VBAC.
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Maintaining IV access is usually indicated as a precaution
in the event of a uterine rupture and the need for blood and
fluid volume expanders. Continuous EFM and uterine
monitoring are recommended for VBAC patients (ACOG,
2010; Simpson, 2008b). Your nursing care should include
ongoing assessment of maternal and fetal status, similar to
that for labor and vaginal birth, so that you are observing for
and reporting signs of abnormal labor progress. If oxytocin
is in use, medication should be started at the lowest dose
needed to achieve contractions and titrated slowly (Curran,
2003; Simpson, 2008b).
You’ll also assess the woman for signs of potential uterine
rupture, alterations in FHR patterns that may be associated
with uterine rupture; the presence of uterine hypertonus; or
persistent, severe abdominal pain, with or without an
epidural. FHR patterns associated with uterine rupture may
include variable, late, or prolonged decelerations or fetal
bradycardia. Other signs may include blood-tinged urine,
rising fetal station, an irregular uterine wall contour (which
may be indicative of the fetus extruding from the uterus),
vaginal bleeding, and symptoms of hypovolemia (Curran,
2003; Simpson, 2008b), such as maternal tachycardia and
hypotension. The graphic image on the slide shows how
uterine rupture may occur in the area of a previous uterine
incision.
Prompt intervention is key when a rupture is identified.
Volume expanders, blood, and blood products should be
readily available and the surgical team mobilized to begin
the emergency cesarean birth (Simpson, 2008b), including
neonatal or pediatric staff who are prepared to evaluate or
resuscitate the newborn (AAP & ACOG, 2012) according to
your facility guidelines. Whenever possible, a staff member
should also be available to help explain circumstances and
provide support to the woman and her partner.
Note to Instructor:
Please review your facility’s guidelines related to VBAC and
emergency care for uterine rupture.
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Now let’s discuss postpartum hemorrhage. Under normal
circumstances, pregnant women lose about 500 mL blood
during normal vaginal birth, and about 1,000 mL of blood
during a cesarean birth. Although some women may be
able to tolerate blood loss in excess of these numbers
without physiologic compromise, hemorrhage is generally
defined as blood loss exceeding 500 mL for vaginal
birth and greater than 1000 mL during cesarean birth.
Postpartum hemorrhage has also been defined as a
10% volume drop in the postpartum hematocrit or
hypovolemia significant enough to warrant transfusion
(ACOG, 2006; Curran, 2003).
The focus of our discussion will be on factors associated
with immediate or early postpartum hemorrhage, that is,
hemorrhage associated with delivery or within the first 24
hours after birth. However, it’s also important to know that
hemorrhage may occur after the first 24 hours, and this
condition is known as delayed or late postpartum
hemorrhage (Bowers et al., 2008; Francois & Foley, 2012).
Maternal hemorrhage is one of the top three causes of
maternal mortality in the United States, along with
embolism and pregnancy-induced hypertension (Berg,
Callaghan, Syverson, & Henderson, 2010).
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Let’s review some of the pregnancy physiology that we
covered in Module II that’s important to remember relative
to the pathophysiology of postpartum hemorrhage. As
you’ll recall, under normal circumstances, blood volume
increases in pregnancy by as much as 50% by term. This
increase provides additional blood volume that supports
the growing uterus and the fetus’ metabolic needs for
oxygen and nutrients. The increased blood volume also
helps to compensate for the normal amounts of blood
lost during the birth process. By term, about 600 mL/min
of blood flows through the uterus. At delivery, with normal
separation of the placenta, the arteries and veins that carry
blood to and from the placenta are severed, and as the
uterus contracts, those vessels are constricted and bleeding
subsides (Cunningham et al., 2010).
When hemorrhage occurs, blood loss of about 1,500 mL
or greater represents about 25% of a pregnant
woman’s total blood volume, which is normally about
6,000 mL. Significantly, estimation of blood loss is often
subjective and may be clinically underestimated by as
much as 50% using visual assessment. Accurate blood
loss assessment may also be difficult when hemorrhage is
concealed (Cunningham et al., 2010), for example, with
placental abruption, bleeding from a surgical site, or
hematoma.
When acute, rapid onset hemorrhage occurs, the initial
hematocrit may not accurately reflect blood loss
because the hematocrit typically falls only by about 3% of
volume in the first hour following a 1,000-mL blood loss.
One way to assess blood loss objectively is to weigh
perineal pads and underpads. For example, 1 mL blood is
equal to about 1 gram in weight (Curran, 2003). So, if an
underpad saturated with blood weighs 2 pounds, or about
1,000 g; that represents about 1,000 mL of blood loss.
Clearly, the severity of the hemorrhage may preclude you
from taking time to weigh underpads or perineal pads; but
when it’s feasible to do so, this information, in addition to
monitoring hematocrit and clotting studies over time, may
be helpful to determine whether and how much blood and
volume replacement is needed.
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Uterine atony (or failure of the uterus to contract) is the
most common cause of immediate postpartum hemorrhage.
We will discuss uterine atony in depth on the next slide. If
placental separation does not occur normally, vaginal
bleeding may be excessive, because the presence of
placental fragments prevents effective uterine contraction.
Conditions associated with retained placenta are
succenturiate placenta (an extra placental lobe) and
placenta accreta. The accessory lobe of the placenta may
be retained when the rest of the placenta is expelled,
resulting in hemorrhage and predisposing to risk of uterine
infection. Placenta accreta occurs when the placenta
implants into the body of the uterine muscle, rather than
into the upper, or decidual, layer. Conditions such as
placenta previa and previous uterine scarring predispose to
abnormal or defective decidual layer formation and, thus,
abnormal placental implantation. If placental fragments
cannot be removed manually, uterine curettage may be
needed. In the case of placenta accreta, ligation of the
internal iliac arteries or hysterectomy may be needed
(AAP & ACOG, 2012; Francois & Foley, 2012).
Lacerations of the birth canal (cervical, vaginal, and
perineal) should be suspected when bright red vaginal
bleeding persists in the presence of a well-contracted
uterine fundus. Risk factors for birth canal lacerations may
include precipitous birth and operative vaginal delivery, as
we’ve discussed. The bleeding associated with vaginal
cervical and lower uterine segment lacerations may be as
profuse and life-threatening as the other causes of
postpartum hemorrhage (Bowers et al., 2008).
Hematomas may develop from injury to the blood vessels
of the lower reproductive tract or branches of the uterine
arteries during spontaneous or operative vaginal or
cesarean birth. The hematoma may not be detected until
significant blood loss or shock has occurred. Perineal
assessment should include observation for redness,
swelling, and perineal or rectal pain that is not relieved
with analgesics (Bowers et al., 2008; Francois & Foley,
2012).
(Continued on the next page.)
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abnormal placental implantation. If placental fragments
cannot be removed manually, uterine curettage may be
needed. In the case of placenta accreta, ligation of the
internal iliac arteries or hysterectomy may be needed
(AAP & ACOG, 2012; Francois & Foley, 2012).
Lacerations of the birth canal (cervical, vaginal, and
perineal) should be suspected when bright red vaginal
bleeding persists in the presence of a well-contracted
uterine fundus. Risk factors for birth canal lacerations may
include precipitous birth and operative vaginal delivery, as
we’ve discussed. The bleeding associated with vaginal
cervical and lower uterine segment lacerations may be as
profuse and life-threatening as the other causes of
postpartum hemorrhage (Bowers et al., 2008).
Hematomas may develop from injury to the blood vessels
of the lower reproductive tract or branches of the uterine
arteries during spontaneous or operative vaginal or
cesarean birth. The hematoma may not be detected until
significant blood loss or shock has occurred. Perineal
assessment should include observation for redness,
swelling, and perineal or rectal pain that is not relieved
with analgesics (Bowers et al., 2008; Francois & Foley,
2012).
(Continued on the next page.)
When the uterine muscle fails to contract following birth,
the blood vessels at the placental site do not constrict;
therefore, blood loss from the placenta site may be rapid
and significant. In a woman with uterine atony, when you
palpate the uterine fundus in the immediate postpartum
period, rather than feeling a hard, grapefruit-like
consistency, the uterine fundus feels soft, mushy, or
“boggy.”
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Overdistension of the uterus is one of the primary risk
factors for uterine atony. Uterine atony resulting from
overdistention is more likely to occur with multiple
gestations, polyhydramnios (excess amniotic fluid), and
fetal macrosomia (large fetus); these conditions tend to
overstretch the uterus and inhibit effective uterine
contraction after the placenta separates. Other factors
associated with uterine atony are multiparity, precipitous or
prolonged labor, oxytocin-induced or augmented labor, use
of tocolytic drugs (e.g., magnesium sulfate and
terbutaline), intra-amniotic infection (e.g.,
chorioamnionitis), and use of halogenated anesthetic
agents (that cause uterine relaxation) (Bowers et al., 2008).
These images illustrate a case of uterine atony and
postpartum hemorrhage with fundal massage. The first
image shows the normal postpartum condition with a
contracted uterus preventing hemorrhage. The second
image illustrates the uterine atony which allows for
hemorrhage to flow into the uterus. The final image
depicts a manual fundal massage attempting to stop the
hemorrhage.
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Now that we’ve discussed causes of postpartum
hemorrhage, let’s examine the primary physical signs of
impending shock. Copious vaginal bleeding is an obvious
indicator of hemorrhage. Bleeding may be dark red with
clots, as is common with uterine atony. The character of
bleeding may also be bright red and free-flowing, which
may indicate a cervical, vaginal, or lower uterine segment
laceration, particularly in the presence of a well-contracted
fundus. Increasing abdominal girth may indicate occult
bleeding or a concealed hemorrhage. When bleeding is not
readily apparent but the woman complains of persistent
abdominal, perineal, or rectal pain that is not relieved
with analgesics, pelvic or retroperitoneal (in the peritoneal
space) hematoma may be suspected (Bowers et al., 2008).
Increasing heart rate or respiratory rate may be among
the first physical symptoms associated with hypovolemia.
Initially, BP may be maintained as a result of the body’s
effort to conserve circulating volume and maintain arterial
pressure. Therefore, alterations in BP may not be observed
until shock has progressed (Curran, 2003). Depending on
the origin and severity of hemorrhage, hypotension may
be a late sign. Other physical symptoms associated with
hypovolemia and the body’s efforts to maintain core
circulating volume are as follows (Bowers et al., 2008;
Curran, 2003):
•  Pallor
•  Lightheadedness
•  Cool, clammy skin
•  Decreased urine output, or oliguria
Note to Instructor:
An in-depth discussion on shock, including compensatory
and progressive shock, is included in Module IV:
Complications of Pregnancy: Part I.
The primary goals of nursing and medical management
of hemorrhage are to identify and correct the source or
sources of bleeding, restore circulating fluid and blood
volume, and re-establish maternal stability,
demonstrated by a return to normal vital signs and level of
consciousness (Curran, 2003; Francois & Foley, 2012).
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To accomplish these goals, nursing and medical
management ideally should be collaborative and based on
knowledge of risk factors for postpartum hemorrhage,
recognition of the signs and physiologic consequences of
impending or fulminate shock, knowledge of treatment
methods, and the ability to mobilize resources to intervene
and evaluate care on a continuum.
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Postpartum hemorrhage is an obstetric emergency, and
management requires teamwork (Bowers et al., 2008).
Your first steps should include summoning help and
ensuring that roles and responsibilities for various
aspects of care are delegated. For example, you may need
additional staff to assign and delegate these roles, prepare
and deliver blood samples, help provide direct care, and
ensure that the woman’s partner receives information and
support. Initial treatment of postpartum hemorrhage
also consists of uterine massage, either externally or
bimanually, particularly if the uterine fundus is not
contracted and firm. Uterine, vaginal, and cervical
exploration may be indicated to help determine the
source of or to manage bleeding.
Blood loss significantly impairs the body’s oxygencarrying capacities. Therefore, supplemental oxygen may
be needed. If so, oxygen should be administered at about
10–12 L/min by non-rebreather mask. The woman should
be placed in Trendelenburg’s or lateral recumbent
position or have her legs elevated to increase venous
return to the heart and perfusion of vital organs and help
maximize cardiac output until blood replacement is
accomplished and vital signs stabilize. (In circumstances
when the woman is undelivered, a wedge should be placed
under the hip to prevent vena cava compression). Pulse
oximetry may not accurately reflect central organ
oxygenation, because peripheral tissue oxygenation is
decreased with hypovolemia. Electrocardiograph
monitoring may be indicated when hemorrhage is
accompanied by profound hypotension, tachydysrhythmia,
or bradydysrhythmia (Bowers et al., 2008; Curran, 2003).
Other nursing interventions include initiation of largebore IV access (e.g., 16- or 18-gauge catheter whenever
feasible), preferably in two sites, to accommodate IV fluid
infusion and blood transfusion (Bowers et al., 2008;
Curran, 2003). One of the first organs affected by
hypovolemia is the kidney. Therefore, assessment of urine
output is a good indicator of maternal (and fetal)
physiologic stability or instability. Therapy is aimed at
replacing circulating fluid and blood volume to avoid
organ damage, such as ischemic necrosis of the kidneys.
Urine output of 30 mL/hour provides objective and
noninvasive evidence that organ perfusion is adequate.
Ideally, a urimeter should be used to facilitate accurate
assessment of small urine volumes (Bowers et al., 2008).
Fluid and blood replacement therapy should be directed
at maintaining circulating volume, cardiac output, and
tissue perfusion. Fluid volume should be replaced using
normal saline or lactated Ringer’s solution at a rate of
approximately 3 mL of fluid volume for every 1 mL of
blood lost; meaning three times the fluid replacement as
the estimated blood lost (Curran, 2003; Bowers et al.,
2008).
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Blood and blood products should be administered as soon
as they are available. Blood replacement typically
includes packed red blood cells or whole blood, fresh
frozen plasma, and cryoprecipitate (Curran, 2003). Fresh
frozen plasma and cryoprecipitate are infused to replace
clotting factors that are not contained in packed red cells or
stored whole blood. Platelet replacement may be
indicated if the platelet count is less than approximately
30,000 cells/mm³ (Bowers et al., 2008).
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When bleeding persists after birth, 20–40 units of oxytocin
in 1,000 mL of fluid may be infused over a 3–4-hour
period. When bleeding and uterine atony persist, 0.2 mg of
methylergonovine, IM, may be administered to promote
uterine contraction. This drug is contraindicated in
hypertensive patients. If methylergonovine therapy fails
or is contraindicated, prostaglandin F2-alpha or
prostaglandin E2 agents may be administered IM or
instilled into the myometrium or both, depending on the
route of birth. The prostaglandins, as you'll recall, produce
uterine contractions and can be very effective in abating
uterine bleeding (ACOG, 2006; Bowers et al., 2008).
Carboprost (Hemabate) 0.2 milligrams IM may be used
every 2–4 hours. However, carboprost should not be
used in hypertensive patients. Misoprostol may be
ordered 800–1000 micrograms rectally.
Note to Instructor:
This would be a good time to review your policy and
procedures regarding the team’s interdisciplinary response
to obstetrical hemorrhage. Remember to review your
facility guidelines for administration of these medications,
because there may be variation in dosing, routes, and
timing of medication administration, depending on your
facility and clinicians’ regimens.
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Laboratory tests that are drawn during a hemorrhagic
episode include blood type and crossmatch for
administration of blood products; hemoglobin and
hematocrit values; and coagulation studies, which
usually include prothrombin time (PT), partial
thromboplastin time (PTT), fibrinogen, fibrin
degradation products (FDP), and platelets. A clot
retraction test may be a valuable first indicator of clotting
status. Blood is drawn using a plain, red-top tube and
observed for clot formation. If the blood does not clot
within 4–8 minutes, coagulopathy should be suspected and
treatment may be initiated. Arterial blood gas assessment
may be needed to determine oxygen and acid–base status
on a continuum, depending on the severity and duration of
the event (Bowers et al., 2008).
Generally, hemoglobin and hematocrit values should be
maintained at about 10 grams/dL and 30%, respectively,
with blood replacement therapy (Curran, 2003), but these
values may vary depending on individual circumstances.
Note to Instructor:
Please review your facility’s laboratory normal and
abnormal ranges for the tests described above, as these
may vary from one institution to another.
The Bakri or Ebb uterine balloons may be used to
temporarily control or reduce bleeding. Both provide a
physical tamponade of the uterine cavity. They are both
placed into the uterine cavity and inflated with fluid per the
manufacturer’s instructions.
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If bleeding continues, a surgical approach may be
needed to manage severe hemorrhage. The least invasive
or traumatic procedures are typically performed first,
depending on the cause of the uterine bleeding. Surgical
intervention may include uterine artery embolization,
uterine artery ligation, ligation of the internal iliac
(hypogastric) artery, or emergency hysterectomy if
other interventions fail (Francois & Foley, 2012).
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The period of labor and birth is an intense time for
physiologic and emotional changes. Learning about the
processes that impact labor will provide you with a strong
foundation in the nursing care of the laboring woman. It is
the nurse’s responsibility to provide physical care and
equally important — to ensure provision of emotions
support and comfort measures while promoting normal
physiologic birth processes whenever possible.
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This concludes Module III. Participants may now access
the online post test, participant feedback form, and the
CNE certificate.
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