1. Normal Labor and Delivery
Nursing Care

2. Stage 1 -- Latent Phase Signs and Symptoms:
Contraction: dilate 0-3 cm.
Mild
Duration – seconds
Frequency – 5-20 minutes
Scant pinkish discharge, bloody show
Mother’s response
Surge of energy and excited
Talkative, outgoing
Anxiety low
**Best time to do teaching!

3. Stage 1 – Latent Phase Nursing Care:
Welcome to the hospital
Assess goals for this labor
Assess Psychological response
Orient to common procedures
Vital signs and FHT’s
Enema IV
NPO
Assessment of Labor Progress – dilation, effacement, station, lie, etc.

4. What would you do?
A woman is admitted to labor and delivery in latent labor. Upon reviewing her birth plan you recognize that you will not be able to honor the woman’s request to keep her baby with her at all times throughout the hospital stay.

5. Stage 1 – Active Phase Signs and Symptoms:
Contractions – dilate 4-7 cm.
Moderate
Duration – seconds
Frequency – 2-5 minutes
Mother’s Response
More serious
Determined, Dependent
Restless
Focuses on self

6. Stage 1 – Active Phase Nursing Care:
Anticipate Needs:
Sponge face with cool cloth
Keep bed clean and dry- change chux
Provide with mouth care – lip balm to lips
Assess voiding
Non-Pharmacological Measures
Modified breathing
Effleurage
Music
Analgesia and Anesthesia

7. Stage 1 – Transition Phase Signs and Symptoms:
Contractions cm
Strong
Irregular with multiple peaks
Duration – seconds
Frequency – 2 minutes
Mother’s response
Withdrawn, drowsy,
Nausea, trembling of legs
Irritable, aggressive
Urge to push

8. Stage 1- Transition Phase Nursing Care:
Provide support- may need to breathe with the patient – get in her face
Back rub
Assist with pant-blow breathing
Watch for hypervention – have breathe in mask and slow down the breathing
Do NOT allow to push by having patient blow-blow-blow with urge.
Do not be offended by irritability

9. Stage 2 of Labor Signs and Symptoms:
Sudden Appearance of sweat on upper lip
An episode of vomiting
Increase in bloody show
Shaking of extremities
Increased restlessness
Pressure on rectum; involuntary bearing down
Bulging of perineum

10. Stage 2 of Labor Nursing Care:
The key to care during this stage
is to teach QUALITY PUSHING !
Keep perineum clean and dry
Provide quiet environment
Support with positive feedback
Repeat doctors instructions
Allow to hold the baby , Congratulate!!

11. Stage 2 – Mechanisms of Labor
1. Engagement and Descent
2. Flexion
3. Internal Rotation
4. Extension
5. Restitution
ALSO known as Cardinal Movements.
The fetus first descends into the pelvis is an oblique position because the pelvic inlet is widest from side to side.
Flexion occurs as the fetal head descends and meets resistance from the soft tissue of the pelvis, the muscles of the pelvic floor and the cervix.
Internal rotation occurs in the pelvic cavity as the widest diameter is not antero-posterior and the fetal head meets resistance from the levator ani muscles and their fascia. The head usually rotates from left to right.
Extension occurs as the fetal head passes under the symphysis pubis allowing the occiput then the brow and face to emerge.
Restitution – the shoulders of the fetus enter the pelvic inlet obliquely.
External rotation – the shoulders rotate to the anteroposterior position of the pelvis
Expulsion – the anterior shoulder meets the undersurface of the symphysis pubis and slips under it.
6. External Rotation
7. Expulsion

12. Episiotomy vs Laceration
Episiotomy is the manual cutting of the perineum to increase room for delivery of fetus.
Midline
Mediolateral
Laceration: tearing of the tissue of the perineum, vagninal wall, or periurethral.

13. Degree’s of Vaginal Tears/Episiotomy
1st - Extends only through the vaginal mucosa
2nd - Extends through the vaginal mucosa and submucosal tissue
3rd - Extends as a partial or complete transection of the anal sphincter muscle
4th - Extends through the anal sphincter and the lining of the rectum
Degrees of vaginal tears:
First Degree-The smallest or most simple episiotomy, extending only through the vaginal mucosa. It does not involve the underlying tissues.
Second Degree-This is the most common type of episiotomy. It extends through the vaginal mucosa and into the submucosal tissues, but does not involve the rectal sphincter or mucosa.
Third Degree-A third degree episiotomy involves the vaginal mucosa, submucosal tissues, and a partial or complete transection of the anal sphincter muscle.
Fourth Degree-The most severe type of episiotomy includes incision of the vaginal mucosa, submucosal tissues, and anal sphincter, and it also involves of the lining of the rectum.
The severity of the episiotomy is directly associated with the amount and seriousness of postpartum and long-term complications. As the degree of the episiotomy increases, there is more potential for infection, postpartum pain, and other complications, such as leakage of stool and development of recto-vaginal fistula. 13

14. Stage 3 of Labor Signs and Symptoms of Placental Separation:
1. A globular rise in the abdomen
the placenta changes from a discoid to a globular shape
2. Sudden gush of blood
3. Lengthening of the cord

15. Stage 3 of Labor Nursing Care:
Congratulate on delivery of baby
Coach in relaxation for delivery of the placenta
Initiate contact with the infant
May allow to breast feed if desires

16. Test Yourself!
The cardinal movement that facilitates the emergence of the fetal head is ____________.
A. Flexion
B. Extention
C. External rotation
Cardinal movement that allows the smallest diameter of the head to pass through the pelvis is__________________.
B. Internal rotation
C. Extension
Cardinal movement that occurs as the fetal shoulders engage and descend through the pelvis is termed ______.
A. Internal rotation
B. External rotation

17. The End of Labor & Delivery & The Beginning of Pain in Labor
RETURN

18. Causes of Pain in Labor Stage One Stretching of the cervix
during dilation & effacement
Uterine Anoxia
Stage One
Stretching of the
uterine ligaments

19. Causes of Pain in Labor Stage Two Distention of the vagina and
perineum
Compression of the nerve
ganglia in cervix & lower uterus
Stage Two
Pressure on urethra, bladder,
rectum during fetal descent
Traction on and stretching of
the perineum

20. Factors affecting Mothers Response to Pain in Labor
Knowledge and confidence gained through childbirth classes
Cultural influences on expression of pain
Maternal fatigue and anxiety
Previous experiences with pain

21. Methods of Pain Relief Non-pharmacologic Childbirth methods Effleurage
Breathing Techniques
Relaxation Techniques
Touch
Focusing attention on one object
Effleurage

22. Methods of Pain Relief Non-pharmacologic cont’d Sensory Stimulation
Listening to music; subdued lighting
Imagery
Applying heat and cold
Massage (lower back); Counter-pressure
TENS
Position Changes

23. Pain Relief in Labor Pharmacologic Methods Analgesia
fentanyl
morphine
butorphinp; (Stadol)
nalbuphine (Nubain)
Naloxone (Narcan) – narcotic antagonist
Tranquilizers Narcotic Poteniators
hydroxyzine (Vistaril)
promethazine (Phenergan)
Stado & Nubain are synthetic agonist/antagonists narcotic analgesia – use caution administering to drug addicted pt. Can be given IM & IV.
Side effects of systemic analgesia
Naloxone used to reverse the side effects of narcotic opiods

24. Anesthesia Regional Local General Paracervical Epidural; Caudal Spinal
Duramorph
Pudendal
Local
Perineum
General
Used mainly in cesarean deliveries

25. Spinal Block

26. Epidural Block

27. Pudendal Block

28. Local Anesthesia
1% Lidocaine solution injected into the perineal tissue prior to an episiotomy or if tears are expected. 28

29. General Anesthesia Used for cesarean-section if:
Spinal / Epidural ineffective
Emergency situation – fetal distress
Maternal conditions which contraindicated regional anesthesia
Maternal refusal of regional anesthesia
Fetal distress
Significant coagulopathy - low platelets
Acute maternal hypovolemia and Homodynamic instability
Sepsis or local skin infection
failed regional anesthesia
Maternal refusal of regional anesthesia 29

30. True or False ?
The anesthesia used for both labor and delivery is an epidural
A. True
B. False
The anesthesia used for delivery and an episiotomy is pudendal
A. True

31. True or False ?
The nurse would be careful to keep the patient flat following delivery with a pudendal block
A. True
B. False
The initial side effect of an epidural anesthesia is fetal bradycardia

32. The End
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