Labor Stages & Pelvic Anatomy PDF

Labor Labor is a physiologic process during which the products of conception (the fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus. Labor is achieved with changes in the biochemical connective tissue and with gradual effacement and dilatation of the uterine cervix...

Labor Labor is a physiologic process during which the products of conception (the fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus. Labor is achieved with changes in the biochemical connective tissue and with gradual effacement and dilatation of the uterine cervix as a result of rhythmic uterine contractions of sufficient frequency, intensity, and duration.  Premonitory Signs of Labor 1. Lightening. Settling/ dropping of the presenting part into the pelvic inlet or true pelvis. And when the largest diameter of the presenting part passes the pelvic inlet or pelvic brim, the head is said to be engaged. Lightening happens 10-14 days before labor in a primigravida and 1 day before labor or on the day of labor in multipara. Lightening is heralded by the following SIGNS: 2. Relief of dyspnea 3. Relief of abdominal tightness 4. Increased frequency of voiding 4.Increased varicosities 5.Shooting pains down the legs/leg cramps. 2. Increased Braxton Hicks’ contractions 3-4 weeks before labor. Braxton Hicks’contractions are false labor contraction, painless, irregular abdominal and relieved by walking. 3.A sudden burst of maternal energy/activity because of hormone epinephrine. 4. Slight decrease in maternal weight, about 2-3 lb. This is related to a drop in the water retaining hormone progesterone. If progesterone hormone drops before labor, retained fluid is excreted and thus , slight weight loss. 5. Show. This is mucus mixed with small amount of blood from the torn capillaries of the cervix giving it a pink tint. Show should be differentiated from bleeding. Show is not bleeding. Bleeding, no matter how slight, is still bleeding and is considered a danger sign. 6. Softening/ ripening of the cervix. 7. Rupture of the bag of water is an occasional sign. 8. Nesting behavior. This is a psychosocial sign of approaching labor. The woman is busy preparing for the arrival of the baby: sewing diapers, buying a crib, preparing mittens and bonnets, decorating a spare room for the baby. TRUE LABOR 1. True labor contraction are:  Regular, progressive, with increasing duration, intensity and decreasing intervals;  With discomfort that starts from the back ( lumbosacral) radiating to the front;  Intensified by walking and enema. 2. Show is present and increasing in true labor. 3. The cervix is open and increasingly dilates and effaces. The presence of cervical dilatation is the most important sign of true labor.  The expectant mother should be counseled that the moment premonitory signs are noted:  She should refrain from engaging in long trips,  she should have someone with her always in the home. Likewise, the expectant mother should contact her doctor or midwife about labor or go to the hospital if:  Show is present;  Contractions are regular, more intense and becoming increasingly frequent occuring every 5 to 8 minutes: or  The bag of waters ruptures. The rupture of the bag of waters is always an indication for hospitalization.  Differentiation between true and false contraction True Contraction  Begins irregular but become regular and predictable.  Felt first in the lower back sweep around to the abdomen in a wave.  Continue no matter what the woman’s level of activity.  increase in duration, frequency and intensity.  Achieve cervical dilation and effacement. False Contraction  Begins and remain irregular.  Felt first abdominally and remain confined to the abdomen and groin.  Often disappear with ambulation and sleep.  Do not achieve cervical dilatation.  COMPONENTS OF LABOR 5P’s  Passage  Passenger  Power  Psyche  Position PASSAGE refers to the route the fetus must travel from the uterus through the cervix and vagina to the external perineum, because these organs are contained inside the pelvis the fetus must also pass through the pelvic ring.  The bony pelvic is divided by the linea terminalis into the false and true pelvis bone.  The true pelvis has 3 subdivisions: 1.Inlet or upper pelvic opening 2. Mid-pelvis or pelvic cavity 3. Outlet or lower pelvic opening 2 pelvic measurements are important to determine the adequacy of the pelvic size.  Diagonal conjugate- anterior posterior diameter of the inlet-11 cm. or greater.  Transverse diameter- 13.cm.  CPD  Pelvimetry Functions of pelvis  It provides protection to the organs found within the pelvic cavity.  It provide attachment of muscle, fascia and ligaments  Supports the uterus during pregnancy.  Serves as birth canal TYPES OF PELVIS The Gynaecoid pelvis This is the ideal pelvis for childbearing. The gynecoid pelvis is one that is generally characteristic of a woman in its bone structure and therefore its shape. Gynecoid means like a woman, womanly, female. The female sacrum is wider than the male's and the iliac bone is flatter.  Justo minor pelvis: This pelvis is like a gynaecoid pelvis in miniature. All diameters are reduced but are in proportion. It is normally found in women of small stature, less than 1.5m in height, with small hands and feet, but occasionally found in women of normal stature. The outcome of labor in this situation depends on the fetus. If the fetal size is consistent with the size of the maternal pelvis, normal labor and birth will take place. Often these women have small babies and the outcome is favorable. However, if the fetus is large, a degree of cephalopelvic disproportion will result. The same is true when a malpresentation or malposition of the fetus exists. The android pelvis is a female pelvis with masculine features, including a wedge or heart shaped inlet caused by a prominent sacrum and a triangular anterior segment. The reduced pelvis outlet often causes problems during child birth. The android or male pelvis is more robust, narrower, and taller than the female pelvis. The angle of the male pubic arch and the sacrum are narrower as well. The female pelvis is more delicate, wider and not as high as the male pelvis. The angle of the female pubic arch is wide and round.  The anthropoid pelvis This has a long, oval brim in which the anteposterior diameter is longer than the transverse. The side walls diverge and the sacrum is long and deeply concave. The ischial spines are not prominent and the sciatic notch is very wide, as is the sub-pubic angle. Women with this type of pelivs tend to be tall, with narrow shoulders. Labor does not usually present any difficulties.  The platypelloid pelvis This flat pelvis has a kidney-shaped brim in which the anteposterior diameter is reduced and the transverse increased. The side walls diverge, the sacrum is flat and the cavity shallow. The ischial spines are blunt, and the sciatic notch and the sub- pubic angle are both wide STRUCTUREANDPARTSOFTHEPELVIS 1. Innominate bones- forms the anterior and lateral aspect of pelvis. a. Ilium- the upper flaring portion which is the largest bone of the pelvis. Its upper, boarder the iliac crest, forms the hip bone. b. Ischium- the portion located below the hip joint. Its ischial tuberosities supports the body in the sitting position. c. Pubes- the front bones. The pubes are connected by the symphisis pubis. 2.Sacrum- the sacrum is the triangular shaped bone forming the triangular portion of the pelvis. It is composed of 5 sacral vertebra. The first sacral vertebra, the Sacral promontory is an important obstetrical landmark. 3. Coccyx- It is the posterior portion of the pelvis composed of the five fused vertebra. Its sacrococcygeal joints joins the sacrum to coccyx into the pelvic canal , the coccyx moves slightly backward to give more room for the fetal head.  Division of the Pelvis 1. False Pelvis- the upper flaring portion of the iliac, its function is to provide support to the uterus during pregnancy and to direct the fetus to true pelvis during labor. 2. True Pelvis- forms the passage way of the fetus during labor, it consists of the following parts. a. Inlet or pelvic brim AP diameter  Diagonal conjugate- 12.5 cm diameter between the midpoint of sacral promontory to the lower margin of the symphisis pubis. Measured by internal examination.  Obstetric Conjugate- 11 cm. distance between the midpoint of the of the sacral promontory to the midline of the symphisis pubis which is ascertained by subtracting 1 to 1.5 cm from the diagonal conjugate.  Conjugata vera b. Pelvic Canal- situated between inlet and outlet. The pelvic and canal curves at its half, below the ischial spine. This curvature is so designed by nature to control the speed of descent of the fetal head. Rapid descent can result to rapture of cerebral arteries due to sudden change in pressure. Snugness of pelvic cavity compress the chest, helping to expel lung fluid and mucus.  Interspinous (smallest diameter of pelvic)-10cm  AP diameter at level of ischial spines-11.5 cm  Posterior sagittal diameter-4.5cm c. Outlet- the most important diameter of the outlet is its transverse diameter or Bi-ischial (distance between two ischial tuberosities) which is about 11.5cm  Posterior sagittal diameter-7.5cm. Monitoring Uterine Contractions Caring for a woman in labor entails monitoring her uterine contraction accurately, there should have an understanding of “basics” related to the ute- rine contraction. THE UTERINE CONTRACTION The uterine contraction is the primary power in labor. It is the one that effects the physiologic alterations in labor which are: 1.Cervical dilatation - opening/widening/enlarging of the cervical os from pin point opening to 10 cm (fully dilated cervix) 2.Cervical effacement - shortening/narrowing/thinning of the cervical canal from about 2.5cm to paper-thin or no canal at all. 3.Physiologic retraction ring - the separation or differentiation of the active, shorter but thicker upper uterine segment from the lower, longer but thinner, passive uterine segment.  The upper passage contracts, retracts, and expels the fetus while the lower uterine segment and the cervix dilate and thereby form a greatly expan- ded , thinned-out muscular and fibro muscular tube through which the fetus can can pass. In obstructed labor, the thinning of the lower segment is extreme that the retraction ring become prominent forming a pathologic retraction ring called “ Bandl’s ring”. Uterine contractions are involuntary and for most part is independent of extra uterine control, rhythmical, intermittent, regular and painful. HOW UTERINE CONTRACTION CAUSE PAIN The exact cause of pain in labor is not known but several have been Suggested 1. Hypoxia due to circulatory stasis in the myometriun and adjacent tissues which may cause local oxygen deficit. 2. Cervical stretching during dilatation 3. Traction on and stretching of the overlying peritoneum and uterocervical supports during contraction and expulsive efforts. 4. Compression of nerve ganglia in the cervix and lower uterus by the tightly interlocking bundles. 5. Emotional tension caused by fear and anxiety. 6. Pressure by the presenting part on the bladder, bowel, or other sensitive pelvic structures PHASES OF A UTERINE CONTRACTION 1. Increment - the “ building up” of contraction; period of increasing cont- raction; the longest phase. 2. Acme - the peak of a contraction 3. Decrement - the period of “letting down” or decreasing contraction CHARACTERISTICS OF UTERINE CONTRACTION In describing a contraction, the following characteristics should be considered Duration – the length of time a contraction lasts; the time from the incre- ment (start/increasing contraction) of one contraction up to the decrement (end /decreasing contraction) of the same contraction. Frequency – the time interval between the beginning of one contraction to the beginning of the next contraction. Interval of Rest – as a characteristic of uterine contraction is the time from the end of one contraction to the start of the next contraction. It corr- esponds to the period of rest of the uterus at which time it is to: a. auscultate FHT b. check maternal blood pressure c. deliver the head in extension  The interval of contraction diminishes gradually from about 10 minutes at the onset of the first stage of labor to as little as 1 minute or less in the second stage Intensity – refers to the strength of a contraction at acme. It is usually estimated by palpating the contraction. Judging the amount of indentability of the uterine wall during the acme of contraction, the midwife determines whether it is mild, moderate or strong. If the uterine wall can be indented easily, the intensity is considered mild. When the uterine wall cannot be indented, it is considered strong intensity. Moderate intensity falls between these two ranges. RULES IN PALPATION OF UTERINE CONTRACTION 1. Use FINGERTIPS ( not the palmar surface), and the fingers must be kept moving The fingertips is the most sensitive portion of the hand. 2. Placed fingertips LIGHTLY, and not firmly on the abdomen. The pacemaker sites in the uterus most often appear to be near the utero- tubal junction so that the uterus begins to contract in the fundal portion (fundus palpation for increment timing) and the end of a contraction is felt in the lower portion of the uterus, not the fundus (lower uterus palpation for decrement timing). SAMPLE CASE: Judy, G1P0, is admitted to the labor unit in active labor. Her cervix is 5cm open,80% effaced : presentation – cephalic; bag of waters – intact (+); station – 0.  In monitoring her labor you noted that the uterus contracted at 8 o’clock in the morning. This contraction was moderate in intensity and lasted 30 seconds. At 8:05,another contraction started with moderate intensity lasting for 30 seconds again. Using this case, the characteristics of the contractions can now be identified. The period from 8:05 is the FREQUENCY: the time interval from the start of one contraction to the start of another. Thirty seconds is the DURATION: the time interval from the start of the contraction (8:00) upto the end of the same contraction (8:00:30). And the period from 8:00:30 upto 8:05 is the INTERVAL.  STAGES OF LABOR FIRST STAGE (DILATING STAGE) 3 PHASES 1. LATENT PHASE or Preparatory phase Begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilation begins. Contractions are mild and shorts, lasting 20 to 40 secs. Cervical effacement occur and cervix dilates from 0- 3 cm. The phase last approximately 6 hours in a nullipara and 4.5 in multipara. Factors for prolong latent phase Non ripe cervix Analgesia given too early Cephalopelvic disproportion Emotional reaction: Excited, alert, talkative or quiet, calm or anxious. NURSING RESPONSIBILITIES: This is the best time to teach breathing techniques and to give instruction bec. The woman is still comfortable, cooperative and can still concentrate on conversation well.  2. ACTIVE PHASE Cervical dilatation occurs more rapidly, increasing from 4-7 cm. Contractions grow stronger, lasting 40-60 secs., and occur approximately every 3-5 mins. This phase last approximately 3 hours in nullipara and 2 hrs. in multipara. Increasing vaginal secretions and spontaneous rupture of membranes my occur. Difficult time for a woman bec. Contractions grow strong, last longer, and begin to cause true discomfort. EMOTIONAL RESPONSE: discomfort, perspiring, flushed, fear losing control, irritable and self focused. NURSING RESPONSIBILITIES: Coach woman on breathing and relaxation technique, abdominal breathing is recommended during latent and active phase. Prescribed analgesic are given. Before giving analgesics, assist woman to void, take maternal v/s and FHT. After taking analgesics: instruct woman to remain in bed, keep noise to minimum Raised side rails Place woman on NPO Check BP 30 mins. After giving analgesics to make sure it is not causing hypotension.  3. TRANSITION PHASE Contractions reach their peak intensity, occurring every 2-3 mins. With a duration of 60-90 secs and causing maximum dilatation of 8-10 cm. If the membranes have not previously ruptured or been ruptured by amiotomy, they will rupture as a rule at full dilatation. End of this phase, both full dilatation and complete cervical effacement have occurred. Most difficult period for the woman. EMOTIONAL RESPONSE: Intense discomfort, so strong that it is accompanied by nausea and vomiting, feeling of loss of control, woman may feel discouraged, repeatedly ask the nurse when labor will end, anxiety, panic, resist being touched, focuses entirely inward on the task of birthing her baby increasing show legs are shaking there is an irresistible urge to push  NURSING RESPONSIBILITIES: Reassure woman that labor is nearing end and baby will be born soon. Reinforced breathing and relaxation technique. Encouraged pant blow breathing, to remove the urge to bear down. Discourage to bear down if she feels the urge to do so. INFLUENCE OF CATECHOLAMINES (e.g. epinephrine, adrenalin) Produced in the brain, nerve endings, adrenal medulla and other body organ. Catecholamine levels are likely to rise in response to increasing stress, pain or intra partum complications during labor. Normal catecholamines production is beneficial because It prepares the body for action and expenditure of energy. Excessive amount may have deleterious effects – decreased efficiency of uterine contractions, longer labor and shunting of blood away from the uterus and placenta. The fetus also produces increasing amount of catecholamines ( nor epinephrine) in response to stress of normal labor and temporary hypoxia caused by normal contractions. Production of fetal catecholamines causes more blood to shunt to vital organs, increased oxygen uptake, and helps to prevent fetal hypoglycemia.  CARE OF THE BLADDER A woman in labor should be encourage to void frequently, at least every 2 hours to prevent bladder distention because a full bladder: Delay fetal descent Predispose to urinary tract infection Prevent uterus from contracting Can be traumatized during labor SECOND STAGE OF LABOR Begins with complete dilatation and effacement of the cervix to birth of the infant. Contractions change from the characteristics of crescendo- decrescendo pattern to an overwhelming uncontrollable urge to push, blood vessel in the neck may become distended. As the fetus touches the internal side of the perineum, the perineum begins to bulge and appears tense. The anus may become inverted, and stool may be expelled. As the fetal head pushes against the perineum, the vaginal interitous opens and the fetal scalp appears at the opening to the vagina. At first ,the opening is slit like, then becomes oval and then circular. The circle enlarges from the size of a dime, then quarter, then half dollar this is called CROWNING.  Maternal Pushing Pushing is voluntary bearing down effort, a secondary power involved in labor. When to Push Pushing is needed to help the primary power, the uterine contraction, in promoting expulsion of the fetus. The woman in labor should push: 1. In the second stage of labor or from the moment the cervix is fully dilated or 10cm open. Pushing becomes a reflex or spontaneous in the second stage of labor because of greater pressure on the rectum. As the fetal head reaches the pelvic floor, most women experience the urge to push. 2. During uterine contraction. the woman should not push at intervals of contraction. This will only tire her unnecessarily. When Not to Push The woman should not push: 2. At interval of contraction and in crowning. 3. Before complete cervical dilatation as this can result to the following: a. greater maternal fatigue b. added fetal strain c. possible injury to the fetal presenting part.  d. possible injury to the cervix:  Cervical edema due to chronic passive congestion which can further delay cervical dilatation and predispose to cervical laceration.  Cervical bruising or trauma as it is forced against the symphysis pubis during pushing. 3. When the woman on labor has a cardiac disease. pushing can cause more straining of the disease heart and can predispose to cardiac failure. The woman with cardiac disease will have minimal regional anesthesia to eliminate the spontaneous pushing and the pain of labor. A cardiac mother will also have shorter second stage of labor as the physician is likely to use forcep extraction. Pushing efforts or tendency can be controlled with the woman taking panting breaths similar to blowing of candles. In bearing down, the woman contracts her diaphragm and abdominal muscles while relaxing her pelvic floor and pushes out the content of the birth canal. HOW TO PUSH  As the woman begins to feel a contraction, she takes a deep breath and blows it all out.  The woman takes a second deep breath which she holds as she closes her mouth, puts her chin on her chest and she bears down.  When the woman “ runs out of air” before the contraction ends, she should take another deep breath and continue pushing. Short pushes are ineffectual, but prolonged pushing so that the woman is holding her breath for more than 5 seconds is NOT recommended.  Holding the breath for more than 5seconds can result to the following: 1. Valsalva manuever. This results to woman’s closing her glottis, thereby increasing intrathoracic and cardiovascular pressure, definitely hazardous for a cardiac mother in labor. 2. Diminished feto-placental gas exchange 3. Diminished perfusion of oxygen across the placenta. The last two effects can result to fetal hypoxia and fetal distress.  Mechanism of Labor  Passage of the fetus through the birth canal involves a number of different position changes to keep the smallest diameter of the fetal head always presenting to the smallest diameter of the birth canal. These position changes are termed Cardinal movements of labor. They are descent, flexion, internal rotation, extension, external rotation, and expulsion.  Descent – is the downward movement of the biparietal diameter of the fetal head to within the pelvic inlet. Full descent occurs when the fetal head extrudes beyond the dilated cervix and touches the posterior vaginal floor. The pressure of the fetus on the sacral nerves causes the mother to experience a pushing sensation. Descent occurs because of pressure on the fetus by the uterine fundus. Full descent may be aided by abdominal muscle contraction.  Flexion- As descent occurs pressure from the pelvic floor causes the fetal head to bend forward onto the chest. The smallest AP diameter is the one presented to the birth canal in this flexion position. Flexion is aided by abdominal muscle contraction during pushing.  Internal Rotation- during descent the head enters the pelvis with the AP head diameter in a diagonal or transverse position. The head flexes as it touches the pelvic floor, and the occiput rotates until it is superior, or just below the symphysis pubis, bringing the head into the best diameter for the outlet of the pelvis. This movement brings the shoulders coming next, into the optimum position to enter the inlet or puts the widest diameter of the shoulders in line with the wide transverse diameter of the inlet.  Extension- as the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. The head thus extends, and the foremost part of the head, the face and chin are born. External Rotation- In external rotation, almost immediately after the head of the infant is born the head rotates back to the diagonal transverse position of the early part of labor. The after coming shoulders is best for entering the outlet. The anterior shoulder is delivered first, assisted perhaps by downward flexion of the infant’s head. Expulsion- once the shoulders are delivered, the next of the baby is delivered easily and smoothly because of its smaller size. This expulsion and is the end of pelvic division of labor. Ritgen’s Manuever- an obstetrical procedure use to control delivery of the fetal head and to prevent laceration.  THIRD STAGE OF LABOR Placental stage, begins with the birth of the infant and ends with delivery of the placenta. 2 Separate phases A. Placental separation B. Placental expulsion Signs of placental separation Change in shape of the uterus or calkin’s sign- earliest sign Lengthening of the umbilical cord Sudden gush of vaginal blood Firm contraction of the uterus Appearance of the placenta at the vaginal opening 2 types of placental separation Schultze- if the placenta separate first at its center and lastly at each edges, it tend to fold like an umbrella and presents at the vaginal opening with fetal surface, appearing shiny and glistening from the fetal membrane. Duncan- placenta separate first at its edges, it slides along the uterine surface and present at the vagina with the maternal surface, it looks like raw, red, and irregular, with the ridges or cotyledons that separate blood collection spaces showing. Shiny for schultze and dirty for Duncan. Normal blood loss is 300-500 ml. B. Placental Expulsion Do not hurry the expulsion of the placenta by forcefully pulling down, just wait for the sign of placental separation. The placenta is delivered either by the natural bearing down effort of the mother or by gentle pressure on the contracted uterine fundus ( crede’s maneuver) Modified Crede’s maneuver- using uterine fundus as a piston the separate placenta is pushed down ward to vagina. Brant Andrew’s maneuver- tracking the cord slowly, winding it around the clamp until placenta comes out, rotating it slowly so that no membrane’s are left inside the uterus. Once the placenta is delivered, oxytocin is usually ordered to be administered intramuscularly or intravenously, it increases uterine contractions thereby minimizes uterine bleeding. Oxytocin (pitocin) may be added to the existing intravenous line or given as 10 u intramuscularly.  Inspecting placenta for completeness and normality A.Assessing Placental membrane The placental membranes are the amniotic membranes, which are made up of the chorion and amnion. B. Assessing the maternal side First, remove theblood clots from the maternal side. Place the blood clots in a container so the amount of blood loss can be ascertained more accurately later. Determine the health of the maternal side. A normal healthy maternal side has a dark-bluish red color and a firm consistency. Determine completeness of cotyledons.if the placenta is complete ( about 15-20) and id laid flat on a surface, they will fit together. C. Assessing fetal side. Check umbilical cord for insertion. Measure its length. It is usually 55-60 cm, with mean length being about 55cm. If cord length is less then 35-40cm. The cord is considered short , short cord can be a factor to uterine inversion and abratio placenta as traction is exerted onto cord every time the fetus moves owing to inadequate allowance for mobility. Check for infarcts. Infarcts are areas of necrosed chorinic villi. They are reddish in the early stage and later become whitish areas usually about 2.5cm or more in diameter. Check for the presence of 3 blood vessels; one umbilical vein,left, and two umbilical arteries left and right. incomplete cord blood vessels is associated with genitourinary problems, particularly renal disorder. The umbilical vein and arteries close at birth with cord clamping. The vein later becomes LIGAMENTUM TERES and the arteries later become the UMBILICAL LIGAMENTS. D. Measuring and weighing the placenta After a thorough inspection of the placenta, it is then weighed and measured. A mature placenta weighs about 500gs, or one-sixth of the weight of the baby, at term. It is about 20cm in diameter and 1 inch in thickness.  Maternal Analgesia and Anesthesia NARCOTIC ANALGESICS Often given during labor because of their potent analgesic effects. Narcotic analgesic commonly used- meperidine hydrochloride( Demerol), morphine sulfate, nalbuphine ( nubain), and butorphanol tartrate (stadol). Meperidine is advantageous as an analgesic in labor bec. It has additional sedative and antispasmodic actions; these make it effective not only for relieving pain but also for helping to relax the cervix and providing a feeling of euphoria( an exaggerated or abnormal sense of physical and emotional well being not based on reality or truth) and well being. It maybe given either IM or IV, the dose is 25-100mg. , depending on a woman’s weight and the route of administration, the drugs begins to act about 30 mins. After IM injection and about 5 mins. After IV administration. Its duration of act is 2-3 hours. Demerol crosses the placenta, it can cause respiratory depression in a fetus, the drug crosses the placenta mins. after administration to the mother, however, bec. the fetal liver takes 2 to 3 hours to activate the drug into the fetal system, the effect will not be registered in the fetus for 2 to 3 hours after maternal administration, so Demerol is given when the mother is more than 3 hours away more birth. LUMBAR epidural, local anesthetic ( ropivacaine/ naropin), administered for 1 st stage of labor with contineous block, anesthesia will last through birth; injected @ L3-4. Effect on mother rapid onset in mins.; lasting 60-90 min; loss of pain perception for labor contractions and birth; possible maternal hypotension. Pudendal block - Local anesthetic lidocaine ( xylocaine). Administered just before birth for perineal anesthesia; injected through vagina. Effects on mother, rapid anesthesia of perineum. Local infiltration of perineum- Local anesthetic lidocaine ( xylocaine). Injected just before episiotomy incision. Effect on mother, anesthesia of perineum almost immediately. General intravenous anesthetic- ( Thiopental) administered IV by anesthesiologist or nurse- anesthetist. Effect on mother rapid anesthesia and rapid recovery.  EPISIOTOMY Is a surgical incision of the perineum that made both to prevent tearing of the perineum and to release pressure on the fetal head with birth. Incision is made with blunt- tipped scissors in the midline of the perineum ( midline episiotomy) or is begun in the midline but directed laterally away from the rectum. ( mediolateral). Mediolateral episiotomy have the advantage over midline cuts, less danger of complication from rectal mucosal tears. Medline episiotomy appear to heal more easily, cause less blood loss, and less postpartal discomfort.  Managing the uterus after placental delivery Immediately after completion of the third stage of labor, the uterus is in the midline, just at the level of the umbilicus or slightly below it and is usually firm. A high, firm fundus usually displaced to one side often indicates urinary distention. 4th stage of Labor The first 2-3 hours after birth. Nursing responsibilities a. Transfer the patient from the delivery table. Remove the drapes and soiled linen. Remove both legs from the stirrups at the same time and then lower both legs down at the same time to prevent cramping. Assist the patient to move from the table to the bed. b. Provide care of the perineum. An ice pack may be applied to the perineum to reduce swelling from episiotomy especially if a fourth degree tear has occurred and to reduce swelling from manual manipulation of the perineum during labor from all the exams. Apply a clean perineal pad between the legs.  c. Transfer the patient to the recovery room. This will be done after you place a clean gown on the patient, obtained a complete set of vital signs, evaluated the fundal height and firmness, and evaluated the lochia. d. Ensure emergency equipment is available in the recovery room for possible complications. (1) Suction and oxygen in case patient becomes eclamptic. (2) Pitocin® is available in the event of hemorrhage. (3) IV remains patent for possible use if complications develop. e. Check the fundus. (1) Ensure the fundus remains firm. (2) Massage the fundus until it is firm if the uterus should relax.  3) Massage the fundus every 15 minutes during the first hour, every 30 minutes during the next hour, and then, every hour until the patient is ready for transfer. (4) Chart fundal height. Evaluate from the umbilicus using fingerbreadths. This is recorded as two fingers below the umbilicus (U/2), one finger below the umbilicus (1/U), and so forth. The fundus should remain in the midline. If it deviates from the middle, identify this and evaluate for distended bladder. (5) Inform the Charge Nurse or physician if the fundus remains boggy after being massaged. NOTE: A boggy uterus many indicate uterine atony or retained placental fragments. Boggy refers to being inadequately contracted and having a spongy rather than firm feeling. This is descriptive of the postdelivery of the uterus. f. Monitor lochia flow. Lochia is the maternal discharge of blood, mucus, and tissue from the uterus. This may last for several weeks after birth.  1) Keep a pad count. Record the number of pads soaked with lochia during recovery. (2) Identify presence of bright red bleeding or blood clots. (3) Document thick, foul-smelling lochia. (4) Observe for constant trickle of bright red lochia. This may indicate lacerations. (5) Identify lochia amounts as small, moderate, or heavy (large). (6) Document lochia flow when the fundus is massaged. (a) Every fifteen (15) minutes times one hour. (b) Every thirty (30) minutes times one hour. (c) Every hour until ready for transfer. Assessing lochia flow.  Classification of Lochia 1. Lochia rubra is vaginal discharge during the first 3 days. It is bright red in color, similar to menstrual bleeding, may be mixed with decidual fragments,and moderate in amount. 2. Lochia serosa is vaginal discharge on the days 4-10. it is still blood – tinged but now pale, serosanguinous, pinkish to brownish and light in amount. The added serous fluid and leukocytes give it the paler, watery color. 3.Lochia alba is vaginal discharge on days 10-14 or as late as day 21, but not uncommon for lochia alba tolast until 6weeks post partum. It is mixture of decidual debris, leucocytes and decreased fluid content giving it characteristics whitish or yellowish-white color scant amount aftr 10 th day.  g. Observe the mother for chills. The cause of the mother being chilled following birth is unknown. However, it refers primarily to the result of circulatory changes after delivery. The best means of relief is to cover the mother with a warm blanket. h. Monitor the patient’s vital signs and general condition. (1) Take BP, P, and R every 15 minutes for an hour, then every 30 minutes for an hour, and then every hour as long as the patient is stable. Take the patient’s temperature every hour. (2) Observe for uterine atony or hemorrhage. (3) Observe for any untoward effects from anesthesia. (4) Orient the patient to the surroundings (bathroom, call bell, lights, etc.). (5) Allow the patient time to rest. (6) Encourage the patient to drink fluids.. Observe patient’s urinary bladder for distention. Be able to recognize the difference between a full bladder and a fundus. (1) Characteristics of a full bladder. (a) Bulging of the lower abdomen. (b) Spongy feeling mass between the fundus and the pubis. (c) Displaced uterus from the midline, usually to the right. (d) Increased lochia flow. (2) Full bladders may actually cause postpartum hemorrhage because it prevents the uterus from contracting appropriately. (3) Nerve blocks may alter the sensation of a full bladder to the patient and prevent her from urinating. (4) If at all possible, ambulate the patient to the bathroom. (5) Urine output less than 300cc on initial void after delivery may suggest urinary retention. (a) Document the fundal height and bladder status before the patient urinates. (b) Reevaluate and document the fundal height and bladder status after the patient urinates to accurately document an empty bladder.  j. Evaluate the perineal area for signs of developing edema and/or hematoma. (1) Predisposing conditions includes prolonged second stage, delivery of a large infant, rapid delivery, forceps delivery, and fourth degree lacerations. (2) Nursing considerations for perineal edema. (a) Apply an ice pack to the perineum as soon as possible to decrease the amount of developing edema. (b) Stress the importance of peri-care and use of “sitz-baths” on the postpartum ward. (c) Assess for urinary distention which is due to edema of the urethra. (3) Assessment for perineal hematoma. (a) Look for discoloration of the perineum. (b) Listen for the patient’s complaints or expression of severe perineal pain. (c) Observe for edema of the area. (d) Observe/listen for patient’s feeling the need to defecate if forming hematoma is creating rectal pressure. (e) Observe for patient’s sensitivity of the area by touch (by sterile glove). k. Observe for signs of hemorrhage. (1) Uterine atony. (2) Vaginal or cervical lacerations. (3) Retained placental fragments. (4) Bladder distention. (5) Severe hematoma in vagina or surrounding perineum.  l. Assess for ambulatory stability. Ambulation is the best way to promote uterine involution. (1) The patient is at risk of fainting on initial ambulation after delivery due to hypovolemia from blood loss at delivery and hypoglycemia from prolonged nothing by mouth (NPO) status. (2) The patient should be accompanied on the first ambulation and observed for stability. (3) Ammonia ampuls should be readily available. (4) The patient should be closely monitored while in the bathroom to prevent injury if fainting does occur. (5) The patient who received regional anesthesia at deliver (that is, pudendal block) should be assessed for possible loss of sensation in the lower extremities. Normal postpartum Psychological adaptations is a mental process which is related to self adjustment of a person after chilbirth Taking-in One of Reva Rubin's three phases that is time immediately after birth when the client needs sleep, depends on other to meet her needs and relives events surrounding the birth process. 24-48 hrs after birth. Taking-hold One of Reva Rubin's three phases that is characterized by dependent and independent maternal behavior. Shows a desire to take charge with support and help from others. 2nd/3rd day- several weeks after birth. Letting-go Reestablishes relationships with other people. She assumes the parental role with more confidence.