Unit 2 (Lesson 1) Recognizing Normal Labor Process PDF

Unit 2 (Lesson 1): Recognizing Normal Labor Process Maternal and Child Course Nursing Notebook MCN Labor Ideally, labor happens wh...

Unit 2 (Lesson 1): Recognizing Normal Labor Process Maternal and Child Course Nursing Notebook MCN Labor Ideally, labor happens when the baby is fully developed at full term, between 37-40 weeks gestation. Labor announces the end of the baby’s time in the uterus and the beginning of adaptation to extrauterine life Only 2% of deliveries occur on the expected date even among women who know their LMP date Parturient a woman in labor What causes labor to begin? Maternal Factors 1. Uterine muscle stretching The uterus stretches to accommodate the growing baby to its maximum capacity during pregnancy. Unit 2 (Lesson 1): Recognizing Normal Labor Process 1  After delivery, the uterine muscles begin contracting to help the uterus return to its normal size and shape (involution). The uterus, as a hollow organ, expands when full during pregnancy and contracts to "empty" itself after birth. Stretching of the uterine muscles triggers the release of prostaglandins, which stimulate uterine contractions. These contractions aid in reducing uterine size, preventing postpartum hemorrhage, and promoting healing. 2. Progesterone deprivation theory As term approaches, the availability of progesterone (which relaxes smooth muscle) decreases in the uterine myometrial cells. Increased estrogen levels cause the uterus to become more sensitive and excited. The shift in hormone balance, with reduced progesterone and higher estrogen, leads to the onset of uterine contractions, signaling the start of labor. 3. Pressure on the cervix Stimulates the maternal posterior pituitary gland. Triggers the release of oxytocin in response to cervical pressure. Increased oxytocin levels enhance uterine contractions, facilitating the labor process. 4. Oxytocin stimulation Oxytocin levels significantly increase during labor. It works alongside prostaglandins to enhance the activation of uterine contractions. Unit 2 (Lesson 1): Recognizing Normal Labor Process 2  This combined effect promotes effective contractions, aiding in the progression of labor. Fetal Factors 1. Placental aging As pregnancy advances, the placenta undergoes aging. This aging process can lead to insufficient nutrients reaching the fetus. The lack of adequate nutrients may signal the body to initiate contractions, promoting the onset of labor. 2. Fetal cortisol concentration Increased levels of fetal cortisol occur as labor approaches. Elevated cortisol levels lead to a decrease in placental progesterone production. This change results in an increase in prostaglandin release. Prostaglandins contribute to the stimulation of uterine contractions, facilitating the labor process. Signs and Symptoms of Impending Labor The changes listed below are usually noted by the primigravid woman at about 38 weeks AOG. In multigravidas, these may not take place until labor begins. 1. Lightening Occurs when the fetal head settles into the birth canal, causing the uterus to move downward. Unit 2 (Lesson 1): Recognizing Normal Labor Process 3  Women may report that the baby has "dropped," leading to noticeable changes in abdominal appearance (flattening of the upper abdomen and increased protrusion of the lower abdomen). Maternal Symptoms Associated with Lightening: Leg cramps or pains: Increased discomfort in the legs. Increased pelvic pressure: Greater pressure felt in the pelvic area. Increased urinary frequency: More frequent need to urinate due to pressure on the bladder. Increased venous stasis: Elevated pressure in the veins leads to edema (swelling) in the lower extremities. Increased vaginal secretions: Due to congestion in the vaginal mucosa, leading to more noticeable discharge. 2. Braxton-Hicks Contractions Irregular contractions that can be felt in the groin region or abdomen. Commonly referred to as false labor, as they do not lead to cervical dilation or effacement. Characteristics: Timing: Can occur sporadically throughout pregnancy, especially in the third trimester. Duration: Typically short-lived and can vary in intensity. Purpose: Help prepare the uterus for actual labor by toning the muscles but do not indicate the onset of labor. 3. Weight Loss Fluctuations in estrogen and progesterone levels can cause electrolyte shifts. These hormonal changes may lead to decreased fluid retention in the body. Unit 2 (Lesson 1): Recognizing Normal Labor Process 4  Increased fluid loss can contribute to a noticeable weight loss. Women may experience a weight loss of up to 3 pounds (0.5 to 1.5 kg) as labor approaches. 4. Cervical Changes The cervix undergoes softening, often referred to as "cervical ripening." The cervix stretches to prepare for the passage of the baby. The cervix also thins out, a process known as effacement. These changes together are referred to as cervical effacement, which is an important indicator of impending labor. 5. Bloody Show The bloody show is the expulsion of a blood-tinged mucus plug from the cervix Occurs with cervical effacement, leading to the rupture of small cervical capillaries. Increased pressure from the engagement of the fetal head contributes to its expulsion. The presence of a bloody show often signifies that labor is likely to begin within 24 to 48 hours. 6. Rupture of the Membranes Refers to the spontaneous rupture of the amniotic sac, commonly called "ruptured membranes" or "ruptured bag of waters." About 12% of pregnant women experience this rupture before labor begins. In most pregnancies, the amniotic membranes rupture once labor is well established. Rupture may indicate the onset of labor or may occur during the early stages. Unit 2 (Lesson 1): Recognizing Normal Labor Process 5  Observations Following Rupture of Membranes 1. Assessment of Amniotic Fluid: Color: The amniotic fluid should be clear and odorless. Composition: It may contain white specks (vernix caseosa) and fetal hair (lanugo). Importance: Noting the color, amount, and odor helps assess the well- being of the fetus and identify potential complications. 2. Urinary Incontinence: Common Symptoms: May be associated with urgency, coughing, and sneezing. Confusion with Ruptured Membranes: Urinary incontinence can sometimes be mistaken for ruptured membranes; therefore, it's essential for the woman to differentiate between the two. 3. Energy Spurt (Nesting) Often referred to as “nesting,” it is characterized by a sudden increase in energy and a strong desire to complete household preparations for the new baby. This energy spurt may be linked to an increase in the hormone adrenaline, which helps support the woman during labor. Caution for Women: Women should be advised not to overexert themselves with household chores. It’s important to “store up” energy for the childbirth process instead. 4. Gastrointestinal Disturbances Unit 2 (Lesson 1): Recognizing Normal Labor Process 6  Common Symptoms: Some women may experience gastrointestinal disturbances, such as: Diarrhea Nausea Vomiting Indigestion The exact cause of these gastrointestinal disturbances is generally unknown, but they may be linked to hormonal changes and the body's preparation for labor. 5 Ps of Labor 1. Power — Refers to the uterine contractions that help facilitate the labor process, including their strength, duration, and frequency. 2. Passageway — Involves the birth canal (pelvis and cervix) through which the baby passes. The shape and size of the pelvis can influence the ease of delivery. 3. Passenger — Refers to the fetus and the placenta. Key factors include the size, position, and presentation of the baby (e.g., head-first, breech). 4. Position of the mother — The mother’s body position during labor can affect the progress of labor, comfort level, and the baby's descent through the birth canal. 5. Psychosocial influences — These include the emotional and psychological state of the mother, support systems, and cultural factors that can impact labor and delivery experiences. Contractions Primary force of labor Unit 2 (Lesson 1): Recognizing Normal Labor Process 7  rhythmic lightening of the uterus that occurs intermittently Over time, shortens the individual uterine muscle fibers and aids in the process of cervical effacement and dilation or dilatation, birth, and postpartal involution (reduction in uterine size after birth) Frequency of contractions increases as labor progresses, typically starting as irregular and becoming more regular and closer together. Generally last 30 to 90 seconds, longer durations indicate more advanced labor Strength of contractions increases as labor progresses, contributing to effective cervical dilation and fetal descent Contractions bring about changes in the uterine musculature. Upper portion of the uterus becomes thicker and more active. Lower uterine segment becomes thin-walled and passive. Uterus elongates with each contraction. As uterus elongates, the longitudinal muscle fibers are stretched upward over the presenting part. This force, along with the pressure from the fluid around the baby, causes the cervix to dilate or open. Elongation causes a straightening of the fetal body so that the upper body is pressed against the fundus and the lower, presenting part is pushed toward the lower uterine segment and the cervix most contractions can be felt on the fundus of the uterus Physiological Retraction Ring boundary between the upper and lower uterine segments during labor presence of the retraction ring indicates effective uterine contractions and can be a sign of labor progression healthcare providers may use the retraction ring to assess the progress of labor and the positioning of the fetus helps in differentiating between the upper segment (where contractions are the strongest) and the lower segment (which accommodates the fetal descent) Unit 2 (Lesson 1): Recognizing Normal Labor Process 8  Prominent retraction ring — active labor, potential for successful vaginal delivery Poorly defined or absent retraction ring — ineffective contractions, complications As contractions progress, the muscle fibers of the upper uterine segment become thicker and more active. The lower uterine segment, in contrast, stretches and thins out. This difference in muscle activity leads to the development of the retraction ring. Characteristics of Uterine Contractions Contractions consist of three distinct components: 1. Increment (building of the contraction) — The building phase of the contraction where the intensity and duration gradually increase. 2. Acme (peak of the contraction) — The peak of the contraction, characterized by the maximum strength and intensity. 3. Decrement (decrease in the contraction) — The decrease in intensity as the contraction comes to an end. Uterine Relaxation Between Contractions Between contractions, the uterus returns to a state of complete relaxation. This rest period allows the uterine muscles to relax and provides the woman with a short recovery period that helps her avoid exhaustion. Important for fetal oxygenation as it allows blood flow from the uterus to the placenta to be restored Unit 2 (Lesson 1): Recognizing Normal Labor Process 9  What to Assess in a Uterine Contraction 1. Frequency measured from beginning of one contraction to the beginning of the next contraction 2. Duration measured from the start of one contraction to the end of the same contraction 3. Intensity most frequently measured by uterine palpation described in terms of mild (nose), moderate (chin), and strong (forehead) 4. Interval measured from the end of one contraction to the beginning of the next contraction When the uterine fundus remains soft at the acme of a contraction, the contraction intensity is described as “mild.” When there is an inability to indent the uterus at the acme of a contraction, the contraction intensity is described as “strong.” Unit 2 (Lesson 1): Recognizing Normal Labor Process 10  “Moderate” intensity falls somewhere in between, characterized by a firm fundus that is difficult to indent with the fingertips Between contractions, the uterus is relaxed and the muscular wall is soft. This is when you will be able to palpate the fetal parts. When a strong contraction comes, you will not be able to feel the fetal parts because the abdominal wall over the uterus is very tense and very painful. Contractions may be measured via electronic monitoring. May be external or internal, provides continuous assessment of uterine activity. External contraction monitoring uses a tocodynamometer, a pressure- sensitive device that is applied against the uterine fundus. Characteristics of a Normal Labor 1. spontaneous onset (begins on its own, without medical intervention) 2. rhythmic and regular 3. vertex or cephalic presentation (baby’s head/”crown” at birth canal) 4. vaginal birth occurs without active intervention in less than 12 hours for a multigravida woman and less then 18 hours for a primigravida woman 5. no maternal or fetal complications During early labor, contractions are weak and irregular Lasts 30 seconds, occurs every 5 to 7 minutes Becomes regular in frequency, longer in duration, and increased in intensity Duration increases to about 60 seconds, occurring every 2 to 3 minutes Woman in labor is unable to control contraction frequency, duration, or intensity Unit 2 (Lesson 1): Recognizing Normal Labor Process 11  Effacement — thinning and shortening of the cervix Dilatation or dilation opening and enlargement of the cervix that progressively occurs throughout the first stage of labor expressed in centimeters full dilation — app. 10 centimeters Distinguishing True from False Labor Braxton Hicks Contractions false labor irregular contractions felt in the groin region or abdomen does not lead to dilatation and effacement of the cervix True Labor False Labor Occurring at regular intervals Occurring at irregular intervals Increase in frequency, duration, and No increase in frequency, duration, and intensity intensity Pains usually begin in lower back, radiating Pains in the abdominal region to abdomen Dilation or dilatation and effacement of the Cervix does not dilate, remains less than cervix are progressive 2cm Activity such as walking increases labor Walking lessens the pain pains Stages of Labor Unit 2 (Lesson 1): Recognizing Normal Labor Process 12  First Stage of Labor — Cervical Opening or Dilatation Stage contractions start slowly and are fairly tolerable contractions increase in frequency, duration, and intensity as the first stage progresses longest stage and duration can vary considerably among women divided into three phases: 1. Latent phase a. regular contractions typically 5 minutes apart, lasts 30-45 seconds, accompanied by low back pain and abdominal cramping b. mother remains chatty and sociable c. this phase can last as long as 10-14 hours d. contractions are mild, cervical changes occur slowly e. completed at home f. cervical effacement and early dilatation will be from 0 to 3 cm 2. Active phase a. more active contractions, every 3 to 5 minutes, lasting 60 seconds and are of a moderate to strong intensity b. nulliparous women generally progress at an average speed of 1 cm of dilation per hour, while multiparas at 1.5 cm of cervical dilation per hour 3. Transition phase a. most intense phase of labor b. frequent, strong contractions that occur every 2 to 3 minutes, lasts 60 to 90 seconds c. dilation usually progresses at a pace equal to or faster than active labor d. during this stage, the mother may feel: Unit 2 (Lesson 1): Recognizing Normal Labor Process 13  i. she can no longer continue ii. rectal pressure iii. increased urge to bear down e. may experience increase in bloody show and spontaneous rupture of membranes Second Stage of Labor — Pushing Stage commences with full dilatation of the cervix, ends with birth of the infant mother experiences the urge to push or have involuntary bearing down efforts some patients may get a spurt of energy or a “second wind” to help them get through the second stage for nulliparous women: second stage involves 1 to 2 hours of pushing for multiparous women: shorter second stage, childbirth may occur within minutes of full dilatation Cardinal Movements/Mechanisms of Labor describes how the fetus (in a vertex or cephalic presentation with their backs toward their mother’s bellies) passes through the birth canal and the positional changes required to facilitate birth Unit 2 (Lesson 1): Recognizing Normal Labor Process 14 Unit 2 (Lesson 1): Recognizing Normal Labor Process 15  1. Descent progression of fetal head into maternal pelvis Four forces that facilitate descent: 1. pressure of the amniotic fluid 2. direct pressure of the uterine fundus on the fetal breech 3. contraction of the maternal abdominal muscles 4. extension and straightening of the fetal body degree of fetal descent is measured by stations Unit 2 (Lesson 1): Recognizing Normal Labor Process 16  2. Flexion occurs as the fetal head descends and comes into contact with the soft tissues of the pelvis, muscles of the maternal pelvic floor, and the cervix Unit 2 (Lesson 1): Recognizing Normal Labor Process 17  resistance from these structures causes the fetal chin to flex downwards onto the chest this allows the smallest fetal diameters to enter the maternal pelvis 3. Internal Rotation fetal head must rotate to fit into the maternal pelvic cavity which is widest in the anteroposterior diameter 4. Extension fetal head meets with resistance from pelvic floor causing it to pivot and extend with each maternal pushing effort 5. Restitution internal rotation causes the fetal shoulders to enter the maternal pelvis in an oblique position 6. External rotation as restitution continues, the shoulders align in the anteroposterior diameter, causing the head to turn farther to one side (external rotation) fetal trunk moves through the pelvis with the anterior shoulders descending first 7. Expulsion after external rotation, maternal pushing efforts bring the anterior shoulder under the symphysis pubis once shoulders are delivered, the rest of the body quickly follows Third Stage of Labor Unit 2 (Lesson 1): Recognizing Normal Labor Process 18  period of time from birth of the baby to the delivery of the placenta usually takes place within 5 to 10 minutes, may last up to 30 minutes once the baby is born, the uterine cavity immediately becomes smaller changes in the interior dimension of the uterus results in a reduction in the size of the placental attachment site. this leads to the separation of the placenta from the uterus Clinical Indicators of Placental Separation 1. Lengthening of the umbilical cord 2. Uterus becomes spherical or globular in shape 3. Uterus rises upward in the abdomen due to the descent of the placenta into the vagina 4. Umbilical cord descends further through the vagina, absence of backflow pressure 5. Gush of blood occurs once the placenta detaches from the uterus placenta is expelled or delivered in either Schultze or Duncan manner Schultze — shiny, fetal side of the placenta presenting first Duncan — inward, rolls up, presents sideways, rough placental surface uterus continues to contract after placenta separates from the uterine wall these contractions minimize the bleeding that results from the open blood vessels left at the placental attachment site Unit 2 (Lesson 1): Recognizing Normal Labor Process 19  failure of uterus to contract adequately can result in excessive blood loss or hemorrhage Fourth Stage of Labor period of maternal physiological adjustment that occurs from the time of delivery of the placenta through the first 1 to 2 hours after birth Unit 2 (Lesson 1): Recognizing Normal Labor Process 20