Labor and birth process

Labor Process

Exact mechanism unknown Theories:

Uterine stretchingProstaglandinOxytocin stimulation Cervical pressureAging placenta Increased fetal cortisol levels

Signs of labor

Lightening Increased level activity Weight loss Braxton hicks contractions Cervical changes Uterine contractions Bloody show Rupture of membranes

True labor verses False labor

Differentiated ONLY by cervical changes:Dilation Effacement

Components of labor

1. Passage

2. Passenger

3. Power

4. Psyche

5. Placenta

Passage

Route fetus must travel from uterus to perineum

Shape of pelvisGynecoidAnthropoidAndroidPlatypelloid

Passage

Bony structuresJoints, bonesFalse pelvisTrue pelvis

Pelvic diametersDiagonal conjugate

Soft tissues

Passenger

Fetal skullBonesSuture linesFontanellesDiameterMolding

Passenger

Presentation – fetal body part that will be first to pass through cervixAffects duration and difficulty of laborAffects method of laborDescribe as variations of:

Cephalic- vertex, brow, sinciput, mentum Breech – complete, frank, incomplete, footling Shoulder – shoulder, iliac crest, hand, elbow

Passenger

Lie – refers to relationship of long axis (spine) of fetus to long axis of motherLongitudinal

Cephalic, breech

Transverse Horizontally, side to side

Oblique 45 degree angles

Passenger

AttitudeComplete flexion – chin to chestModerate flexion – militaryPartial extension – browComplete extension - face

Passenger

Position – relationship of presenting part of fetus to specific section of mother’s pelvis

1. Patient’s pelvis – 4 sections1. Right anterior2. Left anterior3. Right posterior4. Left posterior

2. Fetus parts – 1. Occiput (O)– vertex2. Mentum (M)- face3. Sacrum (S) – breech4. Acromion (A) - shoulder

Passenger position

Fetal position described by using three letters:

1. First letter defines whether fetal landmark pointing to mother’s right or left

2. Second letter designates fetal landmark1. Occiput(O), mentum(M), sacrum(Sa), Acromion(A)

3. Last letter defines whether landmark points anteriorly(A), posteriorly(P), or transverse(T)

4. LOA – left occiput anterior most common

Passenger

Station – relationship of presenting part to ischial spine of mother-5 (pelvis)to +4(perineum)Station 0 is at level of ischial spines –

engagement occursFloating, ballotablecrowning

Cardinal movements of labor

Number of fetal position changes as travels through birth canal

1. Engagement2. Decent3. Flexion4. Internal rotation5. Extension6. External rotation 7. Expulsion

Power

Force of uterine contractions Contractions of abdominal muscles Contraction pattern

Begin pacemaker point upper uterine segment Wavelike pattern relaxation Phases:

Increment Acme Decrement

Duration Contour changes

Power

Cervical changes – increased diameter of cervical canal and lumen occurs by pulling cervix up over present part with uterine contractionsEffacement – shortening and thinning of cervical

canal % - 0 to 100%

Dilation – enlargement of cervical canal from 1 to 10cm

Psyche / Psychological Response

Feeling woman brings to labor Psychological readiness for labor Factors affecting

PreparationSupport personPast experiencesTask of pregnancySituational control

Maternal PositionPhilosophy of ChildbirthPartnersPatiencePatient Preparation

Maternal physiologic response to labor Cardiovascular Fluid and electrolyte Respiratory Hematopoietic GI Renal Musculoskeletal neurologic

Fetal Response to Labor

Healthy fetus adapts to stress of labor Periodic fetal heart rate changes Circulation Increase PCO2 Decrease Partial PO2 Decrease fetal breathing movements

Stages of labor

1. Dilation – 0 to 10 cm

2. Expulsion

3. Placental

4. Immediate postpartum

Dilation

Begins with true labor contractions ends with complete cervical dilation

Divided into 3 phases

1. Latent: 0-3cm

2. Active: 4-6cm

3. Transitional: 7-10cm

Latent Phase

Preparatory phase Contractions mild and short 30-40sec Dilation 0-3cm 4-6 hours Analgesia too early prolongs phase Walking, packing, preparing

Active Phase

Working phase 4-6cm Contractions stronger, 40-60 sec, every 3 to 5

min True discomfort 2-4 hours Rupture of membranes Analgesia little effect on progress of labor

Transition phase

Feeling of loss of control occurs here 7-10cm Contractions peak intensity 2-3 min 90 second duration Feelings of urge to push Intense discomfort, nausea, vomiting, anxiety,

panic, irritability Focus inward on task of birth

Expulsion

Full dilation and effacement to birth of infant 20 min to 2 hours Fetus moved by “cardinal movements of labor Uncontrollable urge to push with contractions 2-3 min n/v, perspires, distended blood vessels, petechae Perineum bulge Inverted anus crowning

Placental

Birth of infant to delivery of placenta Placental separation

Bleeding on maternal side Lengthening of umbilical cord Gush vaginal blood Change shape of uterus Presentation:

Shiny schultz Dirty duncan

Immediate post-partum

3 hours after delivery Stabilizing Mom

Bleeding, bp, perineum, uterus, pain Stabilizing baby

Acclimated extrautering life Promoting bonding

Bleeding, bp, perineum, uterus, pain

Nursing Management

Nursing Management during labor and birth

Assessments

Maternal Vaginal Exam - Dilation, effacement, station,

membranesContraction pattern

Contraction patterns

Phases Duration Frequency intensity

Assessments

FetalPosition – Leopold’s maneuversAmniotic fluidElectronic fetal monitoring

Intermittent Continuous

External Internal

Fetal heart rate patterns

Baseline Fetal Heart Rate Baseline variability Increased variability Decreased variability

Periodic Baseline Changes

Accelerations

Decelerations Early Late Variable

Other Fetal Assessment Methods

Fetal Pulse Oximetry Fetal Stimulation Scalp Ph

Providing comfort

Etiology of pain Perception Fetal position

Nonpharmacologic Measures

Labor Support Ambulation / Position Changes Acupuncture / pressure Focused Imagery Breathing Techniques Therapeutic touch / Massage

Effleurage

Pharmacologic

Systemic IV, IM, PO

Regional Epidural Spinal Regional block

LocalGeneral

Nursing Care

Admission assessment Continual Assessment

First Stage Second, Third, Fourth Stage

Nursing care

VS I&O Pain Emotional support Sterile technique Teaching cleanliness

Nursing care

calm environment Clear liquids Output Ambulate Involve support person IV-blood samples Position changes Breathing techniques Perineal care

Monitor contractions Monitor FHR VE

Nursing Care During First Stage of Labor General measures

Obtain admission historyCheck results of routine laboratory tests and

any special testsAsk about childbirth planComplete a physical assessment

Initial contact either by phone or in person

First Stage of Labor: Phone Assessment

Estimated date of birth Fetal movement; frequency in past few days Other premonitory signs of labor experienced Parity, gravida, and previous childbirth experiences Time frame in previous labors Characteristics of contractions Bloody show and membrane status (whether

ruptured or intact) Presence of supportive adult in household or if she

is alone

First Stage of Labor: Admission Assessment

Maternal health history Physical assessment (body systems, vital signs,

heart and lung sounds, height and weight)Fundal height measurement Uterine activity, including contraction

frequency, duration, and intensityStatus of membranes (intact or ruptured) Cervical dilatation and degree of effacementFetal heart rate, position, stationPain level

First Stage of Labor: Admission Assessment

(cont’d) Fetal assessment Lab studies

Routine: urinalysis, CBCHbsAg screening, GBS, HIV (with woman’s

consent), and possible drug screening if not included in prenatal history

Assessment of psychological status

First Stage of Labor: Continuing Assessment

Woman’s knowledge, experience, and expectations Vital signs Vaginal examinations Uterine contractions Pain level Coping ability FHR Amniotic fluid

Nursing Management: Second Stage Assessment

Typical signs of 2nd stageContraction frequency, duration, intensityMaternal vital signsProgress of labor, crowningFetal response to labor via FHRAmniotic fluid with rupture of membranesCoping status of woman and partner

Nursing Management: Second Stage

InterventionsSupporting woman & partner in active

decision-makingSupporting involuntary bearing-down efforts;

encouraging no pushing until strong desire or until descent and rotation of fetal head well advanced

Providing instructions, assistance, pain reliefUsing maternal positions to enhance descent

and reduce painPreparing for assisting with delivery

Nursing Management: Second Stage Interventions with birth

Cleansing of perineal area and vulvaAssisting with birth, suctioning of newborn,

and umbilical cord clampingProviding immediate care of newborn

Drying Apgar score Identification

Nursing Management: Third Stage Assessment

Placental separation; placenta and fetal membranes examination; perineal trauma; episiotomy; lacerations

InterventionsInstructing to push when separation apparent;

giving oxytoxic if ordered; assisting woman to comfortable position; providing warmth; applying ice to perineum if episiotomy; explaining assessments to come; monitoring mother’s physical status; recording birthing statistics; documenting birth in birth book

Nursing Management: Fourth Stage Assessment

Vital signs, fundus, perineal area, comfort level, lochia, bladder status

InterventionsSupport and informationFundal checks; perineal care and hygieneBladder status and voidingComfort measuresParent-newborn attachment Teaching