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Normal Birth Vol 2 P. 366 – 411. 1. How Do You Know If

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Normal Birth Vol 2 P. 366 – 411. 1. How Do You Know If Normal birth vol 2 P. 366 – 411. 1. How do you know if the labor as actually started? What are the definitive signs and symptoms? Labor has begun if contractions are getting more frequent, more intense and lasting longer occurring with cervical changes. Definitive signs of labor include: bloody show, ROM, 100% of cervical effacement, and contractions 10 minutes apart. 2. As the midwife, what should you be looking for while observing the progress of labor? A midwife must be able to determine progress for a particular woman as progress looks different for every birth. The mother’s reaction to her contractions, her body language, her vocalizations, and the look of her uterus and pelvis can all be used to tell if labor is progressing. The most definite signs of progress are descent and rotation of the presenting part, cervical change in consistency, and movement of the os from posterior to a normal position. 3. How can you distinguish early/prodromal labor? What are the signs and symptoms? Prodromal labor may present with contractions that are consistent and do not stop with activity change, but we know it is prodromal because the contractions do not increase in intensity, duration, or frequency. Early labor is when the contractions begin to increase in frequency and intensity and do not stop with maternal activity change. Contractions in early labor can last from 15 to 40 seconds and can come between every 15 to 30 minutes. Bloody show will most often occur in early labor. Dilation in early labor is between 3 to 4 cm for first time moms and between 5 and 6 for multiparas. 4. What is active labor? Describe the difference in this and early labor. Active labor is increased intensity and frequency. The dilation will be 4 to 5 cm or in some women it could be up to 7 or 8 cm. Contractions in active labor last one minute and come every 4 to 5 minutes. During early labor the mother can carry on will normal life fairly well, during active labor the mother will need to be focused to get through her contractions and she will be increasingly attentive to her labor. During active labor the mother is settling into her rhythm to cope with labor. 5. What is hard labor? What are the signs and symptoms? Hard labor is dilation trough the 7th ,8th, or 9th cm. Contractions are one after another and last 60 seconds. The woman is working extremely hard and is completely focused on labor. The pain is higher and deeper, and the woman may feel her uterus being more involved in the contractions. The woman will be less modest, more serious, and her movements will be slow and intentional. 6. Define transition. How long can it last and what should you be looking for? Transition is the change from labor to pushing. Transition is usually dilation from 8 to 9 until complete. The contractions during transition become extremely irregular and may have more than one peak, may come extremely close together, or they may stop all together. Transition may last between 5 or 20 contractions. Look for the signs of transition – vomiting, flushed cheeks, nausea, shakes, tremors, perspirations, and irrationality. Look for ROM, labial swelling, and a second bloody show. 7. Discuss the various techniques used in abdominal examinations during labor. Ensure you cover both early and established labor. You should spend time discussing uterine changes and activity, palpations, and using both your hands and instruments. This will likely be a longer answer than most other questions. During early labor the uterus is rounder and more pendulous than in the rest of labor. In established labor the uterus is lengthened by the head and spine stretching it with descent. Through labor the contractions will cause the uterus to lengthen and the fibers to be pulled tight, and the horizontal diameter of the uterus is decreased. The uterus will also lean forward away from the maternal spine to help the presenting part to be guided properly into the upper pelvic cavity. The uterine activity is divided into frequency, duration, interval, and amplitude. Each contraction is divided into a building phase, a peak phase, and an easing down phase. Palpating the fundus can be used to determine the strength of contractions. Do this palpation by pressing two fingers into the belly in a spot away from the baby. Through the next few contractions palpate the belly. The fundus will feel soft and indent-able between contractions. During a mild contraction the abdomen will be easily palpable and you will be able to indent the fundus underneath. In a moderate contraction the abdomen will be firm and the fundus will be hardly palpable. In a strong contraction the abdomen and fundus are hard and rigid. The fundus will be impossible to indent in a strong contraction. Palpation can be used to monitor rotation and descent. Using the shoulder and back you can mark the level of rotation as you feel the position of the back change and move down the mother’s midline. You can use the shoulder to mark descent as you feel it move down the belly. The anterior shoulder in relation to the mother’s midline is a direct indication of shoulder rotation and it is an indirect indication of the head rotation. Using a belly chart mark the places you feel the shoulder with a capital “T” and mark the places you hear the heart beat with a “+”. When the shoulder reaches the top of the symphysis pubis the head is most likely distending the perineum. To measure the station of the head externally use your hand to press in between the symphysis pubis and the baby’s head. Each finger is one fifth of a measurement. If the head is engaged this will be represented by a two finger measurement. The fetal heart sounds can be used to determine descent and rotation by listening with a fetoscope and marking where the heart is heard the loudest. The hand can also be used to determine dilation. This is done by pressing the fingers between the fundus and the xiphoid process at the peak of contractions. The lesser the number of fingers the greater the amount of dilation. Other methods of observation include the crease above the pubic bone for measuring descent, and the retraction ring for measuring dilation. 8. What is bloody show? Why does it matter? Bloody show is the presence of blood in the vaginal mucus due to the dilation of the cervix. This is important as it is a sign of dilation and the onset of labor. The bloody show should be mucilaginous; if the bloody show is bright red and is a stream there may be a cervical lip being pulled down with the presenting part. 9. When doing an internal exam during labor, what would you be looking for? Give 5 findings that tell you important information. Why do these 5 things matter? In doing an internal exam you would be looking for: Unusual symptoms such as bleeding, unusual findings on the external genitals, what is the condition of the internal walls of the vagina, where is the cervix; check for effacement and dilation. Determine if the cervix is dilating evenly, and what is the consistency of the cervix. Note if the membranes are intact. Is the head molded and what is the presentation? What is the station of the presenting part? 1. Bleeding – if bleeding is present you must determine if it is normal bloody show or if it is an abnormal sign of previa or abruption. Abnormal bleeding could also be a sign of cervical tears, stretching cervical scars, a ruptured maternal varicosity in the vagina, or a ruptured vasa previa. 2. Condition of the vaginal wall – this should be moist, soft and stretchy. If the walls are dry and hot there may be a presenting part inhibiting the circulation in the pelvis. 3. Herniations – if there are large outpouchings in the vaginal wall labor may be inhibited. 4. Even dilation of the cervix – the cervix may dilate unevenly due to asynclitism, nuchal cord, cervical polyps, posterior babies, or a partial placenta previa. 5. External genitals – scars may need to be separated for birth to happen. If the vaginal discharge is foul smelling there may be an intrauterine infection. 10. Which of these is considered “normal”, with the rest falling outside normal: vasa previa, cord prolapse, caput, compound presentation, shoulder presentation. Caput is normal due to the stress of labor. 11. What is vasa previa? Vasa previa is a fetal blood vessel passing in front of the presenting part above the cervix. 12. What is cord prolapse? Cord prolapse is when the umbilical cord passes in front of the baby and is born out of the cervix prior to birth of the baby. 13. How can you determine caput in an exam? If it is difficult to determine the presenting part even though it is low in the pelvis and the waters are broken there may be a caput. 14. What is a compound presentation? A compound presentation is the presentation of either a cephalic or breech presenting with an extremity such as an arm or leg. 15. How can you identify a shoulder presentation? The presentation of a part without suture lines, orifices, or uniform shape tell that it is an unusual presentation. The tip of the shoulder is more rounded than the elbow and heel and it has three bony ridges that distinguish it from other parts. 16. Why is it good for the amniotic sac to remain intact in labor as long as possible? Intact waters give protection to the uterus from organisms ascending the vagina into the cervix.
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