NURS 1400 Unit 2

Theories for the Onset of Labor

• Maternal factors– Estrogen and progesterone– Prostaglandins– Oxytocin

• Fetal factors– Fetal adrenocorticotropic hormone

Fetal Factors Affecting the Process of Labor

• Head size– Molding

• Presentation– Cephalic, breech,

shoulder• Lie

– Longitudinal, oblique, transverse

• Attitude– Flexion

• Position

Fetal attitude flexion, fetal lie longitudinal

Fetal attitude flexion, fetal lie transverse

Factors Affecting Labor Progress

– The birth passageway (birth canal)– The passenger (fetus)– The physiologic forces of labor– The position of the mother– The woman’s psychosocial considerations

Passenger

• Fetal head• Fetal attitude • Fetal lie• Fetal presentation• Fetal position

Fetal Attitude

• The relation of the fetal body parts to one another (Figure 22-4)

• Normal attitude is flexion

Figure 22–4 Fetal attitude. A, The attitude (or relationship of body parts) of this fetus is normal. The head is flexed forward with the chin almost resting on the chest. The arms and legs are flexed. B, In this view, the head is tilted to the right. Although the arms are flexed, the legs are extended.

Figure 22–4 (continued) Fetal attitude. A, The attitude (or relationship of body parts) of this fetus is normal. The head is flexed forward with the chin almost resting on the chest. The arms and legs are flexed. B, In this view, the head is tilted to the right. Although the arms are flexed, the legs are extended.

Fetal Lie

• The relationship spinal column of the fetus that of the mother

• Longitudinal or transverse

Fetal Presentation

• Engagement • Station (Figure 22-7)• Ischial spines are zero station• Presenting part moves from – to +

Figure 22–7 Measuring the station of the fetal head while it is descending. In this view the station is 22/23.

Fetal Position

• Right (R) or left (L) side of the maternal pelvis• Landmark: occiput (O), mentum (M), sacrum

(S), or acromion (scapula[Sc]) process (A)• Anterior (A), posterior (P), or transverse (T)

Physiology of Labor

• Primary force is uterine muscular contractions • Secondary force is pushing during the second

stage of labor

Uterine Contractions

• Frequency• Duration• Intensity

Figure 22–9 Characteristics of uterine contractions.

Causes ofCervical Effacement

• Estrogen - Stimulates uterine muscle contractions

• Collagen fibers in the cervix are broken down • Increase in the water content of the cervix

Cervical Effacement

• Physiologic retraction ring• Upper uterine segment thickens and pulls up• Lower segment expands and thins out• Effacement

Figure 22–10 Effacement of the cervix in the primigravida. A, At the beginning of labor, there is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head. C, Cervix is about one-half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the fetal head exerts hydrostatic pressure on the cervix. D, Complete effacement and dilatation.

Figure 22–10 (continued) Effacement of the cervix in the primigravida. A, At the beginning of labor, there is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head. C, Cervix is about one-half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the fetal head exerts hydrostatic pressure on the cervix. D, Complete effacement and dilatation.

Figure 22–10 (continued) Effacement of the cervix in the primigravida. A, At the beginning of labor, there is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head. C, Cervix is about one-half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the fetal head exerts hydrostatic pressure on the cervix. D, Complete effacement and dilatation.

Figure 22–10 (continued) Effacement of the cervix in the primigravida. A, At the beginning of labor, there is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid. B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head. C, Cervix is about one-half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the fetal head exerts hydrostatic pressure on the cervix. D, Complete effacement and dilatation.

The Five Ps of Labor

• Passageway• Passenger• Powers• Position• Psychological

response

Station or relationship of the fetal presenting part to the ischial spines.

Positions of a Vertex Presentation

Leopold’s Maneuvers

• Is the fetal lie longitudinal or transverse?• What is in the fundus? Am I feeling buttocks or

head?• Where is the fetal back?• Where are the small parts or extremities?• What is in the inlet? Does it confirm what I found

in the fundus?• Is the presenting part engaged, floating, or dipping

into the inlet?

Figure 23–7 Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth maneuver first to identify the part of the fetus in the pelvic inlet.

Figure 23–7 (continued) Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth maneuver first to identify the part of the fetus in the pelvic inlet.

Figure 23–7 (continued) Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth maneuver first to identify the part of the fetus in the pelvic inlet.

Figure 23–7 (continued) Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth maneuver first to identify the part of the fetus in the pelvic inlet.

Powers of Labor

• Primary powers– Involuntary uterine

contractions• Effacement• Dilation

• Secondary powers– Voluntary pushing in

second stage

Maternal Position

• Ambulation• Lateral recumbent in

bed• Fowler’s position in bed

or chair• Birthing ball• Avoid supine position

Psychological Response of the Mother

• Culture• Expectations and goals for the labor process• Feedback from people participating in the

birth process

Signs and Symptoms of Impending Labor

• Lightening• Cervical change• Braxton Hicks contractions• Bloody show• Energy spurt• Gastrointestinal disturbances

Stages of Labor

• First stage–onset of labor to complete dilation of the cervix– Latent phase (ends with cervix 3–4 cm dilated)– Active phase (3–4 cm to 8 cm dilated)– Transition (8–10 cm dilated)

• Second stage–complete dilation to birth• Third stage–birth to placental expulsion• Fourth stage–four hours following delivery of

the placenta

True Labor

• Progressive dilatation and effacement• Regular contractions increasing in frequency,

duration, and intensity• Pain usually starts in the back and radiates to

the abdomen• Pain is not relieved by ambulation or by resting

True Labor

True Labor

True Labor

True Labor

True Labor

True Labor

False Labor

• Lack of cervical effacement and dilatation• Irregular contractions do not increase in

frequency, duration, and intensity• Contractions occur mainly in the lower

abdomen and groin• Pain may be relieved by ambulation, changes

of position, resting, or a hot bath or shower

First Stage of Labor: Latent Phase

• Beginning cervical dilatation and effacement• No evident fetal descent • Uterine contractions increase in frequency,

duration, and intensity• Contractions are usually mild

First Stage of Labor: Active Phase

• Cervical dilatation from 4 to 7 cm• Progressive fetal descent• Contractions more frequent and intense

First Stage of Labor: Transition

• Cervical dilatation from 7 to 10 cm• Progressive fetal descent• Contractions more frequent and intense

Second Stage of Labor

• Begins with complete dilatation (10 cm)• Ends with birth of the baby

Figure 22–12 Mechanisms of labor. A, B, Descent. C, Internal rotation. D, Extension. E, External rotation.

Third Stage of Labor

• From birth of infant to delivery of placenta

Fourth Stage of Labor

• 4 hours after birth• Physiologic readjustment• Thirsty and hungry• Shaking • Bladder is often hypotonic• Uterus remains contracted

Cardinal Movements of Labor

Palpation: Advantages

• Noninvasive • Readily accessible, requiring no equipment• Increases the “hands on” care of the patient • Allows the mother freedom

Palpation: Disadvantages

• Does not provide actual quantitative measure of uterine pressure

• No permanent record• Maternal size and positioning may prevent

direct palpation

External Electronic Uterine Monitoring: Advantages

• Noninvasive• Easy to place• May be used before and following rupture of

membranes• Can be used intermittently • Provides a permanent, continuous recording

External Electronic Uterine Monitoring: Disadvantages

• The nurse must compare subjective findings with monitor

• The belt may become uncomfortable• The belt may require frequent readjustment • The mother may feel inhibited to move

Internal Electronic Uterine Monitoring: Advantages

• Provides pressure measurements for contraction intensity and uterine resting tone

• Allows for very accurate timing of UCs• Provides a permanent record of the uterine

activity

Internal Electronic Uterine Monitoring: Disadvantages

• Membranes must be ruptured and adequate cervical dilation must be achieved

• Invasive • Increases the risk of uterine infection or

perforation • Contraindicated in cases with active infections • Use with a low-lying placenta can result in

placenta puncture

Figure 23–3 INTRAN Plus intrauterine pressure catheter. There is a micropressure transducer (electronic sensor) located at the tip of the catheter and a port for amnioinfusion at the distal end of the catheter. SOURCE: Photographer: Elena Dorfman.

Auscultation: Advantages

• Uses minimum instrumentation• Is portable• Allows for maximum maternal movement• Convenient and economical

Auscultation: Disadvantages

• Can only provide the baseline fetal heart rate, rhythms, and obvious increases and decreases

• Does not provide a permanent record

External Electronic Fetal Heart Monitoring: Advantages

• Produces a continuous graphic recording• Can show the baseline, baseline variability,

and changes in the FHR• Noninvasive• Does not require rupture of membranes

External Electronic Fetal Heart Monitoring: Disadvantages

• Is susceptible to interference from maternal and fetal movement

• May produce a weak signal• Tracing may become sketchy and difficult to

interpret

Internal Electronic Fetal Heart Monitoring: Advantages

• Clearer tracings• Provides information about short term

variability

Internal Electronic Fetal Heart Monitoring: Disadvantages

• Infection• Injury• Requires ruptured membranes and sufficient

cervical dilatation

Labor Induction and Augmentation

• Bishop score used to evaluate for induction• Cervical ripening methods– Dinoprostone (Prepidil, Cervidil), misoprostel

(Cytotec)

• Oxytocin (pitocin) for induction/augmentation

Labor Induction and Augmentation (continued)

• Nursing considerations– Monitor vital signs, I&O– Monitor for hyperstimulation– Monitor FHR for decelerations

Forceps-Assisted Birth

Vacuum-Assisted Birth

Systemic Responses to Labor

• Changes in cardiac output• Diaphoresis• Hyperventilation• Changes in ABG levels• Polyuria• Slight proteinuria

Systemic Responses to Labor (continued)

• Reduced gastric motility• Increased WBCs• Decreased maternal blood glucose• Pain

Fetal Adaptations

• Fetal heart rate decelerations due to intracranial pressure

• Quiet and awake state• Aware of pressure sensations

Nursing Management of Fetal Intolerance of Labor

• Normal FHR 110–160 bpm• Interventions for abnormal FHR patterns– Reposition the client– Turn off oxytocin if infusing– Increase mainline IV rate– O2 at 8–10 L/minute– Vaginal exam to rule out cord prolapse– Notify health care provider– Prepare to administer terbutaline

Analgesia in Labor

• Medications– Fentanyl (Sublimaze)– Butorphanol (Stadol)

– Nursing implications– Given too early may slow labor– Will decrease variability of the FHR– Given too late may cause respiratory depression in

the newborn

Nurse’s Role in Pain Relief

• Support decision for pharmaceutical pain relief• Offer alternative therapies if pharmaceuticals

not desired• Support changes in decision• Educate about options• Reassure that accepting medication for pain is

not failure

Systemic Analgesia

Common indications for medications

Systemic Analgesia

• Goal is to provide maximum pain relief with minimal risk

• Alteration in maternal state affects fetus

Administration of Systemic Analgesia

• When woman is uncomfortable • Well-established labor pattern • Contractions occurring regularly• Significant duration of contractions• Moderate to strong intensity

Maternal Assessments

• The woman is willing to receive medication • Vital signs are stable• Contraindications are not present• Knowledge of other medications being

administered

Fetal Assessments

• Fetal heart rate between 110 and 160 bpm• Reactive nonstress test • Short-term variability is present• Long-term variability is average

Assessment of Labor Progress

• Contraction pattern• Cervical dilatation • Fetal presenting part • Station of the fetal presenting part

Nursing Considerations

• Record the drug name, dose, route, site on EFM strip and chart

• Record the woman’s blood pressure and pulse (before and after) on the EFM strip and chart

• Safety precautions– Raising the side rails – Assessment of the FHR

Sedatives

• Use: early latent phase• Purpose: relaxation and sleep• Common medications - Seconal and Ambien

H1-receptor antagonists

• Use - Early latent phase• Purpose - Sedative, antiemetic• Common medications - Phenergan, Vistaril,

Bendadryl

Narcotics

• Use: active phase• Purpose - pain management• Common medications - Stadol, Nubain,

Demerol• Narcotic antagonist - Narcan

Regional Anesthesia

• Temporary and reversible loss of sensation• Prevents initiation and transmission of nerve

impulses• Types– Epidural– Spinal– Combined epidural-spinal

Position for Epidural Block

Epidural: Advantages

• Produces good analgesia• Woman is fully awake during labor and birth• Continuous technique allows different blocking

for each stage of labor • Dose of anesthetic agent can be adjusted

Epidural: Disadvantages

• Maternal hypotension• Postdural puncture seizures• Meningitis• Cardiorespiratory arrest• Vertigo • Onset of analgesia may not occur for up to 30

minutes

Spinal Block: Advantages

• Immediate onset of anesthesia• Relative ease of administration• Smaller drug volume• Maternal compartmentalization of the drug

Spinal Block: Disadvantages

• High incidence of hypotension• Greater potential for fetal hypoxia• Uterine tone is maintained, making

intrauterine manipulation difficult• Short acting

Combined Spinal-Epidural: Advantages

• Spinal agent has a faster onset • Medication can be added to increase the

effectiveness• Preserves motor functioning• Most drugs are used in low dose

Combined Spinal-Epidural: Disadvantages

• Higher incidence of nausea and pruritus

Pudendal

• Perineal anesthesia for the second stage of labor, birth, and episiotomy repair

• Advantages are ease of administration and absence of maternal hypotension

• Urge to bear down may be decreased

Figure 25–7 A, Pudendal block by the transvaginal approach. B, Area of perineum affected by pudendal block.

Figure 25–7 (continued) A, Pudendal block by the transvaginal approach. B, Area of perineum affected by pudendal block.

Local

• Used for episiotomy repair• Advantage is that it involves the least amount

of anesthetic agent• The major disadvantage is that large amounts

of solution must be used

Nursing Management: Prior to Administration

• Assess maternal and fetal status• Assess labor progress• Start an IV and administer preload• Help woman into position

Nursing Management: After Administration

• Monitor maternal and fetal vital signs• Assess for hypotension• Tale corrective measures for hypotension• Administer antiemetics as needed• Monitor respiratory rate• Assess bladder and catheterize if unable to

void

Complications of Epidural Anesthesia

• Toxic reactions– Unintentional placement of the drug – Excessive amount of the drug – Accidental intravascular injection

• Spinal headaches

Complications of Spinal Anesthesia

• Hypotension• Drug reaction• Total spinal neurologic sequelae• Spinal headache • Nausea, shivering, and urinary retention• Ineffective anesthesia

Complications of Pudendal Anesthesia

• Systemic toxic reaction• Broad ligament hematoma• Perforation of the rectum• Trauma to the sciatic nerve

Methods of General Anesthesia

• Intravenous injection– Sodium thiopental (Pentothal)– Ketamine

• Inhalation of anesthetic agents– Nitrous Oxide– Low-dose halogenated agents

Complications of General Anesthesia

• Fetal depression– Depth and duration

• Uterine relaxation• Potential for chemical pneumonitis– Decrease in gastrointestinal motility– Acidic gastric secretions

Contraindications

• Preterm infant– Avoid analgesia during labor

• Preeclampsia– Regional anesthesia is preferred– General anesthesia may aggravate hypertension

Contraindications (continued)

• Diabetes– Potential for decreased uteroplacental flow due to

hypotension– Increased risk of cardiovascular depression with

regional

• Cardiac– Continuous epidural avoids cardiovascular changes

with bearing down

Contraindications (continued)

• Bleeding – Regional blocks are contraindication due to

reduction in volume

Regional Analgesia and Anesthesia: Epidural

• Disadvantages– Client is confined to bed– May interfere with pushing efforts– May cause hypotension– May not be aware of the need to void

Regional Analgesia and Anesthesia: Epidural (continued)

• Nursing implications– IV bolus prior to procedure– Monitor VS, especially BP and FHR– Client must remain in bed– Assess bladder filling

Maternal Status Assessment

• Presenting complaint• EDC• Parity• Contraction pattern• Status of the membranes,

fluid color• Allergies• Bloody show• Complications during

pregnancy

Risk Factor Assessment

• Preexisting medical diseases– Diabetes, hypertension, heart disease, infections,

renal disease, anemia

• Previous poor pregnancy outcome– Perinatal mortality, preterm delivery, IUGR,

malformations, hemorrhage

Risk Factor Assessment (continued)

• Risk factors developing during the pregnancy– PIH, GDM, multiple gestation, placenta previa,

abnormal presentation, IUGR, drug exposure, smoking, alcohol use

• Inadequate maternal weight gain

Fetal Status

• Methods for monitoring– External ultrasound transducer– Fetal scalp electrode

• Fetal heart rate and pattern• Fetal heart rate response to

contractions• Presentation• Lie• Engagement (station)

Labor Status

• Methods for monitoring– External tocotransducer– Intrauterine pressure catheter (IUPC)

• Uterine activity– When contractions began– Frequency– Duration– Strength– Resting tone

Fetal Membrane Status

• Normal fluid is colorless and clear• Tests to assess rupture of the membranes– Nitrazine test, Fern test

• Risk factors– Polyhydramnios– Oligohydramnios– Meconium– PROM, PPROM– Foul-smelling fluid (chorioamnionitis)

Cervical Status and Fetal Descent• Effacement

– Thinning of the cervical canal– Expressed in %

• Dilation– Opening of the cervix– Closed to 10 cm (complete)

• Presenting part– Vertex most common

• Station– Expressed in cm above or below

the ischial spines

General Systems Assessment

• Vital signs– BP, P, R, T

• Abdomen– Rash, lesion, scars, Leopold’s maneuvers

• Bladder• Lower extremities– Edema– DTR– Clonus

Evaluation of Laboratory Tests

• Urine specimen analysis– Protein, glucose, ketones, infection

• Blood tests– Rh factor, antibodies, rubella, syphilis, hepatitis B,

HIV, glucose levels, hemoglobin

• Cultures– GBS, gonorrhea, chlamydia, herpes

Nursing Responsibilities During Labor

• Maternal assessment– Vital signs– Hydration and nutrition– Elimination

Nursing Responsibilities During Labor (continued)

• Fetal assessment– Baseline FHR– Variability– Accelerations– Periodic changes (decelerations)

• Early (head compression)• Late (placental insufficiency)• Variable (cord compression)

Interventions for Nonreassuring Fetal Heart Rate Pattern

• Change maternal position• Oxygen• Increase IV fluids• Stop pitocin• Vaginal examination to rule out cord prolapse

• Notify the primary care provider• Anticipate administration of terbutaline• Anticipate starting an amnioinfusion• Document all information

Stages and Phases of Labor

• First stage (0–10 cm dilated)– Latent phase (0–3 cm)– Active phase (4–7 cm)– Transition phase (8–10 cm)

• Second stage (10 cm to birth)• Third stage (birth to delivery of the placenta)• Fourth stage (recovery)

Labor Progress: First Stage

• Uterine assessment– Montevideo units

• Rupture of fetal membranes– Spontaneous (SROM) or artificial (AROM)– Assess FHR, color, odor, amount

• Documentation and communication• Activity

Labor Progress: First Stage (continued)

• Comfort measures• Pain management• Psychologic considerations• Friedman labor curve• Role of the support person

Labor Progress: Second Stage

• Continued assessment of contractions and fetal status

• Fetal descent assessment• Psychological considerations• Maternal positioning• Coaching maternal breathing

and pushing efforts

Preparation for Delivery

• Prepare instrument table• Adequate lighting• Oxygen and suction equipment• Radiant warmer, blankets, identification for

newborn• Pitocin available for administration after

delivery

Preparation for Delivery (continued)

• Positioning of mother for birth• Gown, gloves, and protective equipment for

personnel• Cleansing of the perineum

The Process of Birth

Crowning

Delivery of the head

Delivery of the body

Third Stage• Newborn care

– Time of birth noted– Drying, stimulation, suctioning of the newborn– Respiratory effort, heart rate, color, tone noted– One- and five-minute Apgar scores assigned– Cord blood obtained– Identification

• Delivery of the placenta– Oxytocin administered to control bleeding

• Repair of episiotomy/tears

Immediately after birth Delivery of the placenta

Applying the cord clamp Controlling maternal bleeding

Fourth Stage

• Newborn-family attachment– Family together if infant stable– Breastfeeding initiated

• Maternal status– Uterus– Lochia– Perineum– Bladder– Vital signs– Pain– Psychosocial status

Nursing Interventions: Latent Phase

• Anticipatory guidance• Encourage ambulation • Offer fluids

Nursing Interventions: Active Phase

• Palpate contractions every 15-30 minutes• Vaginal exams to assess cervical dilatation,

effacement, and fetal station and position• Encourage client to void• Assess vital signs every hour

Nursing Interventions: Active Phase (continued)

• Auscultate fetal heart rate every 30 minutes• Start IV fluid infusion if unable to tolerate

fluids• Assess color and odor of amniotic fluid and

fetal heart rate when ruptured

Nursing Interventions: Transition Phase

• Palpate contractions every 15 minutes• Sterile vaginal exams to assess labor progress• Assess maternal vital signs every 30 minutes• Assess fetal heart rate every 30 minutes• Assist with breathing• Keep woman from pushing until fully dilated

Nursing Interventions: Second Stage

• Sterile vaginal exams to assess fetal descent• Assess maternal vital signs every 5 minutes• Provide support and information about labor

progress• Assist with pushing • Assist the physician or CNM with the birth

Nursing Interventions: Third Stage

• Provide newborn care• Assist with delivery of placenta

Nursing Interventions: Fourth Stage

• Palpate fundus every 15 minutes for one hour • Assess vaginal bleeding• Encourage bonding and breastfeeding• Assess perineum• Perineal care

Figure 24–12 Suggested method of palpating the fundus of the uterus during the fourth stage. The left hand is placed just above the symphysis pubis, and gentle downward pressure is exerted. The right hand is cupped around the uterine fundus.

Comfort Measures: First Stage

• Frequent position changes• Hydrotherapy• Perineal care• Clear fluids and ice chips• Birthing balls• Provide information and support

Comfort Measures: First Stage (continued)

• Relaxation between contractions• Distraction• Effleurage• Firm pressure on back or sacrum• Visualization• Controlled breathing

Comfort Measures: Second Stage

• Same as first stage• Cool cloths• Encourage rest between contractions• Assist into pushing position • Sips of fluids or ice chips• Reassurance

Figure 24–4 A birthing ball is used to promote maternal comfort during labor. The birthing ball facilitates fetal descent and fetal rotation and helps increase the diameter of the pelvis.

Comfort Measures: Fourth Stage

• Heated blanket• Provide food• Encourage rest

Care of the Newborn

• Maintain respirations• Provide and maintain warmth• Apgar score• Physical assessment• Newborn identification• Facilitate attachment

Figure 24–11 A newborn infant being suctioned with a DeLee mucus trap to remove excess secretions from the mouth and nares. SOURCE: Photographer, Elena Dorfman.

Third Stage of Labor

• Watch for signs of placental separation• Palpate fundus• Encourage breathing and abdominal relaxation

during delivery of placenta• Possible administration of Pitocin

Facilitating Attachment

• Minimize newborn interventions• Provide privacy• Keep lights low• Facilitate parental wishes

APGAR System

Initial newborn evaluation

Forceps-Assisted Birth: Maternal Indications

• Heart disease• Acute pulmonary edema or pulmonary

compromise• Certain neurological conditions• Intrapartal infection• Prolonged second stage• Exhaustion

Figure 27–5 Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the pelvis over the parietal bone. B, The right blade is inserted along the right side wall of the pelvis over the parietal bone. C, With correct placement of the blades, the handles lock easily. During uterine contractions, traction is applied to the forceps in a downward and outward direction to follow the birth canal.

Figure 27–5 (continued) Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the pelvis over the parietal bone. B, The right blade is inserted along the right side wall of the pelvis over the parietal bone. C, With correct placement of the blades, the handles lock easily. During uterine contractions, traction is applied to the forceps in a downward and outward direction to follow the birth canal.

Figure 27–5 (continued) Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the pelvis over the parietal bone. B, The right blade is inserted along the right side wall of the pelvis over the parietal bone. C, With correct placement of the blades, the handles lock easily. During uterine contractions, traction is applied to the forceps in a downward and outward direction to follow the birth canal.

Forceps-Assisted Birth: Fetal Indications

• Premature placental separation• Prolapsed umbilical cord• Nonreassuring fetal status

Types of Forceps

• Outlet forceps• Midforceps• Breech forceps

Figure 27–4 Forceps are composed of a blade, shank, and handle and may have a cephalic and pelvic curve. (Note labels on Piper and Tucker-McLean forceps.) The blades may be fenestrated (open) or solid. The front and lateral views of these forceps illustrate differences in blades, open and closed shanks, and cephalic and pelvic curves. Elliot, Simpson, and Tucker-McLean forceps are used as outlet forceps. Kielland and Barton forceps are used for midforceps rotations. Piper forceps are used to provide traction and flexion of the aftercoming head (the head comes after the body) of a fetus in breech presentation.

Fetal Risks

• Ecchymosis, edema, or both along the sides of the face

• Caput succedaneum or cephalhematoma • Transient facial paralysis• Low Apgar scores• Retinal hemorrhage• Corneal abrasions

Fetal Risks (continued)

• Ocular trauma• Other trauma (Erb’s palsy, fractured clavicle)• Elevated neonatal bilirubin levels• Prolonged infant hospital stay

Maternal Risks

• Lacerations of the birth canal• Periurethral lacerations• Extension of a median episiotomy into the anus• More likely to have a third- or fourth-degree

laceration • Report more perineal pain and sexual problems

in the postpartum period • Postpartum infections

Maternal Risks (continued)

• Cervical lacerations• Prolonged hospital stay• Urinary and rectal incontinence• Anal sphincter injury • Postpartum metritis

Nursing Management

• Explains procedure to woman• Monitors contractions• Informs physician/CNM of contraction• Encourages woman to avoid pushing during

contraction• Assessment of mother and her newborn• Reassurance

Indications for Vacuum Extraction

• Prolonged second stage of labor• Nonreassuring heart rate pattern• Used to relieve the woman of pushing effort• When analgesia or fatigue interfere with ability

to push effectively• Borderline CPD

Vacuum Extraction Procedure

• Procedure– Suction cup placed on fetal occiput– Pump is used to create suction– Traction is applied– Fetal head should descend with each contraction

Figure 27–6 Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, Traction is maintained to lift the fetal head out of the vagina.

Figure 27–6 (continued) Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, Traction is maintained to lift the fetal head out of the vagina.

Figure 27–6 (continued) Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, Traction is maintained to lift the fetal head out of the vagina.

Nursing Management

• Inform woman about procedure• Pumps the vacuum• Supports the woman• Assesses the mother and neonate for

complications

Neonatal Risks with Vacuum Extraction

• Scalp lacerations and bruising• Shoulder dystocia• Subgaleal hematomas• Cephalhematomas• Intracranial hemorrhages• Subconjunctival hemorrhages

Neonatal Risks with Vacuum Extraction (continued)

• Neonatal jaundice• Fractured clavicle• Erb’s palsy• Damage to the sixth and seventh cranial

nerves• Retinal hemorrhage• Fetal death

Maternal Risks with Vacuum Extraction

• Perineal trauma• Edema• Third- and fourth-degree lacerations• Postpartum pain• Infection • More sexual difficulties in the postpartum

period

Indications for Cesarean Birth

• Complete placenta previa• CPD• Placental abruption• Active genital herpes• Umbilical cord prolapse• Failure to progress in labor

Indications for Cesarean Birth (continued)

• Proven nonreassuring fetal status• Benign and malignant tumors that obstruct the

birth canal• Breech presentation• Previous cesarean birth• Major congenital anomalies• Cervical cerclage

Indications for Cesarean Birth (continued)

• Severe Rh isoimmunization• Maternal preference for cesarean birth