The 5 P's of Labor: Passenger

5 P's of Labor

• Five factors define labor: passenger, passageway, powers, position, and psychological response

Passenger (Fetus & Placenta)

• Fetal head size, presentation, lie, attitude, and position impact the fetus's ability to navigate the birth canal
• Presentation refers to the part of the fetus entering the pelvic inlet first
• This could be the back of the head (occiput), chin (mentum), shoulder (scapula), or breech (sacrum or feet)

Fetal Lie

• Lie describes the relationship of the maternal spine to the fetal spine
• Transverse lie means the fetal long axis is horizontal and forms a right angle to the maternal axis
• Transverse lie does not accommodate vaginal birth, often requiring a C-section if the fetus doesn't spontaneously rotate
• Parallel or Longitudinal lie means the fetal long axis aligns with the maternal long axis
• It presents as either cephalic or breech, and breech presentations sometimes need a C-section

Fetal Attitude

• Attitude refers to the relationship of fetal body parts to one another
• Fetal Flexion involves the chin flexed to the chest with extremities flexed into the torso
• Fetal Extension involves the chin extended away from the chest and extremities extended

Fetopelvic or Fetal Position

• Position describes the relationship of the presenting fetal part (sacrum, mentum, or occiput) to maternal pelvic quadrants
• It's labeled with three letters
• R or L indicates if the fetal position is on the right or left side of the maternal pelvis
• O, S, M, or Sc denotes the presenting part: occiput, sacrum, mentum, or scapula
• A, P, or T indicates the part of the maternal pelvis that the fetus is in: anterior, posterior, or transverse

Fetal Station

• Station measures fetal descent in centimeters
• Zero station is at the level of the ischial spines and plus stations are inferior to the ischial spines

Passageway (Birth Canal)

• The birth canal consists of the bony pelvis, cervix, pelvic floor, vagina, and introitus (vaginal opening)
• The pelvis must be adequate in size and shape, and the cervix must dilate/efface for fetal passage

Powers (Contractions)

• Uterine contractions cause cervical effacement during the first stage of labor
• They also dilate the cervix once labor has begun and the fetus is descending
• Involuntary pushing and bearing down in the second stage aid in fetal expulsion

Maternal Position

• Frequent position changes during labor increase comfort, relieve fatigue, and promote circulation
• Maternal preferences, provider preference, and fetal condition influence the second stage position
• Gravity can aid fetal descent in upright, sitting, kneeling, and squatting positions

Psychological Response

• Maternal stress, tension, and anxiety can produce physiological changes that hinder labor progress

Four Main Pelvic Types

• Gynecoid: Most common (50%), round, moderate depth, and preferred for vaginal delivery
• Android: (23%) Resembles the male pelvis, shaped like a heart
• Anthropoid: (24%) Resembles the ape pelvis, oval-shaped
• Platypelloid: (3%) Flat-shaped

Signs Preceding Labor

• The uterus sinks downward and forward 2 weeks before term
• Lightening or dropping occurs as the presenting part of the fetus descends, relieving ribcage pressure
• Return of urinary frequency occurs from increased bladder pressure from lightening
• Backache involves persistent low back pain and sacroiliac distress
• Stronger Braxton Hicks contractions are more frequent
• Increased vaginal secretions/bloody show includes mucus and blood
• Nesting occurs as a burst of energy to clean and prepare
• Weight loss happens with fluid shift and hormonal changes
• Rupture of membranes means water breaking

True vs False Labor

• True contractions increase in frequency and duration, do not go away with rest, and cause lower back pain that sweeps to the lower abdomen
• True labor involves cervical changes between 2-4 cm
• Progressive effacement and dilation of the cervix take 15 mins to 3 mins
• Effacement is the thinning of the cervix
• False contractions are inconsistent, stop with position change, and cause abdominal discomfort; it also has no cervical changes

Stages of Labor

• First Stage lasts from the onset of regular uterine contractions to full cervical dilation

First stage Latent Phase

• 0-5 cm dilation
• Contractions are irregular to moderate, every 5-30 mins lasting 30-45 seconds
• Scant brownish discharge or mucus plug
• The person is talkative/ calm, focused on labor, and able to walk/talk through most contractions, and follow directions
• Can be apprehensive

First stage Active Phase

• 6-10 cm dilation
• Contractions are more regular and stronger, every 3-5 mins lasting 40-90 seconds
• The person becomes more serious with inward focus, anxiety, and may feel out of control and irritable
• May have nausea, vomiting, urge to push, increased rectal pain, bloody show, which is the most difficult part of labor

First stage Transition Phase

• 8-10 cm dilation

First stage assessment

• Assessment covers prenatal data, psychosocial factors (abuse history), labor stress, cultural factors, and physical exam
• Physical exam includes general systems, vitals, Leopold maneuvers, FHR pattern, uterine contractions, vaginal exam, COVID test, urine/blood tests, Group B results, and amniotic membrane assessment

First stage interventions

• Interventions include general hygiene, oral/IV intake, voiding/ catheterization, bowel elimination, and ambulation

Second Stage

• The second stage involves full dilation/ pushing and fetal descent to newborn birth
• Lasts up to 4 hours with two phases

Second stage Latent phase

• Passive fetal descent through the birth canal
• Fetal station is 0 to +2

Second stage descent phase

• Second stage descent phase is active pushing and bearing down
• Fetal station is +2 to +4

Second stage care management

• Includes assessing BP, FHR, pulse, respiration every 5-30 minutes
• Uterine contractions: coach to push WITH contractions only
• FHR: every 5-15 minutes, assess for bleeding
• Preparing for birth by maternal position, bearing-down efforts, FHR pattern, support, supplies, instruments, equipment, and immediate maternal assessment/care
• Occurs with perineal/ vaginal/ urethral lacerations, cervical injuries, and episiotomy
• Includes vertex presentation, birth of the head/shoulders and rest of the body
• Cord clamping, patent airway, preventing cold stress (warmer), APGAR scoring, and identification on baby and mom

Third Stage

• Third stage involves delivery of the placenta with either "Schultze presentation" (shiny fetal surface) or "Duncan presentation" (dull maternal surface)
• Firmly contracting fundus, change in uterine shape, a gush of dark blood, umbilical cord lengthening, and vaginal fullness also take place
• Assess includes BP, pulse, RR every 15 mins and 1/5 min APGAR scores for the newborn
• Nursing includes instructing the mother to push, keeping parents informed, and administering oxytocics, analgesics, warm water/ice pack for perineal repair
• It also involves promoting skin to skin contact, private time, and breastfeeding

Fourth Stage (Recovery)

• The fourth stage lasts 2 hours postdelivery and involves maternal stabilization and VS homeostasis
• Assessment includes monitoring maternal VS, fundus, lochia, urinary output, and family activities
• Actions involve maternal care, checking BP/pulse every 15 minutes for 2 hours, temperature every 4 hours for 8 hours, fundus/lochia every 15 mins for the first hour, and massage
• Oxytocics are administered to prevent hemorrhage, encourage voiding to prevent distention, and assess episiotomy repair as well as parent baby bonding with feeding

Physiological Adaptation to Labor

• HR, cardiac output, BP, WBC, and RR increase, vomiting may occur in the second stage, and blood glucose levels decrease
• FHR decelerations also happen from fetal movement, vaginal exam, fundal pressure, or uterine contractions

Documenting Contractions

• Documenting involves the start/end, frequency, intensity, and resting tone

Contraction Intensity

• Contraction intensity is assessed by palpation
• Mild intensity means the fundus is slightly tense and easy to indent with fingertips like touching finger to nose
• Moderate intensity means the fundus is firm and difficult to indent, like touching finger to chin
• Strong intensity means the fundus is rigid and nearly impossible to indent, like touching finger to forehead

Documenting Contractions - Duration and Frequency

• Duration refers to the amount of time of a contraction from start to end
• Frequency is how often contractions occur, from the beginning of one to the next
• Resting tone: the uterine tension between contractions or level of relaxation

Intrauterine pressure catheter

• Intrauterine pressure catheter involves inserting a sterile solid/fluid-filled catheter inside the uterus
• It displays the uterine contraction and the membranes should be ruptured with sufficient dilation.

Nonpharmacologic Pain Management

• Nonpharmacologic pain management is simple, safe, with few reactions, and inexpensive
• It gives a sense of control, can be used with drugs, and reduces anxiety and fear

Sensory Stimulation

• Sensory stimulation involves aromatherapy, breathing, imagery, quiet and focal points
• The mother uses a focal point to stare at a still object to keep from getting distracted
• Imagery uses a pleasant scene for relaxation

Cutaneous Stimulation

• Cutaneous stimulation involves touch/ massage, heat/cold, water therapy, walking, sacral pressure, and position changes

Pharmacologic Pain Management

• Pharmacologic pain management involves analgesia; verify labor is well-established with a vaginal exam and alleviate pain by raising the threshold
• Sedatives relieve anxiety and induce sleep and used in early or latent phase of labor

Sedatives

• Adverse Effects of sedatives: neonate respiratory depression, unsteady ambulation, and being hyperactive and disoriented if the mother is in pain
• Nursing includes dimming lights, providing safety and assistance with ambulation, and assessing newborns for resp depression

Opioid (narcotic) Analgesic

• Opioids act in the CNS to decrease pain without loss of consciousness with usually IV delivery in early labor

Opioid (narcotic) Analgesic - Adverse Effects

• Adverse Effects of Opioids: neonate respiratory depression, nausea, tachycardia, hypotension, decreased FHR variability, and alterations in the mental status
• Naloxone is for reversal of opioid induced respiratory depression and should be on hand at all times
• Nitrous oxide: tasteless/ odorless gas as a labor analgesic with opioid analgesic
• It works best when inhaled 30 seconds before a contraction in the second stage

Epidural/ Spinal Analgesia

• Epidural/ Spinal Analgesia involves analgesics like fentanyl and sufentanil that are short-acting opioids that are administered into the epidural/ intrathecal space without anesthesia
• Administered after labor is well-established between 5 to 7 cm dilated

Epidural block

• Epidural block consists of a local anesthetic with analgesics
• It's injected into the epidural space at the level of the 4th and 5th vertebrae
• This eliminates pain by relieving contraction pressure, fetal descent, and stretches to the perineum
• The injections are administered via patient-controlled epidural analgesia, which is suitable for all stages and laceration repair

Spinal Block

• Spinal block consists of a local anesthetic injected into the subarachnoid space at the 3rd, or 4 or 5 lumbar interspace
• It eliminates sensation from the nipples to the feet and is used in C-sections as well as late second stage
• Risks of epidural/ spinal block is limited mobility, longer second stage, not effective for patients, urinary retention, pruritus, maternal hypotension

Post Epidural/Spinal Block Nursing

• Nursing involves assessing VS and O2 sat, observing for distention, giving IV fluids, assisting change of position, and providing safety
• Hypotensive patients should lay on their side or wedge hip, raise IV fluids, and give O2 at 10-12 Liters via a facemask with elevated legs, and be prepared to administer vasoconstrictors per order
• There's also possiblility of Post-dural puncture HA and comfort measures

Pudendal Block

• Pudendal nerve block consists of a local anesthetic transvaginally into the Pudendal nerve, providing local anesthesia for the perineum and vulva/ rectal areas
• It's administered in the late second stage up to 20 minutes before birth and during second and third stages for laceration repair
• There are no maternal effects, but there is the risk of compromising the maternal bearing down reflex

Leopold’s Maneuver

• Leopold’s maneuver involves palpating the maternal abdomen to determine the presenting part, fetal lie, fetal attitude, and the degree of descent as well as the location of the fetal’s back
• Vertex positions require fetal heart tones to be assessed below the client’s umbilicus in the either right or left quadrant
• Breech positions require fetal heart tones to be assessed above the client’s umbilicus in the either right or left quadrant

Electronic Fetal Monitoring

• Electronic Fetal Monitoring: visualizes FHR patterns on monitor in US with potential stress to fetus and maintains oxygen supply
• Factors that decrease fetal oxygen supply includes a reduction of blood flow/oxygen content through maternal vessels, as well as alterations in fetal circulation or blood flow through the intervillous space

Uterine Activity

• Fetal well-being is measured by FHR responses to uterine contractions
• FHR monitoring identifies non-reassuring patterns by uncorrected hypoxemia
• NonInvasive monitoring involves low-tech methods
• Continuous EFM is accomplished by attaching an ultrasound transducer and tocotransducer abdominally

Invasive Methods

• Fetal scalp electrode is an invasive method that monitors the membranes of the cervix
• Important things include maternal consent, maternal risk factors, and being careful to avoid injury
• Advantages: Accurate fetal heart rate monitoring
• Disadvantages:: risk for infection/ restrict movement

FHR Baseline

• FHR baseline is an average taken during 10 minute segments with some exceptions and must be at least 2 minutes
• Baseline rate is 110-160 bpm/minutes
• Tachycardia is described as being >160 bpm
• Bradycardia is <110 bpm

Variability

• Variability is defined as irregular waves and fluctuations in the baseline FHR or as the irregularity of the fetal heart rate
• Absent and minimal variability, with minimal being 5 bpm, indicate hypoxemia
• FHR is described as normal with 6-25 bpm

Accelerations

• Accelerations are changes in the baseline FHR during contractions with 15 bpm of FHR, lasting from 15-30 seconds with a length of up to two minutes
• They happen from fetal movement, vaginal examination, breech, or uterine pressure

Decelerations

• Decelerations may be benign or abnormal

Early Decelerations

• Early decelerations are ok and cause from head compressions of the uterus from any examination and don't require any intervention

Late decelerations

• Late decelerations require intervention or c-section
• They are caused by uteroplacental insufficiency and requires the following
• It's corrected by lying on the side, IV fluids, discontinuing Oxytocin, administering oxygen, elevating legs, and notifying the provider

Variable Decelerations

• Variable decelerations requires repositioning, oxygen administration, and amnioinfusion from cords being compressed or moved out of the way

NICHD FHR Categories

• Normal Category I: 110-160 bpm, moderate variability, accelerations and early declarations absent/ present
• Category II Intermidiate- Accelerations absent and noncategorizable
• Category III ABNORMAL requires attention to the babies condition quick- sinosidal pattern, FHR- , Recurrent variable and late deceleration

Bishops Score

• A scoring system for how well the cervix is and ready for labor. Can get a score between 0-15 -Factors: Dilation- 0cm- 0points, etc Effacemetnt - 0-30%- 0 points ,etc Fetal Station, Cervial Consistancy- all related in this manner

Preterm labor and birth

• Risk of being premature and may depend on gestational age
• Can happen from active herpes, infection, history of pt, or premature rupture of membranes
• Watch for watery discharge from pelvis, uterine dilation
• Tested with - Fibronectin- Normal is low, Test the glycoproteins Can have a vaginal or urinary infection

Preterm labor tests.

• Check if PH is normal, then perform ferning test of rupture- check crystallization process
• Amniotic= Basic
• Check umbilical cord prolapse
• Labor- might want to induce
• Educate lifestyle Modification, activity Restrictio
• Tocolytics- Given to arrest the muscles: relax the uterus/ Stop birth Beta 2/ Magnessium - Nifedpine.

Labor tests- Side effects

• Side effects Nasal congestion Palpitations Arrhythmias Tremors Dizziness Tachycardia Chest Discomfort Headaches Nausea/vomiting

Additional care measures from tests given

• Test if baby is strong for lungs to mature- promote lung development Give corticosteroids-Betamethasone - PROM; premature rupture of membranes; PPROM:
• preterm premature rupture of membranes - PPROM, PROM- rupture before onset of gestation Infection High risk factor

Contributor and intervention to Tests

• Group B, Monitor well in case or infection or something in Virgina is messing with it Limit activities and monitor the kicks the baby does so you know how its health is - Educare the patient
• DYSTOCITIA abnormal birth- caused by all: long birth, uterine contractions
• Power structures
• Pyshcilcial, position and other reasons, or even abnormal uterine causes

Contarxions and phases

• Latent disorders and frequent pain, acitve hypotonica- or In adequate, and epidural use
• Anterior position with back pain/ fetal head is not able to get out for a lot of reasons
• Position, and psycholigcal state all cause problems. - if going long, the can need a csection
• Can cause hypoxia for Baby from a lot reasons, give ventilator assintance

precipitate labor and interventions

• Maternal risks increased
• Traumas such as uterine and infection Preterm and give more oxygen, blood and make sure they get ready for birth