Midterm Lesson 1: Labor and Delivery Process PDF

**OBJECTIVES:** - At the completion of this chapter, the student will be able to: - Discuss various theories concerning the onset of labor. - Describe signs and symptoms of impending labor. - Distinguish between true and false labor. - Contrast advantages and disadvantages of various...

**OBJECTIVES:** - At the completion of this chapter, the student will be able to: - Discuss various theories concerning the onset of labor. - Describe signs and symptoms of impending labor. - Distinguish between true and false labor. - Contrast advantages and disadvantages of various childbirth settings. - Describe the "5 P's" and how each influences labor and birth. - Differentiate among the 4 stages of labor according to the duration, - work accomplished, contraction patterns, and maternal behaviors. - Identify nursing actions for each stage of labor. - Identify common discomforts during labor and delivery. - List 5 nursing diagnosis applicable to child bearing women. **Intrapartum:** ⦿Also known as Parturition, childbirth, birthing ⦿From onset of contractions, dilation of cervix up to first 4 hours after delivery ⦿All products of conception are expelled (baby, placenta, and fetal membranes) **Intrapartum Care:** care during labor and delivery Toco-and toko- (Gr.) are combining forms meaning childbirth Eutocia-normal labor Dystocia-difficult labor **LABOR:** ⦿Fetal expulsion along with products of conception due to regular, progressive & frequent uterine contractions ⦿Parturient -- woman in labor ⦿Puerpera -- woman who gave birth **THEORIES OF LABOR ONSET** a\. Uterine stretch theory b\. Oxytocin theory c\. Prostaglandin theory d\. Progesterone theory e\. Theory of aging placenta a\. Uterine stretch theory - According to the theory, "any hollow muscular organ when stretched to capacity will contract and empty..." b\. Oxytocin theory - Near term oxytocin production by the posterior pituitary gland increases. Oxytocin stimulates contractions. c\. Prostaglandin Theory: - When the fetus reached maturity, the fetal membrane produces large amounts of arachidonic acid which is converted by maternal decidua into prostaglandins, a hormone that initiate uterine contractions. d\. Progesterone Deprivation Theory: - Progesterone helps maintain pregnancy by its relaxant effect on the smooth muscles of the uterus preventing uterine contractions. - As pregnancy nears term, the production of progesterone by the placenta ↓, this decline in progesterone allows the uterine contractions to occur. e\. Theory of the Aging Placenta: - As the placenta "ages", it becomes less efficient, producing↓ amount of progesterone. This progesterone allows the concentration of prostaglandin and estrogen to rise steadily - Fetal Adrenal response theory. - Hippocrates, the father of medicine, was the first person to propose this theory that certain hormones produced by the fetal adrenal and pituitary gland initiates labor contraction **Maternal Factors Affecting Labor Process (5 P's)** 1\. Passenger 2\. Passageway 3\. Power 4\. Psychologic response of mother 5\. Position of mother during labor and delivery **1. PASSENGER (FETUS)** I. HEAD - Biggest part of the fetal body \- Always the presenting part \- Turn to present smallest diameter ⦿Biological influences - A pregnancy that terminates during the 38--42-week gestation is likely to indicate a healthy fetus. ⦿Mechanical influences › Fetal head › Fetopelvic relationships › Cardinal movements **Fetal Head: a mechanical influence** ⦿Bones: The head is the largest portion of the fetal body, & because it is a firm, noncompliant bony structure, it is the fetal component that is of most significance (from an obstetrical perspective). ⦿Sutures & Fontanelles: Between the bones of the fetal head are membranous spaces called sutures. The fontanelles are areas of the head where suture lines intersect. ⦿Landmarks: Head is divided into designated areas (1) the sinciput or brow portion; (2) the vertex, or top of the head between the 2 fontanelles; (3) the occiput or back of the head over the occipital bone. ⦿Diameters: During birth it is desirable that the smallest diameter of the fetal head moves through the maternal bony pelvis. The diameter that presents through the pelvis depends on the amount of flexion or extension of the head (attitude) \*SUTURE LINES -- allow skull bones to overlap (molding) and for further brain development ⦿MOLDING -Due to uterine contractions -Head is pressing against the cervix ⦿Making skull to ↓ in size ⦿Easier passage thru birth canal - Sagittal Suture -between 2 parietal bones - Frontal Suture-between 2 frontal bones - Coronal Suture-between frontal and parietal - Lambdoidal Suture-between parietal and occipital FONTANELS- intersection of suture lines **Anterior Fontanel or Bregma** \> intersection of SFC \> diamond shaped, closes b/n 12 -- 18 months \>3 x 4 cm **Posterior Fontanel or Lambda** \>triangular shaped, closes b/n 2 -- 3 months **Transverse Diameters (BBB)** \*Biparietal -- most important TD - greatest diameter presented to the pelvic inlet's AP and at the outlet's TD - average measurement is 9.25cm \*Bitemporal - average measurement is 8cm \*Bimastoid - average measurement is 7cm **Anteroposterior Diameters:** \*Suboccipitobregmatic -- smallest APD - fully flexed (presenting part) - measured from the inferior aspect of occiput to the anterior fontanel - average measurement is 9.5 cm \*Occipitofrontal -- head partially extended and presenting part is the anterior fontanel - average size is 12cm \*Occipitomental -- head is extended and the presenting part is the face - measured from the chin to the posterior fontanel - average size is 13.5 cm  **Fetal LIE** - This is the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother. - If the two are parallel, then the fetus is said to be in a longitudinal lie. - If the two are at 90-degree angles to each other, the fetus is said to be in a transverse lie. - Nearly all (99.5%) fetuses are in a longitudinal lie. **Fetal PRESENTATION:** - Refers to the fetal part that enters the pelvic inlet first and leads through the birth canal during labor. - The fetal presentation maybe: 1\. Cephalic 2\. Breech 3\. Shoulder **ADVANTAGES OF CEPHALIC PRESENTATION** - The fetal head is usually the largest part of the infant. Once the fetal head is born, the rest of the body usually delivers without complications. - The fetal head is capable of molding. There is sufficient time during labor and descent for molding of the fetal head to occur. Molding helps the fetus to maneuver through the maternal birth passage. - The fetal head is smooth and round, which is the optimal shape to apply pressure to the cervix and aid in dilatation. **FETAL ATTITUDE/HABITUS** - refers to the relationship of the fetal parts to one another. - Fetus is described as in a state of flexion or extension.  **Types:** Complete flexion, moderate flexion, poor flexion, hyperextension  **Presentation of Passenger** Lie A. Longitudinal Lie 1\. Cephalic (head) Presentation a1.1 Vertex -- most ideal \- suboccipitobregmatic is presented (9.5 cm) Attitude -Complete flexion  PRESENTATION a1.2 Brow -occipitomental is presented (13.5 cm) ATTITUDE \- Moderate flexion PRESENTATION A1.3 Sinciput -- occipitofrontal is presented (12.5 cm) ATTITUDE \- Partial flexion (military position)  PRESENTATION A1.4 Face presentation ATTITUDE \- Extension PRESENTATION A1.5 Chin presentation ATTITUDE \- Hyperextended **BREECH PRESENTATION** - Fetal buttocks enter maternal pelvis first - 3% of births - Most likely to occur in preterm births or in the presence of fetal abnormality such as hydrocephaly - Also associated with abnormalities of the maternal uterus or pelvis - Delivery is usually accompanied by CS PRESENTATION A2.1 Complete breech \- feet & legs flexed on the thighs and the thighs are flexed on the abdomen ATTITUDE \- Good flexion PRESENTATION A2.2 Frank breech \- hips flexed and legs extended (MOST COMMON) ATTITUDE \- Moderate flexion  PRESENTATION A2.3 Footling Breech -- one or both feet are the presenting parts ATTITUDE \- Very poor flexion **DISADVANTAGES ASSOCIATED WITH BREECH PRESENTATION:** - Increased risk for umbilical cord prolapse - The presenting part is not as smooth as the fetal head and is less effective in dilating the cervix - Once the fetal body(abdomen) is delivered, the umbilical cord can become compressed **SHOULDER PRESENTATION** - Transverse lie - Rare (1%) - Maternal abdomen appears large from side to side, rather than up and down - May demonstrate a lower-than-expected AOG; low fundic height - Presenting part may be fetal arm, back, abdomen or side - Occurs often with preterm birth, parity PROM, hydramnios and placenta previa Causes: 1\. relaxed abdominal wall 2\. placenta previa PRESENTATION \- Shoulder Presentation -- fetus is lying perpendicular to the long axis of the mother \- vaginal delivery is NOT POSSIBLE ATTITUDE \- Flexion \***Compound Presentation** -- when there is prolapsed of the fetal hand alongside the vertex, breech, or shoulder. **FETAL POSITION:** - Relationship of the fetal reference point (Occiput, Mentum, Sacrum or Acromion process) to one of the four quadrants of the mother's pelvis - Anterior, Posterior, Transverse - Right or left of maternal pelvis - To identify whether the fetus is in optimal position for vaginal birth \*Posterior positions result in more backaches because of pressure of the fetal presenting part on the maternal sacrum\* **Possible fetal positions** **A. Vertex** LOA -- left occipitoanterior (most common and favorable position at birth) LOP -- left occipitoposterior LOT -- left occipitotransverse ROA -- right occipitoanterior ROP -- right occipitoposterior ROT -- right occipitotransverse  **Possible fetal positions** **B. Breech** LSA -- left sacroanterior LSP -- left sacroposterior LST -- left sacrotransverse RSA -- right sacroanterior RSP -- right sacroposterior RST -- right sacrotransverse **Possible fetal positions** **C. Face** LMA -- left mentoanterior LMP -- left mentoposterior LMT -- left mentotransverse RMA -- right mentoanterior RMP -- right mentoposterior RMT -- right mentotransverse  **Possible fetal positions** **D. Shoulder** LADA -- left acromiodorsoanterior LADP -- left acromiodorsoposterior RADA -- right acromiodorsoanterior RADP -- right acromiodorsoposterior **STATION** - relationship of the presenting part of the fetus to the ischial spine of the mother. **Minus (-) station** -- presenting part is above the ischial spine **Zero (0) station** -- presenting part is at the level of the ischial spine **Positive (+) station** -- presenting part is below the level of the ischial spine **FLOATING** -- head is movable above the pelvic inlet **+1 station** -- fetus is engaged **+2 station** -- fetus is in midpelvis **+4 station** -- perineum is bulging **2. PASSAGEWAY (PELVIS)** **FUNCTIONS (Sit Sit)** ○ Serves as birth canal ○ It proves attachment to muscles, fascia, and ligaments ○ Supports uterus during pregnancy ○ It provides protection to the organs found within the pelvic cavity Major pelvic bones include the innominate bones (formed by the fusion of the ilium, ischium, and pubis around the acetabulum), the sacrum, and the coccyx. **DIVISIONS:** Pelvis is arbitrarily divided into halves -- the false pelvis and the true pelvis. False pelvis: wide broad area btw. the iliac crests & has no major clinical significance for L&D.  **Important Measurements:** 1\. Diagonal Conjugate -- measure between sacral promontory and inferior margin of the symphysis pubis. Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC -- 11.5 cm=true conjugate) 2\. True conjugate/conjugate vera -- measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm 3\. Obstetrical conjugate -- smallest AP diameter. Pelvis at 10 cm or more. 4.Tuberischi Diameter -- transverse diameter of the pelvic outlet. Ischial tuberosity -- approximated with use of fist -- 8 cm & above. **SOFT PASSAGE THROUGH MATERNAL SOFT TISSUE STRUCTURES:** - Soft tissues of the cervix, vagina, and perineum must stretch to allow passage of the fetus through the axis of the birth canal. - Progesterone & relaxin help facilitate the softening & increase the elasticity of muscles & ligaments. **1. Gynecoid** - Normal female pelvis - Round & wide - Good vaginal delivery **2. Anthropoid** - Narrow, oval - Like ape pelvis - Good Vaginal Delivery **3. Platypelloid** - Flat - Poor vaginal delivery **4. Android** - Heart-shaped - like male pelvis - Poor vaginal delivery **3. POWERS** **PHASES OF UTERINE CONTRACTIONS** ⦿Force of uterine contractions ⦿Refers to: Intensity Duration Frequency Interval of uterine contractions to result in cervical effacement & dilation **PRIMARY POWER** ⦿Uterine contractions **SECONDARY POWER** ⦿Hydrostatic pressure ⦿Intra-abdominal pressure **I. Uterine Contractions (primary power)** - wavelike manner **Intensity:** **[strength]** of uterine contraction **Phases of Intensity:** ⦿Increment -- intensity ↑ builds up & longest phase ⦿Acme -- contraction is at its strongest peak of contraction ⦿Decrement -- intensity ↓ letting down phase **Monitor contractions:** - Rest a hand on woman's abdomen at the fundus of uterus - Sense the gradual tensing and upward rising of fundus that accompanies a contraction. **INTENSITY OF CONTRACTION:** ⦿[Strength] of contraction during acme ⦿Determined by palpation **Mild**-minimally tense, indented easily with fingertips **Moderate**- feels firm; fundus is difficult to indent **Strong**- so intense; uterus feels hard as wooden board at peak of contraction, Fundus is firm, can't be indented with fingers **⦿Duration - [length]** [ ] of uterine contraction - measured from the beginning of a contraction to the end of the same contraction - Seconds - Report if more than 90 sec - During transition phase (2nd stage of labor) **⦿Frequency - [rate]** [ ] of uterine contraction - measured from the beginning of a contraction to the beginning of the next contraction - Minutes - Report if less than 2 minutes **2 Parts** - Duration of contraction - Period of relaxation  **⦿Interval** -- From decrement of first to increment of 2nd contraction **EFFACEMENT:** ⦿Thinning, shortening of cervical canal ⦿Expressed in % ⦿100% effaced cervix = cervical canal is paper thin or absent ⦿75% = cervix is ¼ of its original length ⦿50% = cervix is ½ of its original length **You are ready to push if:** - Cervix is 10 cm dilated & 100% effaced **Dilatation:** - Widening of cervical canal - Advances from 0 -- 10cm - As cervical canal opens = resistance ↓ - This eases fetal descent - 10 cm = fully dilated **FALSE CONTRACTIONS:** - Begin and remain irregular - Felt first abdominally and remain confined to the abdomen and groin - Often disappear with ambulation or sleep - Do not increase in duration, frequency, or intensity - Do not achieve cervical dilation **TRUE CONTRACTIONS:** - Begin irregularly but become regular and predictable - Felt first in lower back and sweep around to the abdomen in a wave - Continue no matter what the patient's level of activity - Increase in duration, frequency, and intensity - Achieve cervical dilatation **ASPECTS OF CONTRACTION** **A. Blood Pressure** -- should not be taken during a contraction as it tends to increase. Because no blood supply goes to the placenta during a contraction, all the blood is in the periphery that is why there is increased BP during uterine contractions. - BP readings should be taken at least every half hour during active labor - When a woman in labor complains of a headache, the first **nursing action is to take BP.** If it is normal, it is only stress headache; if the BP is increased, refer immediately to the doctor (it could be a sign of toxemia) **B. Fetal heart rate (FHR)** - should not be mistaken for uterine soufflé (synchronizes with maternal pulse rate) Normally 120 to 160 per min. - Should not be taken during a uterine contraction because it tends to decrease. Compression of the fetal head when the uterus contracts stimulate the vagal reflex which, in turn, causes bradycardia - Should be taken every hour during the latent phase of labor, every half hour during the active phase and every 15 minutes during the transition period - For any abnormality in FHR, the **initial nursing action is to change the mother's position (LLP)** **II. Hydrostatic pressure** - another power that facilitates the process of labor and birth. - Includes the pressure of the fetus within the amniotic sac. - As contractions occur, the membranes and amniotic fluid facilitates dilation and effacement. - Since the lower uterine segment and cervix are regions of lesser resistance, the additional pressure of the amniotic sac is of great importance in promoting the birth process. **III. Abdominal Force** = the final power for labor & birth. - This power is reserved for the 2nd stage of labor, after effacement & dilation are complete. - Maternal pushing, or bearing down effort. - In the expulsion stage, the contraction changes in character, & many women begin to experience an involuntary urge to push. **Patient Monitoring:** ⦿Void Frequently - Full bladder hinders fetal descent - Cause dysfunctional labor - If bladder is distended = it is palpable, notify physician - Catheterization may be necessary **4. Psyche/ Psychologic Response of Mother** ⦿Psychological state ⦿Feelings women bring to labor ⦿Experience & coping mechanisms. **5. Position of the mother:** - Frequent changes in position relieve fatigue, increase comfort, and improve circulation - Laboring woman should be encouraged to find positions that are most comfortable to her Upright Lateral Lithotomy Semi recumbent **Sitting** - uses gravity to help baby's descent; allows rest between contractions **Kneeling** - relieve back pain, helps baby rotate to favorable position (OA); relieves Hemorrhoids **Squatting** - uses gravity to help baby's descent; open pelvis to provide more room **Walking, standing, and leaning** - stimulate effective contractions; use of gravity to help baby's descent   **FALSE LABOR (**CANDAC) **C**ontraction disappears with ambulation **A**bsence of cervical dilation **N**o ↑ DIF (duration, intensity, frequency) **D**iscomfort @ abdomen **A**bsence of show **C**ontraction stops when sedated **TRUE LABOR** (CUPPAD) **C**ontraction persists when sedated **U**terine contraction ↑ DIF (duration, intensity, frequency) **P**rogressive cervical dilation **P**resence of show **A**mbulation increases contractions **D**iscomfort radiates to lumbosacral area