Normal Labor PDF

# Normal Labor ## Outlines - Definition of terms related to labor - Factors affecting normal labor - Causes of onset of labor - Premonitory signs of labor - Sure signs of labor - Stages of normal labor - Mechanism & management of first stage - Mechanism & management of second stage - Mechanism & m...

# Normal Labor ## Outlines - Definition of terms related to labor - Factors affecting normal labor - Causes of onset of labor - Premonitory signs of labor - Sure signs of labor - Stages of normal labor - Mechanism & management of first stage - Mechanism & management of second stage - Mechanism & management of third stage - Mechanism & management of fourth stage ## Terminology ### Normal Labor It is expulsion of mature viable fetus presenting by vertex through the birth canal spontaneously within reasonable time, without interference except episiotomy & without complication for both mother & fetus. ### Immature Labor Termination of pregnancy between 20-28 weeks "Fetal WT 500-1000 gm" ### Gravida Number of pregnancies. ### Para Number of pregnancies carried to viability and delivered ### Primigravida Pregnant for the first time ### Multigravida Pregnant more than once ### Viability Able to survive outside the womb (24+ week gestation) ## Signs of Placental Separation ### Nulli Parous Never carried a pregnancy to viability. ### Multi Parous Has had two or more deliveries that were carried to viability. ### Phenomena of normal Labor Labor is the process where the products of conception are expelled from the uterus as a result of regular, progressive, frequent, and strong uterine contractions. ### Duration of Pregnancy Average 28 days of 40 weeks (9 lunar months) ### Estimated Date of Confinement (EDC) **Nagele's Rule:** * Date of first day of LMP * Subtract 3 months * Add 7 days * Add 1 year Accurate to plus or minus 2.5 weeks. ### Terminology: ### Premature Labor Termination of pregnancy between 28-38 weeks "Fetal WT less-2500" ### Post Mature Labor Prolongation of pregnancy 2 weeks or more beyond the calculated data of delivery. ### Prolonged Labor Labor lasting more than 24hrs in Primigravida, 16hrs in multigravida. ### Precipitate Labor Labor lasting less than 3hrs "sometimes few minutes". ## Characteristics of normal labor: - The fetus is born at full term. - The fetus is living. - The fetal presenting by vertex. - The process of labor is completed spontaneously. - The process of labor is completed through the normal passages. - The time of labor does not exceed 24 hours. ## Estimated Date of Birth: * Duration of amenorrhoea (Nagele’s Rule) * First day of LMP: 18/1/2012 First date of LMP: 18/1/2012 * Add 7 days + 7 Add 7 days + 7 * Add 9 months +9 Add 1 year + 1 * Minus 3 months -3 * EDO: 25/10/2012 EDO: 25/10/2012 ## Fundal Level - Lightening - Engagement of head ## Factor affecting process of normal labor (5P): - **Power**: - Primary Power: - Uterine Contraction. (Involuntary) - Secondary Power: - Maternal Pushing efforts. (Voluntary) - **Passage**: - The bony pelvis - Pelvic inlet - Pelvic cavity - Pelvic outlet - Pelvic soft tissues - **Passenger**: - Fetus - Fetal disposition: Lie, Position, Attitude, Presentation, Station - Fetal head (skull), bones: - Occipital bone - Two parietal bones - Two frontal bones - Fontanelles - Posterior Fontanelles: - At junction of lambdoidal and sagittal suture. - Triangular in shape. - Close at 6 weeks of age. -Anterior Fontanelles: - At junction of sagittal, coronal and frontal suture - Kite shaped. - Close at 18 months 12-18 months. - Sutures of Fontanelles: - Lambdoidal suture: Between occipital bone from parietal bone. - Sagittal suture: Between two parietal bones. - Coronal suture: Separate frontal bone from parietal bone. - Frontal suture: Between 2 halves of frontal bone. - **Prejudices**: - Psychological - **Powers**: - Frequency: - The elapsed time from the beginning of one contraction until the beginning of the next contraction. - Duration: - The elapsed time from the beginning of a contraction until the end of the same contraction. - Intensity: - The approximate strength of the contraction. - In most cases intensity is described in words such as “mild”, “moderate,” or “severe”. - Interval: - The amount of time the uterus relaxes between contractions. * Each contraction has three phases: - Increment: The period of increasing strength. - Peak of acme: The period of greatest strength. - Decrement: The period of decreasing strength. ## Secondary Power - Secondary power is voluntary auxiliary forces bearing down effort. - Contraction of diaphragm and abdominal muscle to increase inter-abdominal pressure. - At first voluntary but later it become involuntary due to reflex stimulation from pressure of presenting part on pelvic floor muscle (perineal abdominal reflex). ## The bony pelvis - The bony pelvis is a basin-shaped shaped structure at the lower end of the spine. - It’s posterior wall is formed by the sacrum. - The side and anterior pelvic walls are composed of four fused bones: - Two ilium - One ischium - One pubis ## Types of Pelvis: - **Gynaecoid**: Rounded brim. (female) - **Android**: Heart shaped brim. (male) - **Anthropoid**: Oval brim. - **Platy pelloid**: Kidney shaped brim. ## Differences between Female and male Pelvis | Female Pelvis | Male Pelvis | |---|---| | Brimi’s founded (Gynaecoid) | Heart shaped (Android) | | Pelvis is wide and shallow | Longer and narrower | | Sidewalls are straight | Sidewalls are convergent | | Ischial spines are blunt | Prominent | | Sciatic notch is wider | Narrow | | Sub-pubic angle is 90% | Less than 90° | ## Pelvic bone ### Fake Pelvis: - Part of pelvis situate above pelvic brim. - It forms upper planed out part of ilia bone and no significance in obstetric. ### True Pelvis: - Bony canal through which fetus must pass during birth. - It consists of brim, cavity, and outlet. - The true has three subdivisions: fetus, membranes, placenta ### Passenger - The passenger is the fetus plus the membranes and the placenta. - Fetus to several fetal anatomic and positional variables - Influence the course of labor: - Fetal disposition, health status maturity, size, number influence the course of labor. ## 4th Stage of Labor: - The 4th stage of labor is the stage of physical recovery for the mother. - The delivery of the placenta through to the first 1 to 4 hrs after birth. - The lasts immediately after birth the firmly contracted uterus palpated through the abdominal wall as a firm rounded mass about 10-15 cm. ## Nursing Management of 1st stage of Labor: 1. **Assessment:** - Taking the history of labor. - Examination of woman in labor: - General Examination - Local Examination - The Partograph 2. **Planning & Implementation:** - Nutrition and Hydration - Rest and Sleep - Comfort and Assistance - Preparation of the woman in labor. - Posture of woman in labor. - Care of bladder - Massage the back if she complains of backache. - Observation 3. **Maternal Distress:** - Increased pulse rates over 100 bpm. - Elevated temperature more than 37.5°C - Decreased blood pressure. - Sweating and pale face. ## Signs of dehydration: - Dark vomitus - Ketone bodies in urine - Irritability and restlessness. - Anxious expression ## Fetal Condition: - Monitor and record fetal heart rate to recognize fetal distress or abnormalities. - It should be heard every 4 hours until rupture of membranes then every 30 minutes. ## Signs of Fetal distress - Excessive fetal movement - Excessive molding of fetal head. - Excessive formation of caput succedaneum. - A fetal heart rate increasing to more than 16.bpm or decreasing to less than 10.bpm or becoming irregular. - Passage of meconium in cephalic presentation. ## Nursing Management of 2nd Stage of Labor: 1. **Assessment**: Assessment should include the following - Uterine contraction: - Maternal physical and emotional status. - Fetal well being. - Signs & symptoms of and state of labor. - Contractions become strong and more frequent. - Show is increased suddenly, and becomes more blood tinged. - Membranes rupture. - Perineum starts to bulge and the anal orifice starts to dilate. - Woman starts involuntary beating down and feels the desire to defecate. - She may be eager to sleep. - She is apprehensive, irritable, unwilling to be touched, and may cry if disturbed. - She may frustrated, and unable to manage labor alone. ## Management: - Mother may feel urge to push, coach to push only during a contraction, once the cervix has been determined to be fully dilated. ### Episiotomy: - Perform to avoid unnecessary tearing when head is crowing. - Controlled delivery avoids needs for episiotomy in most cases. - The woman is able to push effectively. - She gains support and comfort from the nursing personnel. - Her physiological and psychological status has been maintained. - The infant is born without difficulty. ## Management of 3rd Stage of Labor: - **Assessment:** - Assessment should include the following: - Assess uterine contraction. - Observe maternal vital signs. - Check placenta for completeness. - Recover missing pieces of placental as necessary. - Massage uterus to aid in hemostasis. - IV oxytocin can be given if available to aid uterine contractions, and aid in homeostasis. ## Stages of Labor: - First stage (dilating stage) - Second stage (expulsive stage) - Third stage (placental stage) - Fourth stage (postnatal stage) ### 1st Stage of Labor - The first stage entails effacement and dilatation of the cervix. - It begins when uterine contractions become sufficiently frequent, intense, and long to initiate obvious effacement and dilatation of the cervix. ### Duration of Labor: Primigravida: 12-16 hours Multipara: 6-8 hours ### Phases: #### Latent Phase - During contraction: Few contractions - First stage: Mid late second state - Present of Labor: Past 1hr - Signs of the onset of labor: - Painful uterine contraction = True Pain. - Show. - Shortening and dilatation of the cervix. - Formation of the bog of fore water. #### Active Phase - Few contractions: 1-2 hours - First stage: 10-30 minutes - During contraction 10-20 minutes - During contraction: 10-20 minutes #### Transition Phase ### 2nd Stage of Labor: - Stage of expulsion of the fetus begins with fully dilatation of cervix and end with delivery of fetus. - Duration of second stage: - Primigravida: 50 minutes - Multiparous: 2 minutes or less. ### Contractions: - Interval: 2 to 3 minutes - Duration: 50 to 100 seconds. ### Criteria of 2nd stage of labor - Involuntary bearing down with uterine contraction. - Increase desire to evacuate rectum or bladder. - Rupture of membranes & passage of amniotic fluid. - Fully dilatation of cervix. - Changes in woman carry. - Plugging of perineum. ## Sweat around lips & on forehead. - Muscle fibrous becomes shorter after each retraction. - Lead to reduction of capacity of the upper segment. ### Mechanism of Labor: - Descent - Engagement - Flexion - Internal rotation - Extension - External rotation - Restitution & expulsion ### 3rd Stage of Labor: - Begins with delivery of fetus and ends with delivery of placenta. - Time: 20-30 minutes. - Average duration: 8 minutes. ### Signs of Placental separation: - **Vaginal**: - Sudden gush of blood - Lengthening of cord - **Abdominal**: - Rise fundal level above umbilicus - Uterus becomes globular hard mobile ### Methods of placenta separation - Duncan's - Schultzie's **Duncan's**: - Less common 3% - Separation start at edge as button. **Schultzie's**: - More Common 97% - Separation start at center like umbrella. ### Bleeding - Excessive: Bleeding is less. - Retention of membranes: Less retention of membranes.