Labor and birth process

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• Labor and birth process

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Labor Process

• Exact mechanism unknown
• Theories
• Uterine stretching
• Prostaglandin
• Oxytocin stimulation
• Cervical pressure
• Aging placenta
• Increased fetal cortisol levels

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Signs of labor

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

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True labor verses False labor

• Differentiated ONLY by cervical changes
• Dilation
• Effacement

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Components of labor

1. Passage
2. Passenger
3. Power
4. Psyche
5. Placenta

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Passage

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

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Passage

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

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Passenger

• Fetal skull
• Bones
• Suture lines
• Fontanelles
• Diameter
• Molding

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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

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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

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Passenger

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

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Passenger

• Position relationship of presenting part of
  fetus to specific section of mothers pelvis
• Patients 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

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Passenger position

• Fetal position described by using three letters
• First letter defines whether fetal landmark
  pointing to mothers 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

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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

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Cardinal movements of labor

• Number of fetal position changes as travels
  through birth canal
• Engagement
• Decent
• Flexion
• Internal rotation
• Extension
• External rotation
• Expulsion

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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

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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

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Psyche / Psychological Response

• Feeling woman brings to labor
• Psychological readiness for labor
• Factors affecting
• Preparation
• Support person
• Past experiences
• Task of pregnancy
• Situational control

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• Maternal Position
• Philosophy of Childbirth
• Partners
• Patience
• Patient Preparation

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Maternal physiologic response to labor

• Cardiovascular
• Fluid and electrolyte
• Respiratory
• Hematopoietic
• GI
• Renal
• Musculoskeletal
• neurologic

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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

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Stages of labor

• Dilation 0 to 10 cm
• Expulsion
• Placental
• Immediate postpartum

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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

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Latent Phase

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

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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

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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

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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

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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

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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

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Nursing Management

• Nursing Management during labor and birth

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Assessments

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

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Contraction patterns

• Phases
• Duration
• Frequency
• intensity

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Assessments

• Fetal
• Position Leopolds maneuvers
• Amniotic fluid
• Electronic fetal monitoring
• Intermittent
• Continuous
• External
• Internal

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Fetal heart rate patterns

• Baseline Fetal Heart Rate
• Baseline variability
• Increased variability
• Decreased variability

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Periodic Baseline Changes

• Accelerations
• Decelerations
• Early
• Late
• Variable

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Other Fetal Assessment Methods

• Fetal Pulse Oximetry
• Fetal Stimulation
• Scalp Ph

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Providing comfort

• Etiology of pain
• Perception
• Fetal position

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Nonpharmacologic Measures

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

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Pharmacologic

• Systemic
• IV, IM, PO
• Regional
• Epidural
• Spinal
• Regional block
• Local
• General

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Nursing Care

• Admission assessment
• Continual Assessment
• First Stage
• Second, Third, Fourth Stage

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Nursing care

• VS
• IO
• Pain
• Emotional support
• Sterile technique
• Teaching
• cleanliness

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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

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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

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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

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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

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First Stage of Labor Admission Assessment
(contd)

• Fetal assessment
• Lab studies
• Routine urinalysis, CBC
• HbsAg screening, GBS, HIV (with womans consent),
  and possible drug screening if not included in
  prenatal history
• Assessment of psychological status

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First Stage of Labor Continuing Assessment

• Womans knowledge, experience, and expectations
• Vital signs
• Vaginal examinations
• Uterine contractions
• Pain level
• Coping ability
• FHR
• Amniotic fluid

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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

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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

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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

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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 mothers physical
  status recording birthing statistics
  documenting birth in birth book

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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