Labor and birth process

Labor Process Exact mechanism unknown Theories: Uterine stretching Prostaglandin Oxytocin stimulation Cervical pressure Aging 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 Passage Passenger Power Psyche Placenta

Passage Route fetus must travel from uterus to perineum Shape of pelvis Gynecoid Anthropoid Android Platypelloid

Passage Bony structures Pelvic diameters Soft tissues Joints, bones False pelvis True pelvis Pelvic diameters Diagonal conjugate Soft tissues

Passenger Fetal skull Bones Suture lines Fontanelles Diameter Molding

Passenger Presentation – fetal body part that will be first to pass through cervix Affects duration and difficulty of labor Affects method of labor Describe 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 mother Longitudinal Cephalic, breech Transverse Horizontally, side to side Oblique 45 degree angles

Passenger Attitude Complete flexion – chin to chest Moderate flexion – military Partial extension – brow Complete extension - face

Passenger Position – relationship of presenting part of fetus to specific section of mother’s pelvis Patient’s pelvis – 4 sections Right anterior Left anterior Right posterior Left posterior Fetus parts – Occiput (O)– vertex Mentum (M)- face Sacrum (S) – breech Acromion (A) - shoulder

Passenger position Fetal position described by using three letters: First letter defines whether fetal landmark pointing to mother’s right or left Second letter designates fetal landmark Occiput(O), mentum(M), sacrum(Sa), Acromion(A) Last letter defines whether landmark points anteriorly(A), posteriorly(P), or transverse(T) 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 occurs Floating, ballotable crowning

Cardinal movements of labor Number of fetal position changes as travels through birth canal Engagement Decent Flexion Internal rotation Extension External rotation 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 contractions Effacement – 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 Preparation Support person Past experiences Task of pregnancy Situational control

Maternal Position Philosophy of Childbirth Partners Patience Patient 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 Dilation – 0 to 10 cm Expulsion Placental 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

Nursing Management Nursing Management during labor and birth

Assessments Maternal Vaginal Exam - Dilation, effacement, station, membranes Contraction pattern

Contraction patterns Phases Duration Frequency intensity

Assessments Fetal Position – Leopold’s maneuvers Amniotic fluid Electronic 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 Regional Local General IV, IM, PO Epidural Spinal Regional block Local General

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 history Check results of routine laboratory tests and any special tests Ask about childbirth plan Complete 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 intensity Status of membranes (intact or ruptured) Cervical dilatation and degree of effacement Fetal heart rate, position, station Pain level

First Stage of Labor: Admission Assessment (cont’d) Fetal assessment Lab studies Routine: urinalysis, CBC HbsAg 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 stage Contraction frequency, duration, intensity Maternal vital signs Progress of labor, crowning Fetal response to labor via FHR Amniotic fluid with rupture of membranes Coping status of woman and partner

Nursing Management: Second Stage Interventions Supporting woman & partner in active decision-making Supporting involuntary bearing-down efforts; encouraging no pushing until strong desire or until descent and rotation of fetal head well advanced Providing instructions, assistance, pain relief Using maternal positions to enhance descent and reduce pain Preparing for assisting with delivery

Nursing Management: Second Stage Interventions with birth Cleansing of perineal area and vulva Assisting with birth, suctioning of newborn, and umbilical cord clamping Providing immediate care of newborn Drying Apgar score Identification

Nursing Management: Third Stage Assessment Placental separation; placenta and fetal membranes examination; perineal trauma; episiotomy; lacerations Interventions Instructing 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 Interventions Support and information Fundal checks; perineal care and hygiene Bladder status and voiding Comfort measures Parent-newborn attachment Teaching