1. Labor and Birth Process and Nursing Management Chapter 13 & 14
Mary L. Dunlap MSN
Fall 2015

2. Labor Definition
Coordinated sequence of involuntary uterine contractions
Contractions 3 minutes apart or less lasting 60 seconds or longer
Resulting in effacement and dilatation of the cervix and delivery of the fetus and placenta.

3. Possible Causes of Labor Maternal
Uterine muscle stretching
Pressure on the cervix
Oxytocin
Placental aging
Estrogen/Progesterone ratio change
Fetal cortisol concentration
Prostaglandins

4. Possible Causes of Labor Fetal
Placental aging
Fetal Cortisol concentration
Prostaglandin

5. Signs Preceding Labor Energy burst Lightening
Braxton-Hicks contractions
Weight loss
Bloody show
Lightening
Increase vaginal discharge
Cervix softening
Rupture of membranes

6. False Labor Does not cause cervical change Irregular contractions
Activity does not increase contractions
Sedation will stop or decrease contractions
Irregular contractions
No regular pattern
Discomfort in lower abdomen and groin
Show is not present

7. True Labor Activity increases contraction frequency
Sedation does not diminish contraction pattern
Causes cervical changes
Show usually present
Regular contractions
Contractions Progresses to a pattern
Discomfort begins in back and radiates to the abdomen

8. Factors That Affect Labor
The Five P’s:
Passageway (birth canal)
Passenger (fetus and placenta)
Powers (contractions)
Position of the mother
Psychologic response

9. Passageway Pelvic structure and shape Soft tissues cervix Pelvic floor
Vagina

10. Passenger Size of the fetal head Presenting part Fetal lie
Fetal attitude
Fetal position

11. Passenger: Fetal Skull
Largest and least compressible structure
Sutures: allow for overlapping and changes in shape (molding); help identify position of fetal head
Fontanels: intersections of sutures; help in identifying position of fetal head and in molding

12. Fetal Skull
Figure 13-3 p.399

13. Passenger: Presenting Part
Cephalic
Breech
Frank
Full or complete
Footling or incomplete
Shoulder
Fetal presentation- fetal part enters pelvic inlet 1st

14. Breech Presentations

15. Fetal Lie
Fetal lie is the relationship of the spine of the fetus to the spine of the mother
Longitudinal
Transverse
Go to next slide and use picture and mannequins to discuss concept

17. Fetal Attitude
Fetal attitude is flexion or extension of the joints and the relationship of fetal parts to one another

19. Passenger: Fetal Position
Fetal position- relationship of the presenting part of the fetus to a designated point of the maternal pelvic structure

20. fig 13.9 pg. 402

21. Powers Contractions primary force Frequency Duration Intensity
Pushing secondary force

22. Maternal Position
Affects woman’s anatomic and physiologic adaptations to labor
Frequent changes in position
Relieve fatigue
Increase comfort
Improve circulation
Facilitates decent and rotation

23. Psychological Response
Factors Influencing a Positive Birth Experience
Clear information on procedures
Support, not being alone
Sense of mastery, self-confidence
Trust in staff caring for her
Positive reaction to the pregnancy
Personal control over breathing
Preparation for the childbirth experience

24. Factors That Affect Labor
5 Additional P’s
Philosophy
Partner
Patience
Pain management

25. Cardinal movements of Labor
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation (restitution)
Expulsion (birth)

27. Four Stages of Labor
First Stage starts with Onset of labor to complete dilation
Latent phase Dilatation 0 to 3 cm
Effacement 0 to 40%
Active phase Dilatation 4 to 7 cm
Effacement 40 to 80%
Transition Dilatation 8–10 cm
Effacement 100%

28. Stages of Labor Second stage–complete dilation to birth
Third stage–birth to placental separation and expulsion
Fourth stage–four hours following delivery of the placenta

30. Initial Maternal Assessment
Presenting complaint
EDC
Gravida/Para
Contraction Pattern
Membrane status
Presence of fetal movement
Complications

31. Fetal Assessment
FHR provides information about the fetal oxygen status.
Locations for auscultating
Doppler Nursing Procedure 12.1 pg. 355
Continuous FHR via ultrasound transducer
Fetal movement

33. Doppler

34. Doppler

35. Continuous Fetal Monitoring

36. Contraction Assessment
Frequency
Duration
Strength/Intensity
Resting tone

37. Contraction Phases

40. Pelvic Exam Effacement Dilation Presenting part Station
Status of membranes

42. New classifications -5 to +5 measured in centimeters now

43. General Systems Assessment
Vital signs
General physical assessment
Leopold’s maneuvers
Procedure 14.1 pg. 424
DTR and clonus
Review prenatal record for lab results and history

45. Leopold’s Maneuver Video12310

46. Physiologic Adaptation to Labor
Maternal Adaptation
Cardiovascular changes
Respiratory changes
Musculoskeletal changes
Gastrointestinal changes

47. Physiologic Adaptation to Labor
Fetal adaptation to labor
Fetal heart rate changes due to contractions
Fetal circulation & respiratory changes preparing for birth
Fetal heart rate baseline and variability
Fetal heart rate response to contractions

48. Nurses Role
During labor and delivery fetal assessment includes determining fetal well-being and interpreting signs and symptoms of possible compromise
Nurse needs to be knowledgeable of the different FHR categories and the appropriate interventions that may be required

49. Monitoring Techniques
Electronic fetal monitoring
External monitoring
FHR—ultrasound transducer
UCs—Toco transducer
Internal monitoring (invasive)
Spiral electrode (FSE)
Intrauterine pressure catheter (IUPC)

51. Amnio Hook

53. Fetal Scalp Electrode

54. Placement of FSE

55. IUPC

56. Internal Fetal Monitoring

57. FHR Categories Category I normal Category II indeterminate
Category III Predictive of abnormal fetus
acid base status
Tab pg.429
Developed to have effective clinical communication about variant FHR patterns
Preventing miscommunication between professionals & To promote maternal fetal safety
Category I normal no intervention required
Category II indeterminate requires evaluation and continued monitoring
Category III Predictive of abnormal fetus acid base status
requires prompt evaluation and interventions

58. Determining FHR Patterns
Fetal assessment
Baseline FHR
Variability
Accelerations
Periodic changes (decelerations)
Early (head compression)
Late (placental insufficiency)
Variable (cord compression)

60. Baseline Fetal Heart Rate
Baseline Rate is the average FHR that occurs during a 10-minute segment excluding periodic or episodic rate changes
Normal
Bradycardia <110
Tachycardia >160

61. Fetal Heart Rate Variability
Irregular Fluctuations in FHR baseline measured as amplitude of the peak to trough in bpm
Absent fluctuation undetectable
Minimal <5 bpm
Moderate (normal) 6-25 bpm
Marked >25bpm

62. Fetal Heart Rate Patterns
Changes in fetal heart rate
Periodic occur with Contractions
Episodic (non-periodic) not associated with contractions
Accelerations
Decelerations

63. Accelerations Positive sign of fetal wellbeing
Abrupt increase in FHR above the base line lasting <30 sec from onset to peak
Term 15 bpm above baseline & duration >15 sec. but <2min
Prior to 32 weeks 10 by 10
Prolonged 2 min. to <10min

64. Decelerations Early decelerations Late decelerations
Variable decelerations
Prolonged decelerations

65. Early Decelerations
Gradual decrease in FHR, nadir coincides with the peak of the contraction
Mirror image of the contraction
Head compression/vagal response
No treatment required/benign pattern

67. Late Decelerations
Gradual decrease in FHR with the nadir of the deceleration occurring after the peak of the contraction. The FHR does not return to baseline until the contraction has ended
Caused by uteroplacental insufficiency
Fetus is in distress
Interventions Box pg.432

71. Variable Decelerations
Abrupt decrease in FHR below the baseline. The decrease is at least 15 bpm, lasting between 15 sec and under 2 minutes. They can vary with contractions.
Shaped like a “V” or a “W”
Associated with cord compression

73. Prolonged Deceleration
Abrupt decrease in FHR of at least 15 bpm lasting longer than 2 minutes, but less than 10 minutes.
FHR usually drops to less than 90 bpm

74. Decelerations

75. Fetal Heart Rate V Variable E Early A Acceleration L Late C Cord
H Head Compression
O Oxygenated fetus
P Placental problems

76. Fetal Assessment Methods
Umbilical Cord Blood Analysis
Fetal Scalp Stimulation

77. Pain Management
Nonpharmacologic
Pharmacologic

78. Nonpharmacologic Management
Simple, safe, and inexpensive
Provide sense of control over childbirth
Natural child birth requires practice for best results
Try variety of methods and seek alternatives, including pharmacologic methods if needed

79. Nonpharmacologic Management
Imagery and visualization
Position Changes Table 14.2 pg.437
Music
Touch and massage
Breathing techniques
Effleurage and counter pressure
Water therapy (hydrotherapy)
Nonpharmacologic Management

81. Pharmacologic Management
Systemic Analgesia
Regional Analgesia/Anesthesia

82. Systemic Analgesia
Use of one or more drugs administered orally, IM, or IV. These meds are distributed via the circulatory system.
Pain relief can occur within a few min. and last up to several hrs.
Side effect can be respiratory depression in the mother as well as the newborn after birth

83. Systemic Analgesia Opioids Ataractics/Antiemetics Benzodiazepines
Drug Guide 14.1 pg. 441

84. Regional Analgesia/Anesthesia
Pudendal never block
Epidural (Vaginal Del or C/S)
Spinal (C/S)
General (C/S)

86. Epidural Analgesia
Combination of local anesthetic (lidocaine) & an opioid (morphine or fentanyl)
Injected into the epidural space
Medication can be balanced to provide pain relive and the ability to ambulate

87. Epidural Analgesia

88. General Anesthesia
Reserved for emergency cesarean births when there is not enough time to do a spinal or epidural for anesthesia
Combination of IV injection and inhalation agents

90. Epidurals/Spinals/General Anesthesia
Anesthesia interview
Consent form
Labs (platelets less than 100,000 can place an epidural/spinal)

91. Nursing Responsibilities During 1st Stage of Labor
Vital signs
Hydration and nutrition
Elimination
Assessment of contractions and FHR
Labor Support
Comfort measures/Pain management
Education

92. Second Stage of Labor Assessment of contractions and FHR Fetal descent
Psychological considerations
Maternal positioning
Coaching maternal breathing and pushing efforts

93. Preparation for Delivery
Prepare instrument table
Adequate lighting
Oxygen and suction equipment
Radiant warmer, blankets,
identification for newborn
Pitocin

94. Delivery Table

95. Preparation for Delivery
Positioning of mother for birth
Gown, gloves, and protective equipment for personnel
Cleansing of the perineum
Deliver the newborn

97. Second Stage of Labor Perineal Lacerations (Depth) * 1st degree
* 2nd degree
* 3rd degree
* 4th degree
Episiotomy
* midline
* mediolateral

101. Third Stage of Labor Delivery of the placenta
Assess for perineal trauma
Repair of episiotomy/Perineal lacerations
Newborn care
Emotional support /Foster bonding

102. Episiotomy

103. Episiotomy Repair

105. Apply ice pack as soon as possible

106. Third Stage of Labor Placental separation and expulsion
Firmly contracting fundus
Change in uterus
Sudden gush of dark blood from introitus
Apparent lengthening of umbilical cord
Vaginal fullness

109. Fetal Side
Shinny Schults

110. Maternal Side
Dirty Dunkin

111. Third Stage of Labor Newborn care Time of birth noted
Drying, stimulation, suctioning of the newborn
Respiratory effort, heart rate, color, tone noted
One- and five-minute Apgar scores
Cord blood obtained
Identification

112. Apgar Score Assessment 0 Point 1 Point 2 Point Heart Rate Absent
< 100 bpm
> 100 bpm
Respiratory effort
Apneic
Slow, irregular, shallow
Regular breaths/min
Strong, good cry
Muscle Tone
Limp, Flaccid
Some flexion, limited resistance to extension
Tight flexion, good resistance to extension with quick response to flexed position
Reflex irritability
No Response
Grimace or frown when irritated
Sneeze, cough, or vigorous cry
Skin color
Cyanotic or Pale
Appropriate body color; blue extremities
Completely pink
A= appearance (color)
P = pulse (heart rate)
G = grimace ( reflex irritability)
A = activity ( muscle tone)
R = respiratory ( respiratory effort)

113. Apgar Score

122. Fourth Stage of Labor Maternal Assessment Uterus Lochia Perineum
Bladder
Vital signs
Pain
Newborn-family attachment
Breastfeeding initiated