Labor Theories and Stages PDF

The Labor Phenomena  Labor and Delivery Also known as parturition, childbirth, birthing Is the process by which the fetus and the placenta are expelled from the uterus and the vagina into the external environment A parturient is a woman in labor Toco- and toko- (Gr) are combi...

The Labor Phenomena  Labor and Delivery Also known as parturition, childbirth, birthing Is the process by which the fetus and the placenta are expelled from the uterus and the vagina into the external environment A parturient is a woman in labor Toco- and toko- (Gr) are combining forms meaning childbirth Eutocia – normal labor Dystocia – difficult labor  The trigger that converts the random, painless Braxton-Hicks contraction, into strong coordinated labor contractions is unknown Normally labor begins when the fetus is sufficiently mature, yet not too large to cause difficulties in delivery In some instances labor begins before the fetus is mature (premature birth); in others labor is delayed (postmature birth). It is unknown why this occurs Theories proposed why Labor begins: 1. Uterine Stretch Theory. Any hollow body organ when stretched to capacity will necessarily contract and empty because of pressure on nerve endings and increased irritability of the uterine musculature. 2. Oxytocin Stimulation Theory. Because labor is considered a stressful event, the hypophysis is stimulated to initiate production of oxytocin by the posterior pituitary gland. Oxytocin is known to stimulate uterine contractions. 3. Progesterone Deprivation Theory. Progesterone is believed to inhibit uterine motility. A decrease in the amount of the hormone, therefore, results in uterine contractions. 4. Prostaglandin Theory. The relative progesterone deprivation and estrogen predominance set off production of cortical steroids which act on lipid precursors to release arachidonic acid and, in turn, increase the synthesis of prostaglandins. 5. Theory of Aging Placenta. The decrease of nutrients and blood supply in the aging placenta causes uterine contractions. (By 260 days the placenta began to age; life span of placenta is 42 weeks. At 36 weeks, degenerates leading to contraction-onset of labor)  Factors affecting Labor & Delivery (5 P’s) 1. Passenger 2. Passageway 3. Power 4. Person (Psyche) 5. Placenta  1. Passenger The passage of the fetus through the birth canal is influenced by: -size of the fetal head and shoulder -dimensions of the pelvic girdle -fetal presentation -fetal position  Fetal head – is the largest presenting part – common presenting part – ¼ of its length Bones – 6 bones S – sphenoid P – parietal 2x F – frontal-sinciput T – temporal E – ethmoid O – occipital/occiput Measurement of fetal head: 1. Transverse diameter – 9.25 cm -biparietal –largest transverse 2. Bimastoid 7 cm – smallest transverse SUTURES – intermembranous spaces that allow moulding 1. Sagittal suture – connects 2 parietal bones (sagitna) 2. Coronal suture – connect parietal & frontal bone (crown) 3. Lambdoidal suture – connects occipital & parietal bones MOLDINGS – the overlapping of the sutures of the skull to permit passage of fetal head during delivery Fontanels: 1. Anterior fontanel – bregma, diamond shape, 3x4 cm (> 5 cm-hydrocephalus) 12-18 mos. After birth, close 2. Posterior fontanel or lambda (vertex) – triangular shape; 1x1 cm; 2-3 months, close Anteroposterior diameter suboccipitobregmatic, 9.5 cm, complete flexion, smallest AP occipitofrontal 12 cm, partial flexion occipitomental 13.5 cm hyperextension submentobregmatic – face presentation  Shapes of Pelvis 1. Gynecoid – round shape 2. Android – describe as male pelvis; heart shape 3. Anthropoid – apelike pelvis; diamond shape; narrowed transverse diameter 4. Platypelloid – widen transverse; narrow antero- posterior; flat in front & back; oval shape/pear shape Fetal lie – relationship of the long axis of the fetus to the long axis of the mother ►if the two are parallel, then the fetus is said to be longitudinal lie ►if the two are at 90 degree angle to each other, the fetus is said to be in transverse lie  PASSAGES PELVIS = 4 BONES Linea Terminalis – 2 hip bones (innominate) imaginary line that 1 sacrum; 1 coccyx separates the false & Pelvic brim – False pelvis; true pelvis supports the uterus True pelvis – lower part of the pelvis Pelvic Inlet- where the baby passes first a. Diagonal conjugate – posterior border of the pubis – anterior portion of sacral promontory. Ave. 12.5 – 13 cm a. Conjugate vera (true) – anterior border of the pubis – anterior portion of sacral promontory. 11.0 cm. Can be measured only thru radiographic films b. Obstetric conjugate – shortest. Estimating by subtracting 1.5 to 2 cm ˂ the diagonal conjugate. Measures 10 cm or more Ex.: DC = 12.5 cm – 1.5 = 11 cm Transverse diameter – line between the points farthest from the ileopectineal line - 13 cm. Pelvic Outlet -antero posterior – lower border of the symphysis pubis to the sacro coccygeal points. Diameter: 13 cm -transverse diameter – between the 2 ischial spines. Diameter: 10-11 cm. - Narrower diameter is much important than the wider diameter 1. Lightening. This is defined as the settling of the fetal head into the pelvic brim which occurs 2-3 weeks before labor onset. Lightening causes relief of abdominal tightness and diaphragmatic pressure so that respiration becomes easier. – Lightening should not be confused with engagement, since engagement is defined as that point when the biparietal diameter of the fetal head has passed the pelvic inlet. 2. Loss of weight. There is loss of weight of about 2-3 lbs. one to two days before labor onset, due to loss of appetite and decrease in progesterone level. Progesterone is known to cause fluid retention. Its decrease, therefore is known to cause fluid excretion, thus causing loss of weight. 3. Increase level of activity (“nesting behavior”). The sudden burst of energy is believed to be due to increase in epinephrine in response to the stress brought about by the approaching delivery. The pregnant woman should be cautioned not to use this energy to carry out household chores because it is meant to prepare the body for the “labor” ahead. 4. Braxton Hicks Contraction – these are painless, irregular ad intermittent uterine contractions are also known as practice contractions. 5. Ripening of the cervix- The cervix becomes even softer, now described as “butter-soft”. 6. Rupture of the membranes- Also known as the bag of waters, its rupture may be seen as a sudden gush, or a scanty, slow sleeping, of amniotic fluid from the vagina. The color of the amniotic fluid should always be noted. At term, it is clear, almost colorless, and contains white specks of vernix caseosa. Green staining means the amniotic fluid has been contaminated with meconium, a sign of fetal distress if the fetus is in non-breech presentation. Yellow staining may mean blood incompatibility, while pink staining may indicate bleeding. 7. Show- This is the blood-tinged mucus discharged from the vagina because of pressure of the descending fetal part on the cervical capillaries, causing their rupture. True labor is said to occur when the following signs are observed: Uterine contractions. The surest sign that labor has begun is the initiation of effective, productive, and involuntary uterine contractions. There are three phases of uterine contractions: Crescendo / Increment – intensity of the contraction increases. This phase is longer than the other two phases combined. Acme / Apex – the height or peak of the contraction. Decrescendo/Decrement – intensity of the contraction decreases. Show: Capillary blood mixes with mucus when operculum is released, that is why show is no more than a pinkish vaginal discharge. Show should be distinguished from bright red vaginal bleeding because the latter is a danger sign during this phase of pregnancy. False Labor Pains True Labor Pains 1.Remain irregular 1.May be slightly irregular at first nut become regular and predictable within a matter of hours. 2.Generally confined to the abdomen 2.First felt in the lower back and sweep around to the abdomen in a girdle-like fashion. 3.No increase in duration, frequency and intensity. 3.Increase in duration, frequency and intensity. 4.Often disappear if the woman ambulates. 4.Continue no matter what the woman’s level of activity 5.Absent cervical changes. 5.Accompanied by cervical effacement and dilatation.  Dilatation- This is the process by which the external cervical is enlarges from a few millimeters wide to 10 cm full dilatation. In primigravidas- effacement occurs before dilatation; in multigravidas, however, dilatation may precede effacement Effacement – thinning/shortening of the cervical canal Cervix = 1 inch thick; during labor, paper thin ½ inch cervix = 50% effaced ¼ inch cervix = 75 % effaced ¾ inch cervix = 25 % effaced  Uterine Changes The uterus is gradually differentiated into two distinct portions. These are distinguished by a ridge formed in the inner uterine surface, the physiological retraction ring. 1. Upper uterine segment is the portion from the isthmus (or the physiological retraction ring) up to the fundus. 2. Lower uterine segment is the portion from the isthmus (or the physiological retraction ring) down to the cervix.  In general multigravidas deliver 6 hours earlier than primigravidas. Labor which is completed in more than 18 hours in primigravidas or more than 12 hours in multigravidas is called prolonged labor. Labor which is completed in less than 3 hours is termed precipitate delivery.  Stage of Labor Primigravidas Multigravidas First Stage 12 ½ hours 7 hours, 20 minutes Second Stage 80 Minutes 30 minutes Third Stage 10 Minutes 10 minutes TOTAL 14 hours 8 hours  STAGES OF LABOR STAGES DURATION START-END STAGE I CERVICAL P - 10-14 Hrs TRUE LABOR – DILATATION M - 6-8 Hrs FULL DILATION STAGE II FETUS P – 1.5 Hrs FULL DILATION – M – 30-45 Min. FETAL EXPULSION STAGE III PLACENTA 5 – 30 Min. FETAL EXPULSION – PLACENTAL DELIVERY STAGE IV RECOVERY/ 1 – 2 Hrs. Watch out for signs IMMEDIATE of hemorrhage POSTPARTUM  PHASES OF THE 1ST STAGE OF LABOR PHASES DILATION DURATION INTERVAL INTENSITY A. LATENT 0-4 CM 30-45 SEC. 15 MIN. MILD B. ACTIVE 4-8 CM 45-60 SEC. 5 MIN. MOD-STRONG C. TRANSITION 8-10 CM 60-90 SEC. 2-3 MIN. VERY STRONG  The first stage of labor, otherwise known as the Stage of Dilatation, is a very important stage in so far as assessment of fetal and maternal well-being is concerned. The following are discussions of this stage of labor.  Phases Latent Phase. The phase begins with onset of regular contraction and ends with complete effacement (100%) and cervical dilatation of about 4 cm. Mild uterine contractions occur regularly 10-20 minutes apart and are of short duration (10-30 seconds). The woman usually experiences low backaches and abdominal cramps and is generally excited, alert, talkative, and in control.  Active or Accelerated Phase. This begins with complete effacement and cervical dilatation of about 2-3 cm and ends with cervical dilatation of approximately 8 cm. Moderate uterine contractions occur at 2-5 minute intervals and last 30-45 seconds. The woman experiences moderately increased pain, may be more apprehensive, and fears losing control. Nursing care of the woman in her first stage of labor includes the following considerations: Hospital Admission. Privacy and reassurance are both very important at this time and throughout the other stages of labor. Establishing the maintaining rapport with the woman in labor will go a long way towards alleviating fear and apprehension. Keeping her informed of the progress of labor is the best way of giving emotional support. Such important data as the expected date of confinement (EDC), the condition of the membranes, and the show should be elicited at the onset on order to determine the kind of management to be given to the particular patient. Physical Assessment. General physical examination. Leopold’s maneuvers and/or internal examination are done to determine the following: Effacement, dilatation, and condition of the membranes. Lie or presentation – the relation of the long axis of the fetus to the long axis of the mother. Lie may either be vertical or horizontal. Location of the fetal heart tone in relation to the presentation.  Outline of Various Presentation And Their Presentations Parts I.VERTICAL LIE A.Cephalic Presentation – head is the presenting part 1.Vertex – head is sharply flexed, making the parietal bones the presenting part 2.Face 3.Brow 4.Chin A.Breech Presentation – buttocks are the presenting parts 5.Complete breech – thighs are flexed on the abdomen and legs are on thighs 6.Frank breech – thighs are flexed and legs are extended, resting on the anterior surface of the body 7.Footling a.Double – legs unflexed and extended; feet are presenting parts b.Single – one leg unflexed and extended; one foot is the presenting part I.HORIZONTAL LIE –Shoulder Presentation Station the relation of the fetal presenting part to the level of the ischial spines are explained below. Station 0 – when the fetal presenting part is at the level of the ischial spines. Station 0 is synonymous to engagement. Station – 1 or 2 – when the fetal presenting part is above the level of the ischial spines. Station + 1 or +2 – when the fetal presenting part is 1 cm or 2 cm below the level of the ischial spines. Station +3 or +4 – is synonymous to crowning. Crowning is defined as the encirclement of the largest diameter of the fetal head by the vulvar ring. Station +3 or +4 – is synonymous to crowning. Crowning is defined as the encirclement of the largest diameter of the fetal head by the vulvar ring. Position – the relation of the fetal presenting part of a specific quadrant of the woman’s pelvis. The woman’s pelvis is divided into four quadrants: right anterior right posterior left anterior left posterior Four parts of the fetus have been chosen as points of direction: occiput – in vertex presentations chin (mentrum) – in face presentations sacrum – in breech presentations scapula (acromion) – in shoulder presentations. The word “dorso” is added to indicate the position of the fetal back. An outline of the different possible fetal positions is shown in Table 4. the most common and favorable position is the loccipito-anterior position. (LOA). In the ROA position, the occiput of the fetus is the right side of the mother and is directed towards her front; in such position, the fetus, therefore, is facing the mother’s right buttock. Vertex Presentation Face Presentation LOA – left occipitoanterior LMA – left mentoanterior LOP – left occipitoposterior LMP – left mentoposterior LOT – left occipitotransverse LMT – left mentotransverse ROA – right occipitoanterior RMA – right mentoanterior ROP – right occipitoposterior RMP – right mentoposterior ROT – right occipitotransverse RMT – right mentotransverse Breech Presentation Shoulder Presentation LSA – left sacroanterior LADA – left acromiodorsoanterior LSP – left sacroposterior LADP – left acromiodorsoposterior LST – left sacrotransverse RADA – right acromiodorsoabterior RSA – right sacroanterior RADP – right acromiodorsoposterior RSP – right sacroposterior RST – right sacrotransverse Bath Bath is advisable if contractions are still tolerable or are not too close to one another. Bathing will not only ensure cleanliness but will also provide comfort and relaxation. Perineal Preparation The perineum is cleansed from front to back using the No. 7 stroke in order to disinfect the area surrounding the vagina, this procedure helps to prevent contamination of the birth canal and reduce possibilities of postpartum infection. Perineal shaving is no longer a routine procedure nowadays but if and when it is ordered, the techniques vary from one hospital to the other. The basic steps are as follows: The perineal hair is first lathered well. The skin from above is stretched and kept taut and with the use of a safety raxor, hair is shaved downward from the mons veneris, using long single strokes running along the growth of the hair. The perineum is again washed thoroughly after shaving. The woman is instructed not to touch the genitals afterwards to keep the area as clean as possible during labor. Perineal Skin Prep Ambulation Ambulation is advised during the latent phase of labor in order to help shorten the first stage of labor. Diet Solid or liquid foods are avoided for the following reasons: Digestion is delayed during labor. A full stomach interferes with proper bearing down. Aspiration may occur during the reflex nausea and vomiting of the transition phase or when anesthesia is used. Enema Administration Enema is not a routine procedure for all women in labor but may be done for the following reasons: A full bowel hinders labor progress; enema increases the space available for passage of the fetus and improves frequency and intensity of uterine contractions. The effectiveness of enema administration is therefore, shown by evaluating the change in uterine tone and the amount of show. Enema decreases the possibility of fecal contamination of the perineum during the second stage of labor. A full bowel can add to the discomfort of the immediate postpartum period. The procedure of enema a administration during labor consists of the following considerations: Soapsudsor Fleet enema is usually given The optimal temperature of the solution is 105 -115o1 (40.5 -54.6.1oC). The patient is placed on side –lying position Voiding The woman in labor should be encourage to empty her bladder every to 2-3 hours because full bladder retards fetal descent. Urinary stasis can lead to urinary tract infection A full bladder may be traumatized during delivery. Breathing Technique The woman in the first stage of labor should be instructed not to push or bear down during contractions because it will not only lead to maternal exhaustions but, more importantly, unnecessary bearing down can led to cervical edema because of the excessive pounding of the fetal presenting part on the pelvic floor, thus interfering with labor progress. To minimize bearing down, the patient should be advised to do abdominal breathing during contractions. Position Encourage the woman in labor to assume Sim’s position because the inferior vena cave is caught between the gravid uterus and the spinal column, causing a drop in arterial blood pressure, which leads the woman to complain of dizziness. it favors anterior rotation of the head it promotes relaxation between contractions. It prevents Supine Hypotensive Syndrome Contractions Uterine contractions are monitored every hour during the latent phase of labor and every 30 minutes during the active phase by spreading the fingers lightly over the fundus. Duration – from the beginning of one contraction to the end of the same contraction. Interval- from the end of one contraction to the beginning of the next contraction. Early in labor interval is 40-45 minutes; late in labor, interval is only 2 minutes. Frequency – from the beginning of one contraction to the beginning of the next contraction (A to C of Fig. 3). A woman in labor should seek hospital admission when her contractions are already occurring every 5-10 minutes. The nurse should time 3-4 contractions at a time to have a good picture of the frequency of contractions. Intensity – prolonged and sustained uterine contractions can lead not only to fetal distress but also to rupture of the uterus. Vital Signs Blood Pressure (BP) and Fetal Heart Rate (FHR) are taken every hour during the latent phase and every 30 minutes during the active phase. Definitely, BP and FHR should never be taken during contraction. During uterine contractions, no blood goes to the placenta. The blood is pooled to the peripheral blood vessels which results in increased blood pressure. Therefore, the blood pressure should be taken in between contractions and whenever the mother in labor complains of a headache. FHR, on the other hands, tends to decrease during a contraction because of the compression of the fetal head. When the fetal head is compressed by the contracting uterus, the vagus nerve is stimulated, thus causing bradycardia, FHR normally 120-160 per minute. It should not be mistaken for the uterine soufflé the sound which results when the uterine blood vessels refill with blood. Uterine soufflé synchronizer with maternal heartbeat. For any abnormality in FHR the initial nursing action is to change the mothers in position because the abdormality may just be due to Supine Hypotensive Syndrome. If the rate does not change despite positioning the attending physician should be informed. Danger Signals The nurse must be aware of the following danger signals labor and delivery. Signs fetal and maternal distress are given below. SIGNS of fetal distress Tachycardia (FHR more than 180) Bradycardia (FHR less than 100) Meconium-stained amniotic fluid in non breech presentation Fetal thrashing or hyperactivity due to fetal struggling for more oxygen. Signs of maternal distress BP over 140 /90, or failing BP associated with clinical signs of shock (pallor, restlessness or apprehension, increased respiratory and pulse rates) Bright red vaginal bleeding or hemorrhage (blood loss of more than 500 cc) Abnormal abdominal contour (may be due to uterine rupture of Band’s pathological ring, a condition wherein the muscles at the physiological retraction ring become very tense, gripping the fetus causing possible fetal distress. Administration of Analgesics Narcotics are the most commonly used analgesics, specifically Demeerol (meperidine hydrochloride). Its dosage is based on the patient’s weight the status of labor, and the size and stage of gestation. Demerol acts to suppress the sensory portion of the cerebral cortex. A dose of 25-100 mg is given and it takes effect within 20 minutes when the patient experiences a sense of well-being and euphoria. Demerol, being also an antispasmodic, should not be given very early in labor because it will retard labor progress. It should not also be given when delivery is less than an hour away because it can cause respiratory depression in the newborn. It is, therefore, preferably given when cervical dilatation is around 5-8cm. Administration of Anesthethics Regional anesthesia is preferred over any other form because it does not enter maternal circulation and therefore does not retard labor contractions nor cause respiratory depression in the newborn. The patient is completely awake and aware of what happening, but since there is loss of coordination between contractions and pushing, the baby will have to be delivered with the aid of forceps. One of the more commonly used anesthesia is the low spinal, specially saddle block. Xylocaine is injected into the 5th lumbar space, causing anesthesia into the parts of the body that come in contract with a saddle, e.g., the perineum, the upper thighs, and lower pelvis. Postspinal headaches, however , may occur because of leakage of cerebrospinal fluid (CSF) or air at the time of needle insertion. The patient should be kept flat on bed for 13 hours and her fluid intake increased to prevent postspinal headaches. Local anesthesia in the following forms may also be administered: Paracervical – transvaginal injection into either side of the cervix. Pudendal block – injection through the sacrospinous ligament into the posterior areolar tissues to reduce perception of pain during the second stage of labor. Transfer of Patients A sure sign that the baby is about to be born is the bulging of the perineum. The Transition Phase of Labor Nursing Management Breathing Technique The patient should be assisted in controlled chest (costal) breathing during contraction of the transitional phase. Avoidance of Bearing The patient is discouraged from bearing down until cervical dilatation is complete to prevent cervical edema. Emotional Support The patient should be helped to relax between contractions. Comfort Measures. Effleurage (slight stroking on the abdominal skin surfaces), back rubs, and sacral pressure (the heel of the hand is placed against the sacrum) during contractions provide relief. The Second Stage of Labor DEFINITION The second stage begins with complete dilatation of the cervix and ends with delivery of the infant. MECHANISMS OF LABOR/FETAL POSITION CHANGES As the fetus passes through the birth canal for delivery, it goes through different position changes so that the smallest diameter of the fetal head (in cephalic presentation) will fit through the pelvic inlet and outlet. Descent The fetus goes down the birth canal. Descent either follows or includes engagement. Flexion As the fetus descends down the birth canal, pressure from the pelvic floor causes he fetal heard to be flexed, so that the chin touches the chest. This brings the smallest diameter of the fetal head into a good position, which is termed attitude. Attitude, therefore, is the degree of flexion that the fetus assumes prior to delivery. Internal Rotation The wider anteroposterior (AP) diameter of the fetal head enters the wider transverse diameter of the pelvic inlet and will rotate so that fetal head is positioned at the wide AP diameter of the pelvic outlet. Extension As the head comes out, the back of the neck stops beneath the public arch. The head then extends and the head, face, and chin are born. External Rotation After the head has been delivered, it rotates 45 to the left so that the anterior shoulder is just below the public arch NURSING MANAGEMENT The care of the woman during the second stage of labor, which is focused on the delivery of the baby, consists of the following: Positioning on the Delivery Table When positioning the woman on lithotomy on the delivery table, the legs should be put up slowly at the same time on the strirrups in order to prevent trauma to the uterine ligaments and back aches or leg cramps. Bearing Down Techniques This is the best time to encourage strong pushing with contractions. At the beginning of a contraction, the woman is asked to take two short breaths, then to hold her breath and bear down at the peak of the contraction. Care of the Episiotomy Wound Episiotomy, a perincal incision done to facilitate the birth of the baby is made by the doctor primarily to prevent lacerations. Other reasons for doing episiotomy are to: Prevent prolonged and serve stretching of the muscles supporting the bladder or rectum, which can later lead to stress incontinence of urine or even vaginal prolapse. Reduce duration of the second stage of labor in cases of maternal hypertension of fetal distress. Enlarge the vaginal outlet in breech presentation or forceps delivery. Spare the infant’s head from having brain damage prolonged pressure which may result in brain damage, especially in the premature baby. The two types of episiotomy are: Median – begun in the midline of the perineum and directed toward rectum Mediolateral- begun in the midline of the preneum but directed laterally away from the rectum. Breathing Technique As soon as the head crowns, woman is instructed not to push any longer because it cause rapid expulsion of the fetus. Ritgen’s Maneuver The basic steps is applying this method of delivery are as follows. Time of delivery Take note of the time the baby is delivered. Handling of the Newborn Immediately after delivery, the newborn should be held below the level of the mother’s vulva so that blood from the placenta can enter the infant’s body on the basis of gravity flow. Cutting of the cord Cutting of the cord is postponed until pulsations have stopped because it is believed that 50-100 ml of blood is flowing from the placenta to the newborn at this time. It is then clamped twice, an inch apart, and cut in between. Initial Contact Maternal-infant bonding is initiated as soon as the mother has eye-to-eye contact with her baby. The mother is informed of her baby’s sex and helped to hold and inspect her baby if she wished. THE THRID STAGE OF LABOR DEFINITION The third stage, also know as the Placenta Stage, begins with the delivery of the infant and ends with the delivery of the placenta. PHASE Placental Separation Phase Separation of the placenta results from the disproportion between the size of the placenta and the reduced size of the site of placental attachment after the delivery of the baby. The signs of placental separation are the following: The uterus becomes more firm and round in shape again and rising high to the level of the umbilicus. Placental Expulsion Phase This phase is effected by the mother’s bearing down or by gentle pressure on the fundus. There are two mechanisms by which the placenta is separated and expelled from uterus. Schultz – clear type of placenta, “aw” – separation in “center” shiny, reddish in color. Duncan – dark, dirty “dweg” – edges (separation) NURSING MANAGEMENT Method of placental delivery Do not hurry the delivery of the placental by forcefully pulling out the cord or by vigorous fundal push as this can lead to uterine inversion. Time of placental delivery 10 minutes immediately notified as it could be a sign of uterine atony. Uretent “atony” never contact to massage Õ uterus Care after placental delivery The following aspects are important: a. Inspection of placenta for completeness of cotyledons. b. The initial nursing action for a non-contracted or boggy uterus is gentle massage of the fundus. An ice cap may also help. c. Oxytocic agents may be administered as ordered to ensure uterine contractions, thus preventing hemorrhage.  Methergin (0.2mg) and  Syntocinon (10 U) are two of the more commonly given oxytocics.  Common side effect of oxytocins in hypertension. Monitor the blood pressure. d. Lacerations are rugged edged which heal more slowly and therefore predispose infection, if healing process is prology. 1. First-degree – vaginal mucous skin. 2. Second-degree – vagina, perineal skin, fascia, levator ani muscle and perineal body. 3. Third-degree – entire perineum. 4. Fourth-degree – entire perineum rectal sphincter and some of the mucous membrane for the rectum. NURSING MANAGEMENT Care during and after Perineal Repair. A local anesthetic, usually Xylocaine, is given in order to minimize pain during episiorrhaphy. In vaginal episiorrhaphy, packing is done to maintain pressure on the suture line and, therefore, prevent bleeding. The nurse should be aware that this packing is usually removed after 24 or 48 hours. Estimation of blood loss. 250-300cc – N 500cc hemorrhage. THE FOURTH STAGE OF LABOR DEFINITION Fourth stage first one or two hours vital signs of the mother are quite unstable. NURSING MANAGEMENT Nursing interventions during the fourth stage of labor are focused mainly:. 1. Assessment. a. Fundus – should be palpated every 15 minutes during the first hour postpartum and then every 30 minutes for the next 4 hours. b. Bladder – checked every 2 hours during the first 8 hours postpartum and then every 8 hours for 3 days. Suspect a full urinary bladder if the fundus is not well contracted and is shifted to the right. A full urinary bladder prevents good contraction of the uterus and therefore may cause hemorrhage. c. Vaginal discharge – the amount of blood flow should be checked every 15 minutes and should be moderate. It is said that if a newly-delivered woman saturates a sanitary napkin more often than every 30 minutes, the flow is excessive necessitating immediate referral to the doctor. d. Blood pressure and pulse rate – should be checked every 15 minutes during the first hour postpartum and then every 30 minutes until stable. BP and pulse rate are slightly increased from excitement and the effort of delivery but normally stabilizes within one hour. e. Perineum – should be inspected every 8 hours for 3 days. Take note of the condition of the episiorrhaphy: BLADDER ASSESSMENT DEFINITION Voiding pattern, complete emptying, pain burning on urination Record first three voids with the amount and times voided A full bladder displaces the uterus upwards and laterally and prevents contraction of the uterus = UTERINE ATONY = > risk of postpartum hemorrhage. 2. Comfort Measures. Helping the mother feel comfortable after delivery can be effective by the following measures: a. perineal care gently b. position her flat on bed without pillows to prevent dizziness due to sudden release of intraabdominal pressure. c. Mother a soothing sponge bath change her soiled gown/dress and dirty linens. d. Additional blankets if the mother suddenly complains of chilling. e. Mother initial nourishment of coffee, tea or milk. f. Mother to sleep in order to regain lost energy. PHYSICAL EXAMINATION OF THE LABORING WOMAN Steps you should take to prepare for the examination: Ask woman to empty bladder (collect urine for testing). Prepare to follow a logical order. Prepare to chart logically immediately after exam (make notes). Remember to use all your senses during assessment. Remember to explain everything you are doing. Exam should be carried out immediately and as quickly as possible. Urine tests used during intrapartum Ph - Measures acidity/alkalinity of the urine, Levels below normal indicate high fluid intake, levels above the norm indicate inadequate fluids & dehydration. Protein - Normal = Negative, Small amounts may be in urine from vaginal secretions & dehydration, Amounts of 2+ to 4+ may indicate be one indicator of possible UTI, Kidney Infection or PIH. Glucose - Normal = Negative or + I. High levels of glucose may be one indicator of high blood sugar, gestational diabetes or diabetes mellitus. Always ask what woman has recently eaten if her BS is high. Ketones - Normal = Negative. Ketones are products of the breakdown of fatty acids caused by fasting. The body breaks down fats because there are not enough carbohydrates and proteins available. Ketones may be deleterious to fetus. Abdominal examination An abdominal examination should include a measurement of fundal height as well as an assessment of fetal size (estimated fetal weight), presentation and position using Leopold's maneuvers. Inspect: Scars, linea, striae, symmetry Palpate: fundal height, fetal position Osculate: fetal heart tones Determine and palpate contractions Inspect and palpate lower extremities Press firmly with thumbs about 5 seconds over shin If any signs of elevated blood pressure, elicit DTR If reflexes are hyperactive, check for clonus Measuring fundal height Place the zero line of the tape measure on the anterior border of the symphysis pubis and stretch tape over midline of abdomen to top of fundus. The tape should be brought over the curve of the fundus. The height of the fundus in centimeters equals the number of weeks gestation plus or minus 2. After 32 weeks the relationship is less accurate. Perform Leopold maneuver. Abdominal Examination for Contractions An initial abdominal examination is carried out on admission by laying a hand on the uterus and palpating, noting the degree of hardness during a contraction and timing its length. This should be repeated at intervals throughout labor in order to assess the length, strength and frequency of contractions and the descent of the presenting part. The uterus should always feel softer between contractions. The monitor should never be relied on; the mother’s abdomen should be regularly palpated by hand. Uterine Contractions There is no place for routine vaginal examinations in any labor. Vaginal examination should only be done when there is doubt about the clinical situation or symptoms, and the information gathered is necessary or likely to be of use in making a clinical decision. (1) Significant vaginal bleeding of unknown etiology (delay examination until placenta previa has been ruled out by ultrasonography), (2) Presence of placenta previa, (3) Ruptured membranes in patients who are not in labor and for whom immediate induction of labor is not anticipated, (4) Presence of active HSV lesions in a patient with ruptured membranes. How to palpate presenting part: Palpate the hard skull; palpate for sagital suture; follow to anterior or posterior fontanel If what you feel is soft it may be breech or face. Assessing Cervical effacement Cervical effacement: Palpate degree of thickness; normal cervix about 1 inch thick Speculum examination A speculum examination will be necessary in cases of suspected "leaking" or ruptured membranes. The presence of "leaking" or ruptured membranes can be confirmed by performing a nitrazine test, inspecting the posterior fornix for pooling of fluid and by obtaining a sample of the fluid with a sterile applicator and applying the fluid to a glass slide. The glass slide is allowed to air dry and is subsequently inspected for an arborization pattern ("ferning"). Stages of Labor Chart The first stage of labor begins when uterine contractions of sufficient frequency, intensity and duration result in effacement and dilation of the cervix. The first stage is completed when the cervix reaches 10 cm. The second stage involves descent of the fetus and its eventual expulsion from the vagina. It begins with complete cervical dilation (10 cm) and ends with delivery of the infant. The third stage of labor involves delivery of the placenta. It begins with the completion of the infants' delivery and ends with delivery of the placenta and membranes. FIRST STAGE LATENT- ACTIVE TRANSITION SECOND STAGE THIRD STAGE LABOR EARLY LABOR LABOR LABOR LABOR Delivery of the LATENT (0-3 cm.) (4-8 cm.) (8-10 cm) (10 cm. -Birth) Placenta Pre-labor  Ripening Contractions: Contractions: Contractions: Contractions: Contractions: and effacement  5-20 minutes  2-5 minutes  1 -2  3-5 minutes  Irregular of the cervix apart apart minutes apart apart  A feeling of  30-45  45-60  45-90  60-120 seconds fullness and seconds long seconds long seconds long long cramping as placenta separates  Mild, feel  Stronger  The  Less aware of like cramps, and more strongest they contractions,  A time for back pain, intense will get more aware of mom to hold and pressure urge to push and enjoy baby. fullness in vagina as baby moves down Crowning and birth of the baby and placenta  Father or SO Cuts the Cord Hand baby to mom: if baby is stable