Precipitous Labor and Delivery

Precipitous labor means the labor that lasting less than three hours.

Nursing Interventions:

• Provide emotional support to calm mother
• Stay with the mother
• Encourage the mother to pant between contractions
• Prepare for rupturing membranes when the head crowns
• Do not try to keep fetus from being delivered

Interventions if Delivery is Necessary:

• Apply gentle pressure to fetal head upward toward the vagina to prevent damage to the fetal head and vaginal lacerations
• Support infant's body during delivery
• Deliver the infant between contractions and check for the cord around the neck
• Use restitution to deliver the posterior shoulder
• Use gentle downward pressure to move the anterior shoulder under the pubic symphysis
• Clear the infant's mouth
• Dry and cover the infant to keep the body warm
• Let the placenta separate naturally
• Place the infant on the mother's abdomen or breast to induce uterine contractions

Propalse Cord

Prolapse cord is displacement of umbilical cord between the presenting part and the amnion or protruding through the cervix. It causes compression of the cord and compromise fetal circulation.

Signs and Symptoms:

• Umbilical cord is visible or palpable
• Mother has feeling that something is coming through the vagina
• Fetal heart rate is irregular and slow
• Variable deceleration or bradycardia after rupture of the membranes
• Violent fetal activity may occur and then cease if fetal hypoxia is severe

Nursing Interventions:

• Relieve umbilical cord immediately
• Reposition mother: turn her side to side or elevate her hips to shift the fetal presenting part toward her diaphragm
• Apply finger pressure with a sterile glove hand to elevate fetal presenting part that is lying on the cord
• Do not attempt to push the cord into the uterus
• Assess fetus for hypoxia
• Prepare for emergency cesarean birth
• Administer oxygen by face mask to the mother as prescribed

Distocia

Dystocia means prolonged or more painful labor. It can caused by uterine contractions, the fetus, or the bones and tissue of the maternal pelvis, large fetus, malpositioned, or abnormal presentation.

The contraction may be hypertonic or hypotonic. Dystocia can cause maternal dehydration, infection, and fetal injury or death.

Sign and Symptoms:

• Contraction pattern is abnormal
• Abdominal pain
• Fetal distress
• Lack of progress in labor
• Maternal or fetal tachycardia

Nursing Intervention:

• Assess and monitor fetal heart rate and fetal distress
• Monitor maternal temperature and heart rate
• Monitor uterine contraction
• Assist with pelvic examination, measurement, ultrasound or other procedures
• Administer antibiotic and IV fluid as prescribed
• Monitor intake and output
• Assess for dehydration
• Monitor color of amniotic fluid
• Teach mother in breathing and relaxing techniques
• Provide good rest and comforts
• Assess for prolapse of the cord

Fetal Heart Rate Monitoring

Fetal monitoring is the way to displays the fetal heart rate (FHR). Fetal heart rate is monitored in relation to maternal contraction. The baseline FHR is measured between contraction and the normal FHR at term is 120-160 beats per minute. The device that monitors uterine activity can assess frequency, duration and intensity of contractions.

There are two types of fetal monitoring: external fetal monitoring and external fetal monitoring.

External Fetal Monitoring
It is noninvasive procedure and is performed using a tocotransducer or Doppler ultrasonic tranducer. The ultrasound transducer is placed over the area in which the fetal back is located and fasten with a belt. The tocotransducer is placed over the fundus of uterus where contractions feel stronger and fasten with a belt. This external fetal monitoring will allow the client to get position comfortably.


Internal Fetal Monitoring It is invasive procedure and requires rupturing of the membranes and the electrode is attached to the presenting part of the fetus. For being available of internal fetal monitoring, the mother must be dilated 2-3 cm.

FETAL HEART RATE PATTERN

Fetal Bradycardia:
The FHR is less than 120 beats per minute for 10 minutes of more

Fetal Tachycardia:
The FHR is greater than 160 beats per minute for 10 minutes or more.

Acceleration
Accelerations are temporary increases of FHR at least 15 beats greater than the baseline and lasting at least 15 seconds, reflect a responsive nonacidotic fetus. Acceleration may occur with fetal movement, uterine contraction, vaginal examinations, or when the fetus is in a breech presentation.

Early Decelerations
In early decelerations, the fetal heart rate is below baseline and return to the baseline by the end of the contraction. It usually occurs during contractions and not associated with fetal compromise and requires no interventions. A uniform shape and mirror image of uterine contraction are showed.

Late Decelerations
In late decelerations, the fetal heart rate looks similar to early deceleration but begin well after the contraction begins and return to baseline after the contraction ends. Late decelerations reflect impaired placental exchange or uteroplacental insufficiency. The intervention includes improving placental blood flow and fetal oxygenation by placing patient on side, administer oxygen by tight face mask, discontinue oxytocin (if any), hydration, and correct hypertension (if any).

Variable Deceleration
In variable decelerations, the fetal heart rate does not have the uniform appearance. Shape, duration and degree of FHR fall below baseline are variable. Variable decelerations are significant when the FHR repeatedly decreases to less than 7- beats per minutes and persists at the level for at least 60 seconds before returning to the baseline. The cause of variable decelerations is the conditions that restrict flow through the umbilical cord (compressed umbilical cord). Interventions include change position (trendelenburg may be helpful), discontinue oxytocin (if any), check for cord prolapsed or imminent delivery by vaginal exam, consider amnioinfusion, and administer 100% oxygen by tight face mask.

Breathing in Labor

Breathing technique during labor and delivery will promote relaxation and oxygenation.

FIRST STAGE LABOR BREATHING

Cleancing Breath
Each contraction begins and ends with a deep inspiration and expiration.

Slow Paced Breathing
It is used as long as possible during labor, and promotes relaxation

Modified Paced Breathing
Breathing is shallow and fast, and it is used when slow paced breathing is no longer effective.
Pattern Paced Breathing (pant blow)
After a certain number of breaths, the client exhales with a slight emphasis or blow, and then begins the modified paced breathing.


Breathing to Prevent Pushing
Encourage client to blow repeatedly using short puffs when the urge to push is strong.

SECOND STAGE LABOR BREATHING

Traditional Pushing
The client takes on or more cleansing breaths at the beginning of a contraction and then hold it, pushing as hard as she can for as long as possible. Then quickly exhales, takes another breath and pushes again, repeating the process until the contraction is over.

Other Pushing Methods
The client exhales small amounts of air through an open glottis during pushing.
The client pushes in short bursts only when the urge is strong instead of using prolonged expulsive efforts.

Leopold’s Maneuvers

Leopold’s Maneuvers are methods to determine position, presentation and engagement of fetus.

They will include:

1. Determination of what is in the fundus
2. Evaluation of the fetal back and extremities
3. Palpation of the presenting part above the symphysis, and
4. Determination of the direction and degree of flexion of the head.

How to Perform Leopold’s Maneuver

Before performing Leopold’s Maneuver, ask the mother to empty the bladder, warm hands, and apply them to the mother’s abdomen with firm and gently pressure.

First Leopold’s Maneuver:

1. It will determine which part of the fetus is in the fundus.
2. Place pals on each side of the upper abdomen and palpate around the fundus
3. You would feel a hard, round, movable object if the head is in the fundus
4. You would feel soft and have an irregular shape and are more difficult to move if the buttock is in the fundus

Second Leopold’s Maneuver:

1. Move hand downward over each side of the abdomen, applying firm, even pressure.
2. The fetus’s back which is a smooth, hard surface should be felt on one side of the abdomen.
3. The hands, feet, elbows, and knees which are as irregular knobs and lumps will be felt on the opposite side of the abdomen.

Third Leopold’s Maneuver:

1. It will determine fetal position
2. Place hand above the symphysis pubis
3. Bring thumb and fingers together and grasp the part of fetus between them that may be the head or the buttocks

Fourth Leopold’s Maneuver:

1. It is used in the late stage of pregnancy to determine how far the fetus has descended into the pelvic inlet.
2. Place hand on the sides of the lower abdomen close to the midline
3. Slide hands downward and press inward
4. If you have determined that the buttocks are in the fundus, then feel for the head
5. If you cannot feel the head, it probably has descended

Mechanism of Labor

There are eight classical steps in the normal mechanism of labor as following here:

Engagement

• This is also called lightening or dropping
• The fetus nestles into the pelvis

Descent

• This process starts from the time of engagement until birth and is assessed by the station.
• The fetal head undergoes as it begins its journey through the pelvis.

Flexion

• The fetal head’s nodding forward toward the fetal chest
• While descending through the pelvis, the fetal head flexes so that the fetal chin is touching the fetal chest. This functionally creates a smaller structure to pass through the maternal pelvis

Internal Rotation

• With further descent, the occiput rotates anteriorly and the fetal head assumes an oblique orientation. In some cases, the head may rotate completely to the occiput anterior position.

Extension

• It begins after the head crowns
• This means that the fetal chin is no longer touching the fetal chest.
• It enables the head to emerge when the fetus is in a cephalic position
• The extension of labor is completed when the head passes under the symphysis pubis and occiput and the anterior fontanel, brow, face and chin pass over the sacrum and coccyx and are over the perineum

Restitution

• After the head emerges, the fetal head becomes in a realignment

External Rotation

• The shoulder of fetus externally rotates after head emerging and restitution
  
• The shoulder is in the anteroposterior diameter of the pelvis.

Expulsion

• This is the birth of entire body.