Chapter 24: Labor and Delivery and Associated Complications

Welcome to Last Minute Lecture.

This free chapter overview is designed to help students review and understand key concepts.

These summaries supplement, not replace, the original textbook and may not be redistributed or resold.

For complete coverage, always consult the official text.

It's really quite incredible when you think about it, isn't it, bringing new life into the world?

Absolutely.

The whole process.

Yeah, just the sheer power, the complexity.

It demands so much resilience.

Right.

And it unfolds through this cascade of events.

Exactly.

And that's what we're diving into today, labor and delivery.

We are.

We're going to be looking at it pretty comprehensively using the Saunders Comprehensive Review for the NCLE -XPN Examination, the seventh edition.

Right.

The labor and delivery and associated complications chapter specifically.

That's the one.

Think of this as getting you straight to the core understanding.

So our mission for you, the learner, is really to break down the key concepts, the procedures, potential complications.

Yeah.

Basically give you a clear roadmap.

Exactly.

So you feel informed, prepared, and not bogged down by too much jargon without explanation.

We'll cover the stages,

fetal monitoring, pain management, complications, and really importantly, those key nursing actions.

All the essentials.

All right.

Let's jump in.

So clinically speaking, what is labor and delivery?

Well, fundamentally, labor is this series of coordinated involuntary uterine contractions.

Rhythmic ones, right?

Rhythmic, yes.

And they lead to the cervix thinning out and opening up.

Delivery is then the culmination, the birth of the baby, and then the placenta.

Got it.

And the chapter talks about the four P's.

These seem pretty fundamental.

They really are.

You can't look at labor without considering these four interconnected factors.

Powers, passageway, passenger, and psyche.

Interconnected, that's key.

They all influence each other.

Absolutely.

It's like a delicate balance between all four for a safe birth.

Okay.

Let's break them down.

First up, powers.

What forces are we talking about?

Powers primarily means the uterine contractions.

They're the engine basically pushing the fetus and placenta out.

And these contractions do more than just push, right?

Especially early on.

Definitely.

In the first stage, they're also responsible for effacement and dilation of the cervix.

Two really common terms.

Can you explain effacement first?

Sure.

Effacement is the shortening and thinning of the cervix.

Think of it like a thick bottleneck getting shorter and thinner.

Okay.

Thinning out.

And dilation.

Dilation is the opening, the enlargement, of the cervical opening, the oz, and the canal itself.

It goes from closed up to about 10 centimeters.

Which is what's needed for the baby to pass through.

Exactly.

Fully dilated.

And do the powers change later in labor?

Yes.

In the second stage, you add the mother's pushing efforts.

That voluntary pushing, combined with the contractions, becomes a really significant force.

Makes sense.

Okay.

Second P, passageway.

What constitutes the route?

The passageway is made up of the mother's bony pelvis, that's the hard structure, and then the soft tissues.

Soft tissues like?

Like the cervix itself, the muscles of the pelvic floor, the vagina, and the vaginal opening, the introitus.

They all have to stretch and accommodate.

Right.

They need to be adaptable.

Then we have the passenger, obviously the baby,

but it's more than just the fetus.

Correct.

The passenger includes the fetus, yes, but also the amniotic membranes, the sac and fluid, and the placenta.

And things like the baby's size and position matter here, too.

Huge factors.

Also, how the membranes are holding up, how the placenta is working.

It all plays into the passenger aspect.

Okay.

And the last P, psyche.

This one focuses on the mother's emotional state.

How significant is that?

It's incredibly significant.

A woman's feelings, anxiety, fear, calm, confidence, can really impact the physiology of labor.

How so?

Well, high anxiety can increase tension, maybe even slow things down.

Feeling supported and calm can often lead to a more efficient, less stressful labor.

That mind -body connection is powerful.

Definitely.

Okay, so those are the four Ps.

Now the chapter digs deeper into the passenger, the fetus.

Let's start with attitude.

Not the baby's mood, I assume.

No, definitely not.

A fetal attitude is about how the baby's body parts are related to each other.

Like how flexed or extended they are.

Exactly.

The normal and best attitude is flexion.

The back is rounded, head tucked down with the chin near the chest, arms and legs pulled in.

Kind of curled up tightly.

Why is that best?

Because it presents the smallest diameter of the head to the pelvis, making passage easier.

And the opposite.

Extension.

Right.

If the head is tilted back, for example, that presents a larger diameter.

It can make labor harder, potentially leading to a more difficult delivery.

Okay.

Next concept.

Lie.

How the baby is oriented overall.

Precisely.

Fetal lie compares the baby's spine to the mother's spine.

So parallel or perpendicular?

Those are the main ones.

Longitudinal or vertical lie means the spines are parallel.

This could be a head -first, cephalic or butt -first preach presentation.

Any other way?

That's transverse or horizontal lie.

The baby's spine is at a right angle to the mother's.

Here, the shoulder usually presents first.

And that means?

Usually means a cesarean section is needed.

Vaginal birth isn't typically possible in a stable transverse lie.

Okay.

That leads us to presentation.

Which part is coming out first?

Exactly.

Presentation is the part of the fetus lowest in the abdomen ready to enter the pelvis.

Cephalic head -first is the most common and usually the easiest.

Are there variations within head -first?

Yes.

The best is vertex, where the head is down and chin tucked.

Smallest diameter.

But you can also have military, where the head isn't flexed or extended, brow presentation or even face presentation.

And then there's breach, which sounds more complicated.

It can be.

Breach means the buttocks or feet are presenting first.

There's a higher risk of complications, so cesarean is often the safer route, though vaginal breach is sometimes possible with experienced providers.

What are the types of breach?

You have frank breach, where the legs are straight up by the head, complete breach, where knees and hips are flexed, like sitting cross -legged, and footling breach, where one or both feet are below the buttocks.

And if it's neither head nor butt first?

That would be a shoulder presentation, linked to that transverse lie we mentioned.

Unless the baby turns, somehow it's a cesarean delivery.

Okay.

So presentation is the general part.

What about presenting part?

Is that more specific?

Yes.

It's the specific fetal structure closest to the cervix that you'd feel on a vaginal exam.

Like the back of the head in a vertex presentation.

Exactly.

The occiput or the sacrum, the tailbone area in a frank breach.

It gives a more precise picture of orientation.

Which then leads to position.

How does that add to the picture?

Position relates that presenting part, like the occiput or sacrum, to the mother's pelvis,

specifically to the four quadrants.

Left anterior, right anterior, left posterior, right posterior.

Can you give an example?

Sure.

A common favorable position is LOA left occiput anterior.

That means the back of the baby's head, occiput, is facing the mother's left front side.

LSA would be left sacroenterior for a breach.

It helps predict how labor might go.

Got it.

And finally, station.

This sounds like it measures progress downwards.

That's exactly what it is.

Station measures how far the presenting part has descended into the pelvis relative to the ischial spines.

Those are bony landmarks in the mid -pelvis.

Right.

That level is considered zero station.

So what do the plus and minus numbers mean?

Minus stations, like MEDIC -1, MEDIC -2, plus 3, mean the presenting part is still above the spines, measured in centimeters.

Plus stations, plus 1, plus 2, plus 3, mean it's descended below the spines.

And what's engagement?

Engagement is when the widest part of the presenting part has passed through the pelvic inlet.

That usually corresponds to zero station.

As labor goes on, the station becomes more positive.

Plus 4 or plus 5 is basically crowning.

Wow.

Okay.

That's a lot of detail about the passenger.

Yeah.

Now, as labor gets closer, what signs might someone notice?

The chapter calls it data collection.

Signs preceding labor.

Yes.

There are several clues.

One is lightning or dropping, that's the baby settling into the pelvis, or engagement.

Which happens maybe a couple weeks before in first -time moms.

Often, yes.

Mom might feel like she can breathe easier, but might have more pelvic pressure or need to pee more often.

What else might happen?

Braxton -Hicks contractions, those practice ones might get more frequent or stronger.

But not necessarily regular or painful yet.

Right.

Also, vaginal discharge might increase, and the mucus plug, that collection of mucus blocking the cervix, might come out.

It can be clear, brownish, or slightly blood -tinged.

The bloody show.

That term is often used for it, yes.

It means the cervix is starting to change to ripen.

Ripen, meaning soften and maybe start to efface or dilate a little.

Exactly.

And interestingly, some women get this sudden burst of energy about 24 to 48 hours before labor starts.

The nesting instinct.

I've heard of that.

A sudden urge to clean and organize everything.

Yep.

And there might be a slight weight loss, maybe one to three pounds, from fluid shifts due to hormone changes.

And the most definitive sign.

Probably the spontaneous rupture of membranes, the water breaking.

Could be a gush or a trickle.

Now, distinguishing true labor from false labor can be tricky.

How does the chapter differentiate them?

That's a key point.

True labor has contractions that become regular, stronger, last longer, and get closer together over time.

And crucially.

Crucially, they cause progressive cervical change dilation and effacement and fetal descent.

The pain might start in the back and wrap around like strong cramps.

And false labor.

Or prodromal labor.

False labor contractions are usually irregular.

They don't get stronger or closer together consistently.

And they don't change the cervix.

Right.

No progressive dilation or effacement.

Often felt more in the abdomen or groin.

And they might stop if you walk around or change position.

True labor usually keeps going or gets stronger with activity.

Okay, that distinction is helpful.

So once labor seems to be starting, how do providers figure out the baby's exact position?

That's Leopold's maneuvers, right?

Correct.

Leopold's maneuvers are a set of four specific ways to palpate or feel the mother's abdomen to determine the baby's presentation, lie, and position.

And it helps find the heartbeat, too.

Yes.

It helps locate the best spot to listen to the fetal heart sounds.

So what are the steps?

What are you feeling for?

Okay, the first maneuver, you feel the top of the uterus, the fundus.

Is it the head firm, round, movable?

Or the breech, softer, less regular, harder to move on its own.

Okay.

And the second?

You feel the sides of the abdomen.

One side should feel smooth and hard.

That's the back.

The other side will feel more irregular, knobby.

Those are the limbs, the small parts.

Got it.

What about the third and fourth maneuvers?

Third maneuver, you grasp the lower part of the abdomen just above the pubic bone.

Is the presenting part engaged?

If it's not engaged, you can wiggle it.

To have the fourth?

For the fourth, you face the mother's feet and use your fingertips to feel just above the pelvic inlet again.

This helps figure out the fetal attitude, how flexed the head is.

So it's a hands -on map of the baby's position.

Now, shifting gears to comfort and pain management.

Breathing techniques, how do they actually help?

They work in a few ways.

They give the mother something to focus on during contractions, which can actually distract from the pain signals.

Like interrupting the pain pathway.

Sort of, yeah.

Plus, controlled breathing promotes relaxation, reduces muscle tension, and importantly, ensures good oxygen supply for both mom and baby.

Are there different breathing patterns for different stages of labor?

Yes.

Typically, women learn of progression.

Early labor might use slow, deep breaths.

As things intensify, maybe faster, shallower breathing, modified pace.

And during the really intense part of pushing?

Sometimes pattern breathing, like a hee -hee -hoo or a pant blow rhythm, can help during transition.

And specific techniques for pushing help optimize effort without holding the breath too long, which can decrease oxygen to the baby.

Makes sense.

Alongside breathing, we have fetal monitoring.

This is constant during labor, right?

What key information does it give us?

Absolutely crucial.

It tracks the fetal heart rate, FHR, and the mother's contractions frequency and duration.

Seeing how the FHR responds to the contractions tells us how the baby is coping.

And it establishes a baseline SHR.

Yes.

The average rate between contractions, normally 110 to 160 beats per minute at term.

What are the main ways to monitor?

External versus internal?

External is non -invasive.

You use two belts around the mom's abdomen.

One has a TOCO transducer over the fundus to pick up contractions.

Frequency and duration, but not intensity, right?

Exactly.

The other belt has an ultrasound transducer placed usually over the baby's back after doing Leopold's to get the FHR.

And positioning is important here.

Very.

Need to avoid lying flat on the back to prevent vena cava compression.

Side lying is often preferred because it helps placental blood flow.

Okay.

And internal monitoring.

More invasive.

Yes.

It requires the membranes to be ruptured and the cervix to be dilated a bit.

Usually two to three centimeters.

How does it work?

A small electrode is attached directly to the baby's scalp for a very precise FHR.

And an intrauterine pressure catheter, an IUPC, can be inserted into the uterus to measure the exact pressure, the intensity of contractions.

So it gives more accurate data, but it's not always necessary.

Right.

It's used when the external trace isn't clear or if more precise info is needed.

When looking at the FHR patterns, what specific changes signal potential stress?

Let's talk about periodic patterns.

bradycardia and tachycardia first.

Fetal bradycardia is a heart rate below 110 for 10 minutes or more.

Tachycardia is above 160 for 10 minutes or more.

Both are concerning.

Both can be, yes.

They require immediate action, change mom's position, give oxygen, check her vital signs, especially temperature for tachycardia, and notify the RN and provider right away.

What about variability?

Why is that important?

Variability means the small fluctuations beat to beat in the baseline FHR.

It shows the nervous system is working well.

Good variability is reassuring.

And decreased variability.

Decreased or absent variability is non -reassuring.

It could mean fetal hypoxemia, acidosis, or effects from certain drugs.

Though a temporary decrease can happen if the baby is just asleep, usually for less than 30 minutes.

Got it.

Accelerations, those are good, right?

Generally yes.

Accelerations are brief increases in the FHR, at least 15 beats above baseline for at least 15 seconds.

They often happen with fetal movement and show the baby is responsive and not acidotic.

Okay.

Now for the decelerations.

Early, late, and variable.

Let's start with early decels.

Early decelerations mirror the contraction.

They start when the contraction starts, the lowest point is at the peak of the contraction, and they're back to baseline by the end.

What causes them?

Usually head compression as the baby moves down.

They're generally considered benign, not associated with fetal compromise, and don't typically need intervention.

Okay.

What about late decelerations?

They sound more serious.

They are.

Late decels are non -reassuring.

They signal utero placental insufficiency.

The baby isn't getting enough oxygen through the placenta.

How do they look on the monitor?

They also have a gradual onset, but they start after the contraction begins, the lowest point is after the peak, and they don't recover until after the contraction ends.

And the priority is?

Immediately improve placental blood flow and oxygenation.

We'll get to those specific interventions.

Okay.

And the third type,

variable decelerations.

Variable decels are abrupt drops in the FHR.

They look like a U, V, or W shape on the tracing, and can happen at any time relative to contractions.

What's the cause here?

Usually, umbilical cord compression could be low fluid, cord around the neck, baby's position.

Are they always bad?

Not always.

Depends on how deep and long they are and the baseline variability.

They become significant if the FHR drops below 70 for over 60 seconds repeatedly.

And interventions would focus on relieving cord compression.

Exactly.

Position change is key.

Also oxygen, maybe stopping oxytocin, checking vitals, notifying the provider.

Sometimes an amnioinfusion might be ordered to cushion the cord.

The chapter also mentions hypertonic uterine activity.

What's that?

That's when contractions are too frequent, less than two minutes apart, last too long over 90 seconds, or the uterus doesn't relax enough between them.

The resting tone is too high.

Why is that a problem?

Because it reduces blood flow to the placenta, cutting down the baby's oxygen supply.

It can lead to fetal distress.

Normal resting tone should be low, allowing the uterus to refill with blood.

So the chapter summarizes these issues as non -reassuring FHR patterns.

Yes, it lists things like bradycardia, tachycardia, late D cells, prolonged D cells, severe variables, decreased variability, and that hypertonic activity.

All red flags.

And when these happen, what are the absolute priority nursing actions?

Okay, first, call the RN and stay with the patient.

Try to figure out the cause.

Stop oxytocin if it's running.

Change the mother's position, usually side -lying.

Give oxygen 8 -10 liters by mask.

Increase 5E fluids.

Get ready for internal monitoring if needed.

And prepare for a possible C -section if things don't improve.

And document everything meticulously.

Got it.

Critical steps.

Okay, let's move through the actual stages of labor.

Stage one is the longest, right?

And it has phases.

Correct.

Stage one goes from the start of regular contractions to full cervical dilation.

Zero to four centimeter dilation.

Contractions are usually mild, maybe 15 -30 minutes apart, lasting 15 -30 seconds.

It can take a while.

And nursing care here?

Focuses on support, comfort measures like position changes, walking if she wants, keeping her informed, offering fluid -sized chips, and encouraging her to empty her bladder regularly.

Then comes the active phase.

Active phase is typically four to seven centimeter dilation.

Contractions get stronger, more frequent every three to five minutes, lasting 30 -60 seconds, moderate intensity.

How does nursing care change?

Encourage breathing techniques, keep the environment calm, continue updates, comfort measures like back rubs, sacral pressure, pillows for positioning,

oral care, fluids.

Maybe teach the partner effleur's light abdominal stroking.

Still encouraging voiding.

And the transition phase sounds intense.

It usually is.

This is eight to ten centimeter dilation.

Contractions are strong, close together every two, three minutes, lasting 45 -90 seconds.

Mom might feel shaky, nauseous, or have an urge to push before it's time.

What's the focus for nursing care, then?

Lots of encouragement.

Help her rest between contractions, but remind her to breathe when one starts.

Provide privacy, keep up with comfort measures, fluids, ice chips, lip balm, and keep reminding her to empty her bladder.

Are there key nursing tasks throughout all of stage one?

Absolutely.

Monitor mom's vital signs regularly,

monitor the FHR continuously or intermittently, always checking before, during, and after contractions.

Monitor the contractions themselves, frequency, duration, intensity by palpation or external monitor.

Assess cervical progress via vaginal exams as ordered.

Check fetal station and position.

Assist with tests like nitrazine or fern test if water breaking is suspected.

And if the membranes rupture, what's the immediate priority?

Check the fetal heart rate immediately.

Risk of cord prolapse is highest right then.

After checking FHR, assess the amniotic fluid color odor amount.

Look for meconium.

Okay.

Stage one gets us to 10 centimeters.

What's stage two?

Stage two is from complete dilation until the baby is born.

This is the pushing stage.

What are the signs?

Cervix is fully dilated.

Baby descends, further station changes.

Contractions are strong every two, three minutes, 60, 75 seconds long.

Increase in bloody show.

Mom usually feels an overwhelming urge to bear down.

Nursing care must be very focused here.

Very.

Assessments every five minutes.

Monitor mom's vitals, FHR, contractions.

Provide lots of encouragement and praise.

Help her rest between pushes.

Keep her informed.

Privacy.

Comfort measures like ice chips, lip balm.

And helping with pushing positions.

Yes.

Assist her into positions that are comfortable and effective for her lithotomy.

Semi -sitting, sideline, squatting, kneeling.

Monitor for signs of imminent birth, perineal bulging, crowning.

And prepare the delivery setup.

Baby's born.

Now stage three.

What happens here?

Stage three is from the baby's birth until the placenta is delivered.

Usually takes five to 30 minutes.

Contractions continue.

Yes, milder ones to help the placenta detach and expel.

We watch for signs of separation, a gush of blood, the cord lengthening, the uterus changing shape.

Nursing interventions.

Monitor mom's vitals and uterine status closely.

Explain placental expulsion.

Check that the fundus is firm and midline after delivery, usually below the umbilicus.

Examine the delivered placenta.

Make sure it's intact.

All lobes, cotyledons are there.

Membranes look complete.

Check the cord for two arteries in one vein.

Keep mom warm if she's shivering.

And really importantly, promote that early skin -to -skin contact and bonding.

And the final stage, stage four.

Stage four is the immediate recovery period.

The first one to four hours after delivery, the body starts stabilizing.

What are the key assessments?

Blood pressure should return to pre -labor levels.

Pulse might be a bit lower.

Fundus should stay firm, midline, one to two finger breaths below the umbilicus.

Locea, the vaginal discharge should be moderate.

Red, locea rubra.

How often are checks done?

Frequently at first, typically every 15 minutes for the first hour, then every 30 for the next hour, then hourly for two hours or per facility policy.

Other interventions in stage four.

Provide warm blankets, ice packs to the perineum for swelling pain.

Assess the fundus regularly and massage if boggy.

Teach mom how to do this too.

Support breastfeeding initiation.

All right.

Let's shift to anesthesia options.

Local anesthesia.

What's that used for?

Local is usually just for numbing the perineum right before birth, mainly for an episiotomy or repairing tears.

No real effect on the baby.

Then the epidural, the lumbar epidural block.

Very calm.

Very.

It's an infusion of anesthetic and or pain medicine into the epidural space in the lower back, usually L3, L4.

When is it given?

After labor is established or before a scheduled C -section, it relieves contraction pain, numbs the vagina and perineum.

Any downsides or side effects?

Potential for maternal hypotension, low blood pressure, bladder distension because sensation is reduced.

It might prolong the second stage slightly, but typically no spinal headache because the dura isn't punctured.

Nursing care for epidurals.

Monitor BP frequently.

Assess the bladder.

Keep mom positioned on her side or with a hip wedge to avoid vena cava compression.

Administer the fee fluids as ordered.

Watch for side effects like nausea, itching, or respiratory depression if opioids are used.

What about intrathecal opioids?

Different from an epidural?

Yes, it's an injection directly into the subarachnoid space.

Rapid onset pain relief, but shorter duration than an epidural can be used alone or with an epidural.

And a subarachnoid or spinal block?

That's also an injection into the subarachnoid space, L3, L5, usually given right before birth, especially for C -sections.

What kind of relief does it provide?

Numbs from about the navel down, uterus, perineum, legs, very effective.

Side effects.

Maternal hypotension is common.

And there's a risk of that post -dural puncture headache, the spinal headache.

Often worse when upright, better lying flat.

So keeping flat for 8 -12 hours post -procedure is typical.

4V fluids help too.

And general anesthesia, when is that used?

Usually only for emergency C -sections or certain surgical situations where a regional isn't possible or fast enough.

The mother is completely asleep.

What are the risks?

Risk of respiratory depression for both mom and baby, maternal vomiting, and aspiration.

It requires careful airway management.

Okay.

Moving on to obstetrical procedures.

What's the Bishop's score?

The Bishop's score assesses cervical readiness for induction.

It looks at dilation, effacement, consistency, position, and fetal station.

How does the score work?

Each factor gets 0 or 3 points.

A total score of 6 or more usually means the cervix is ripe or favorable for induction.

Speaking of induction deliberately starting labor, when is that done?

Various reasons.

Post -term pregnancy, ruptured membranes without labor starting.

Certain maternal health conditions like preeclampsia or diabetes.

Fetal concerns like growth restriction,

sometimes elective induction.

How is it typically done?

Often with oxytocin infusion.

You get a baseline FHR and contraction tracing first, then start oxytocin IV, increasing the dose gradually based on uterine response and fetal tolerance.

What's the goal contraction pattern?

Usually contractions every 2 -3 minutes lasting about 60 seconds.

Once that's achieved, you don't increase the dose further.

When would you stop the oxytocin?

Immediately if contractions are too close, less than 2 minutes or it lasts too long, over 90 sec, or if there's any sign of fetal distress.

Another procedure is amniotomy artificially breaking the water.

Right.

AROM.

Done by the provider to stimulate labor, usually when the baby's head is well down, a zero station or lower.

What are the risks?

Main risks are prolapsed cord and infection.

So key nursing actions after AROM.

Check FHR immediately before and after.

Record the time, FHR and fluid characteristics, color, meconium, odor amount.

Be aware that variable D cells might increase due to potential cord compression.

Activity might be limited.

What about external cephalic version or ECV?

That's trying to turn a breech or transverse baby to a head -down position by manipulating through the mom's abdomen.

Usually done after 34 weeks.

What's involved?

Monitor mom's vitals.

Ensure Rh negative mom's got row D.

Often do a non -stress test before.

May use IV fluids and a tocolytic to relax the uterus.

It's done under ultrasound guidance.

What do you monitor for during and after?

During.

Vena Cava syndrome.

Pain.

After.

Another NST.

Uterine activity.

Bleeding.

Ruptured membranes.

Fetal movement.

Check Klyhauer -Betka test and Rh negative moms if ordered.

A pesiotomy, that incision.

Use has declined, right?

Yes, significantly.

Not done routinely anymore.

But if one is done, what's the care?

Assess the site using RETA, redness, edema, ecumosis, discharge approximation.

Pain relief.

Eyes first 24 hours, then sits baths.

Analgesics, pre -emptment if ordered.

Proper perineal care front to back, blot dry.

Report excess bleeding or discharge.

Forceps and vacuum extraction assisted delivery tools.

Let's start with forceps.

Spoon -like blades applied to the baby's head to help with rotation or traction during delivery.

Nursing roll.

Reassure mom, explain.

Monitor both mom and baby closely during.

Check both for injury, afterward mom for lacerations, baby for bruising marks.

Assist with repairs.

And vacuum extraction.

A suction cup applied to the baby's head.

Traction is applied during contractions.

Key points for vacuum.

Limit suction time, usually max 25 minutes.

Monitor FHR frequently.

Check the newborn for trauma afterward.

Watch her cephalometoma.

Cuplet sixidanium, scalp swelling, is common and usually resolves quickly.

Finally, cesarean delivery.

Surgical birth.

Pre -op care.

Prepare mom and partner, can be quick in emergencies.

Informed consent.

Pre -op tests like RH factor.

Start four, insert Foley catheter.

Abdominal prep, continuous monitoring.

Emotional support.

Pre -op meds.

And post -op care.

Monitor vitals, fundus, incision, pain relief.

Encourage turning, coughing, deep breathing, ambulation.

Support bonding.

Monitor for complications like infection, incision, bladder, uterus, bleeding, thrombophlebitis, leg clots.

Okay, let's talk about placental abnormalities.

Placenta accreta, increta, percrita.

These describe how deeply the placenta attaches to the uterine wall.

Accreta is stuck to the muscle.

Increta invades the muscle.

Procreta goes through the uterine wall, possibly into other organs.

Reign risk.

Severe postpartum hemorrhage.

Because it doesn't separate cleanly.

Interventions.

Monitor closely for hemorrhage shock.

Be prepared for a possible hysterectomy if a large part is adherent.

Next, placenta previa.

What's the issue here?

The placenta implants low in the uterus, near or covering the cervical opening, OS.

Can be total, partial, or marginal depending on how much it covers.

What's the classic sign?

Sudden, painless, bright red vaginal bleeding, usually in the second half of pregnancy.

The uterus is typically soft and non -tender.

Key interventions.

Monitor vitals, FHR, fetal activity.

Ultrasound confirms diagnosis.

Absolutely NO vaginal exams.

Bed rest, usually sidelying.

Monitor bleeding amount.

Treat shock if needed.

May need four fluids.

Blood, tocolytics, Roa -D.

Caesarean delivery is usually required if bleeding is heavy or near term.

How does abruptio placenta differ?

Abruption is premature separation of the placenta after 20 weeks but before birth.

And the signs?

Often dark red vaginal bleeding, though it can be concealed.

Uterine pain or tenderness.

Uterine rigidity feels hard.

Severe abdominal pain.

Signs of fetal distress and possibly maternal shock.

Interventions for abruption.

Monitor vitals, FHR.

Assess bleeding, pain, fundal height.

Bed rest, oxygen, IV fluids, blood products.

Position might be trendylinbergs or lateral, depending on shock status.

Monitor uterine activity.

Prepare for delivery ASAP vaginal if possible and stable but often emergency C -section.

Monitor for DIC postpartum.

So the key difference.

Previa, painless bright red bleeding, soft uterus.

Abruption, painful dark red bleeding usually.

Rigid tender uterus.

That's a crucial distinction.

What about premature rupture of membranes, PROM?

That's when the water breaks before labor starts.

Management depends on gestational age.

Main risk is infection, especially if preterm.

How is it confirmed?

What are the assessments?

Pooling fluid in vagina.

Positive nitrazine test turns blue.

Positive fern test under microscope.

Assess fluid amount, color, consistency, odor.

Monitor mom's vitals.

Espiritem for infection.

And FHR, tachycardia, can mean infection.

Interventions.

Avoid vaginal exams as much as possible.

Monitor mom and baby for infection compromise.

May give antibiotics.

Prolapsed umbilical cord, a major emergency.

What happens?

The cord slips down ahead of or beside the presenting part after a membrane's rupture.

Getting compressed and cutting off baby's oxygen.

Signs.

Mom feels something in vagina.

Cord visible or palpable.

Sudden severe variable D cells or prolonged bradycardia on FHR monitor, especially right after membrane's rupture.

Maybe sudden violent fetal activity then nothing.

Priority nursing actions.

This is critical.

Absolutely.

Call for help immediately, but stay with the patient.

Use a sterile gloved hand to lift the presenting part off the cord.

Keep your hand there.

Position mom in extreme trindellenberg.

Modified sims or knee chest.

Give oxygen 810L, monitor FHR.

Increase 5E fluids.

Prepare for immediate birth, usually C -section.

Document everything.

What do you not do?

Never try to push the cord back in.

If it's protruding, cover it loosely with a warm sterile saline towel.

Okay.

Supine hypotension or vena cava syndrome.

What causes this?

Uterus compresses the vena cava and aorta when mom lies flat on her back.

Reducing blood return to the heart and cardiac output.

Feeling faint, dizzy, breathless.

Pallor, clammy skin.

Low BP, high pulse.

Fetal distress can occur too.

Intervention.

Immediately turn her onto her side, preferably left side.

Monitor vitals and FHR until stable.

Prevention is key.

Avoid supine position.

Use a hip wedge if needed.

Let's talk about preterm labor before 37 weeks.

Risk factors.

Many.

History of preterm birth.

Infections, multiples, uterine issues, social factors, age extremes.

Signs and symptoms.

Regular contractions, painful or not.

Cramping, maybe with diarrhea, low backache, pelvic pressure, change in vaginal discharge, ruptured membranes.

Positive fetal fibronectin test or shortened cervix on ultrasound can be indicators.

Interventions.

Goal is often to stop labor if possible.

Treat any infection, restrict activity, often bed rest, side lying, hydration for fluids.

Monitor fetal status.

May give to eucalyptics to stop contractions and corticosteroids for fetal lung maturity.

What about precipitous labor?

Labor less than three hours.

Yes, very fast.

Key is to stay with the mother.

What should the nurse do?

Have a precip delivery kit ready.

Provide support.

Keep her calm.

Encourage panting between contractions to control pushing.

Prepare for membranes rupturing if they haven't.

Do not try to stop the delivery.

If the provider isn't there.

Apply gentle pressure to the baby's head as it emerges to prevent tearing.

Support the perineum.

Support the baby's body.

Deliver between contractions if possible.

Check for neutral cord.

Suction mouth then nose.

Dry and warm the baby immediately.

Let placenta separate naturally.

Place baby skin to skin.

Dystocia difficult or prolonged labor.

Causes.

Problems with the powers.

Contractions too weak hypotonic or too strong but uncoordinated hypotonic.

The passenger, big baby macrosomia, malposition.

Or the passageway.

Pelvis shape size.

Designs.

Excessive pain.

Abnormal contraction pattern.

Fetal distress.

Maternal fetal tachycardia.

Lack of progress and labor.

Interventions for dystocia.

Monitor FHR contractions maternal vitals closely.

Assist with exam sultrasound.

Maybe antibiotics, IV fluids.

Monitor intake output.

Breathing relaxation support.

Position changes.

Fetal monitoring if oxypoin is used.

Contraindicated and hypertonic.

Assess amniotic fluid rest comfort measures.

Assess fatigue pain.

Watch for cord prolapse after ROM.

Amniotic fluid embolism rare but devastating.

Yes, amniotic fluid gets into maternal circulation causing a severe reaction.

Often fatal.

Signed.

Abrupt respiratory distress, chest pain, cyanosis, cardiovascular collapse.

Fetal bradycardia distress if undelivered.

Interventions.

Emergency.

Maintain life.

High flow oxygen.

Prepare for intubation ventilation.

Position on side.

Frighty fluids, blood products, meds for coagulopathy.

Monitor fetus.

Prepare for emergency delivery once stable support family.

Fetal distress signs the baby isn't coping.

What are they?

FHR below 110 or above 160.

Meconium stained fluid.

Fetal inactivity or hyperactivity.

Decreasing variability.

Severe variable or late decelerations.

Interventions.

Lateral position for mom.

Oxygen 810L.

Stop oxytocin.

Monitor mom and baby closely.

Prepare for emergency C -section.

Intrauterine fetal demise.

IUFD.

What are the signs and care focus?

Loss of fetal movement.

Absent heart tones confirmed by ultrasound.

May see DIC signs.

Coagulation problems in mom later.

Nursing care focus.

Emotional support is huge.

Encourage verbalization.

Respect cultural or religious needs.

Offer choices in labor delivery if desired.

Assist with medical management for DIC.

Rupture of the uterus.

Another emergency.

A tear in the uterine wall during labor.

Can be complete or incomplete.

Risk factors include prior C -section.

Especially classical incision.

Uterine trauma.

Over -distension.

Signs.

Sudden severe abdominal pain tenderness.

Chest pain.

Contractions might stop or change.

Rigid abdomen.

Absent FHR.

Signs of maternal shock.

Fetus might be palpable outside the uterus in complete rupture.

Interventions.

Monitor treat shock.

Oxygen.

IV fluids.

Blood.

Prepare for immediate C -section.

Possible hysterectomy.

Emotional support.

And finally, uterine inversion.

Uterus turns inside out during or after delivery.

Risk factors.

Fundal placenta pulling too hard on cord.

Uterine atony.

Adherent placenta.

Depression where fundus should be.

Uterus visible through cervix vagina.

Severe pain.

Hemorrhage.

Shock.

Intervention.

Monitor treat hemorrhage shock.

Prepare for provider to manually replace uterus via vagina.

Or possibly laparotomy if that fails.

Give uterotonics after replacement.

Okay, back to that critical thinking question.

Active labor.

FHR 180 for 10 mils.

What should the nurse do first?

Right, that's fetal tachycardia.

Priority actions.

Change maternal position.

Sideline.

Give oxygen 810 lmin via mask.

Check maternal vital signs, especially temperature.

And immediately notify the RN provider.

Perfect.

And the chapter ends with practice questions.

231, 245.

These really reinforce everything, don't they?

Absolutely.

They cover initial assessments.

Leopolds.

Managing hypotension.

Priorities after ROM.

Signs of placental separation.

Handling precipitous labor.

Recognizing previa versus abruption positioning.

Responding to FHR issues.

Hitting all the key points we've discussed.

Reviewing those rationales is key for learning the why.

Definitely.

It solidifies the understanding.

So that wraps up our deep dive into the Saunders chapter on labor and delivery and its complications.

We've covered a lot of ground.

From the basics of the four P's all the way through complex procedures and emergencies.

Hopefully you, the learner, feel more confident and informed about this entire process now.

It's such a dynamic process, isn't it?

Every labor is unique.

But understanding these core principles is essential.

For me, really understanding the nuances between the different FHR decelerations and the immediate actions needed was a key takeaway.

Yes, those patterns tell such an important story about fetal well -being and distinguishing previa from abruption crucial.

So a final thought for you to consider.

How does the interplay of those four P's powers, passageway, passenger, psyche,

truly make each and every labor experience unique, even when the underlying physiology seems similar?

That's a great point to reflect on.

We encourage you to explore the source material further if you'd like.

Thank you so much for joining us on this deep dive today.