Lecturer of maternity & Neonatal Nursing Nursing Management Of Labor stages Dr/Sahar Elkheshen Lecturer of maternity & Neonatal Nursing

OBJECTIVES: at the end of the following lecture the student will be able to: Define three stages of normal vaginal delivery. Identify care items needed during first stage of labor. Define the key terms related to labor process. Mention cardinal movements of the second stage of labor. Describe tow methods of placental separation. Provide necessary care required for the second and third stages of labor.

Prepare equipment: Fetal heart monitoring set P.V Set Supplies I.V Solutions Enema set Medication set Linens, Gowns, Towels

Labour stages There are three stages of labor, each of which is considered separately. The first stage (stage of dilatation of the cervix) is from the onset of true labor (regular uterine contractions) to complete dilatation of the cervix.

Contin., The second stage (stage of fetal delivery ) is from complete dilatation of the cervix to the birth of the baby. The third stage (stage of placental delivery) is from the birth of the baby to delivery of the placenta.

TRUE LABOR Contractions are regular. Frequency and duration of the contractions also change; they get closer together and last longer. There is cervical dilation and effacement. Discomfort begins in the back and radiates to the abdomen. Interventions such as rest and warm baths do not decrease contractions.

FALSE LABOR Contractions are irregular. There is no change in frequency and duration. There is no cervical dilation and effacement. Usually, discomfort is solely in the abdomen. Rest and warm baths lessen contractions.

THE FIVE “P”s Passenger Passageway Powers Position Psychological response

PASSENGER Passenger = Fetus (and placenta) Fetal head – Fontanels, molding Fetal presentation – Cephalic, breech, shoulder – Presenting part: occiput, sacrum, scapula Fetal lie Fetal attitude Fetal position – Station, engagement

Passageway = Birth canal Bony pelvis: true and false pelvis Type of pelvis: – Gynecoid – Android – Anthropoid – Platypelloid Soft tissues of cervix & vagina

Powers = Forces that expel fetus –Uterine contractions Primary Powers (involuntary) –Dilation, effacement, – Valsalva maneuver

PSYCHOLOGIC RESPONSE Preparation for childbirth – child education classes Sociocultural background Anxiety Comfort Support from significant others Ability to communicate with others Previous childbirth experience Environment Emotional integrity

POSSIBLE CAUSES OF LABOR ONSET Mature fetus: 38-42 weeks Hormonal changes: –Progesterone withdrawal –Increased level of prostaglandins –Increased level of estrogen & oxytocin –Fetal secretion of cortisol steroids Placental aging

Station This is the relationship between the presenting part of the baby -- the head, shoulder, buttocks, or feet -- and two parts of the mother's pelvis called the ischial spines.

Fetal Lie This is the relationship between the head to tailbone axis of the fetus and the head to tailbone axis of the mother. If the two are parallel, then the fetus is said to be in a longitudinal lie. If the two are at 90-degree angles to each other, the fetus is said to be in a transverse lie. Nearly all (99.5%) fetuses are in a longitudinal lie.

Fetal Attitude The fetal attitude describes the relationship of the fetus' body parts to one another. The normal fetal attitude described as the head is tucked down to the chest, with arms and legs drawn in towards the center of the chest.

Presentation Cephalic presentations Breech presentation Shoulder presentation

Admission: Welcome the woman, Explain all procedures, Seek informed consent, Help her undress, Ensure privacy, Wash hands before each procedure.

Take complete history: Family history, Assessment: Take complete history: Family history, Obstetric history: previous and recent. Menstrual history, Contraceptive history.

Determine whether the woman in labor or not: Uterine contraction (10/30 minutes), Show, Membranes, Frequency of micturation, Cervical changes.

Examination of the woman in labor: Explain all the procedure; Inform her of the procedures results; Perform general examination: Observe general condition weight , hight, limbs edema, ….). Measure vital signs accurately in between contractions, Test urine for sugar and albumin.

Perform Local Examination: Examination of the abdomen (abdominal Maneuver). Examination of the Vulva(gapping of the entroitus, presence meconium, presence of offensive odor, presence of blood). Vaginal examination

Nutrition and hydration: Meet women's needs of energy through oral fluids. In case of vomiting, ketosis and possible use of anesthesia, I.V fluids are given. Maintain intake and output chart. Solid food is usually avoided (???).

Rest and sleep: Latent phase Active phase Effect of ambulation on the progress of labor

Apply measures of infection control: Follow aseptic technique Provide dry and clean clothes Trimming hair Bathing Nails Swapping the perineum

Posture of the woman: Lying walking

Frequency of micturation Effect of full bladder: Care of bladder: Frequency of micturation Effect of full bladder: Its effect on descent In relation to uterine contractions Complication of full bladder

Observe signs of maternal distress: Increased pulse rate ???? Elevated temperature ???? Decreased blood pressure Sweating Signs of dehydration Dark vomitus Anxious & depression

Second stage of labor

MECHANISM OF LABOR: 7 CARDINAL MOVEMENTS Engagement Descent Flexion Internal rotation Extension Restitution/external rotation Expulsion

1 - Engagement: It’s a state that the infant head entered the true pelvis inlet. The biparietal diameter (BPD) is inside the inlet. At this time the head partially flexed and the occipito-frontal diameter is on the right-oblique diameter of the inlet.

2 - Descent: Descent continued progressively during labor until baby is delivered. It is brought about by the contractions of uterus and the bearing-down efforts. Other movements are superimposed on it .

3 - Flexion: Partial flexion of the head exists before labor and on engagement . When the fetus descents, the head meets the resistance of the pelvic floor, especially the levator ani, the fetus neck vertebra further flexed, and the chin approach the chest, at this time, the fetus suboccipito-bregmatic diameter(9.5cm) is on the diameter of mid plane of true pelvis .

4 - Internal Rotation When the infant descends continually the head meet the resistance of the pelvic floor, when the uterus contracts, the pressure inside the uterus cavity will made the head turn anteriorly towards the symphysis pubis, the sagittal suture is in anterior-posterior direction. It will be finished by the end of first stage.

5 - Extension : The flexed head in a occipital anterior position continues to descend through the passage. Since the vaginal outlet is directed upwards and forwards, so with the contraction of uterus and contractions of levater ani, the baby's head may extend under the pubic arch, the occiput come out first, then the brow 、the face、the chin.

6.Restitution and external rotation: The shoulder was in the oblique diameter of the inlet when it enter the pelvis. When the head is delivered from under the pubic arch, the neck twisted, and the shoulder can not move, so the occiput will have to turn back to the position of LOA, make the body of the baby in the same longitudinal axis. This action call restitution.

7. Expulsion (Delivery): After the external rotation when the uterus contract, the anterior shoulder (right shoulder) slip from under the pubis followed by the left shoulder over the perineum and then the body.

Signs of progress Transition signs: Loss of control Fearfulness Disorientation Nausea Uncontrollable shivering Demands for pain relief Need to shout Variable urge to bear down

Nursing Care Hygiene and comfort measures Support during transition Support during expulsive phase : early & delayed bearing down efforts. Pushing techniques Perineal practices. Assessing need for episiotomy

Third Stage of Labor

Process of Placental Separation

Nursing management Signs of placental separation: Elongation of the umbilical cord Formation of suprapubic pulg Absence of pulsation in the umbilical cord. Gushing of blood from the vagina

Examination of Normal Placenta

Fourth Stage of Labor

First 2-4 hours post partum Check vital signs Check fundal level and uterine status Assess lochia Assess perineal state Observe for vaginal bleeding Observe warning signs and symptoms

Health Educational topics Personal hygiene Psychological changes Importance of birth spacing Breast feeding Baby care Warning signs and symptoms

Thank You