Labor Stages and Care (PDF)

labor Labour is process by which the fetus, placenta and membranes are expelled through the birth canal beyond 24 weeks of pregnancy after regular uterine contractions, brings about progressive effacement and dilatation of the cervix. Cervical dilatation: The cervix begins dilating and...

labor Labour is process by which the fetus, placenta and membranes are expelled through the birth canal beyond 24 weeks of pregnancy after regular uterine contractions, brings about progressive effacement and dilatation of the cervix. Cervical dilatation: The cervix begins dilating and stretching beyond the normal dimensions and is measured in centimeters. (0-10cm). Cervical effacement: softening, thinning and shortening of the cervix. It is expressed in percentage (0 – 100%)  Normal labour Normal labour is characterized by Term, Spontaneous in onset ,with low risk, The fetus presented by vertex, No complications arise  Labour can occur at: Term Labour PTL prolonged 24 W 28 W 37 W 40W 42W 1 LMP  Causes of onset of labor Not definitely known – however there are several theories, but none of them is completely proven. 1-Hormonal: Decrease in progesterone. Release of Oxytocin – increase estrogen in relation to progesterone. fetal cortisol 2- Mechanical : Over stretching of the uterus result in prostaglandin release. Pressure of presenting part on cx stimulate oxytocin release.  cortisol It is well established that cortisol levels increase throughout pregnancy and continue to increase with advancing labor at term. These physiological changes are important and may be viewed as a necessity for maintaining maternal/fetal wellbeing and promoting normal labor progression.  What is the role of cortisol during labor? cortisol increases prostaglandin production by the placental and fetal membranes thereby promoting cervical ripening and uterine contractions.  Can cortisol induce labour? Fetal cortisol stimulates the hormonal pathway that results in increased maternal plasma concentrations of estrogen and oxytocin, key hormones involved in the development of contractions.  Oxytocin and uterine contractions Oxytocin also increases the production of prostaglandins (a group of lipids with hormone-like actions), which move labor along and increase the contractions even more. This enables the mother to carry out vaginal delivery completely.  Oxytocin is a reproductive hormone implicated in the process of parturition ‫والدة‬and widely used during labor. Oxytocin is produced within the supraoptic nucleus and paraventricular nucleus of the hypothalamus and released from the posterior pituitary lobe into the circulation. Oxytocin is released in pulses with increasing frequency and amplitude in the first and second stages of labor, with a few pulses released in the third stage of labor. During labor, the fetus exerts pressure on the cervix of the uterus. When myometrial contractions activate sympathetic nerves, it decreases oxytocin release. When oxytocin binds to specific myometrial oxytocin receptors, it induces myometrial contractions. High levels of circulating estrogen at term make the receptors more sensitive. In addition, oxytocin stimulates prostaglandin synthesis and release in the decidua and chorioamniotic membranes by activating a specific type of oxytocin receptor. Prostaglandins contribute to cervical ripening and uterine contractility in labor.  Physiology of the 1st stage Uterine contraction:-(fundal dominance ) Each uterine contraction starts in the fundus near the one corn and spread across down words. Contraction lasts longer in the fundus and most intense. The peak is reached simultaneously over the whole uterus. The contraction spreads from all part s together. It allows the cervix to dilate and expel the fetus.  Polarity :- it is the harmony of the neuromuscular action between the upper and lower uterine segment , the upper contract strongly and retract to expel the fetus and the lower uterine segment dilate to allow expulsion take place. Polarity of the uterus  Contraction and retraction :- The uterine muscle has a unique polarity. The contraction dose not pass off entirely. The muscle fibers retain some of the shortening of contraction instead of complete relaxation (retraction) The upper uterine segment become shorter and thicker and decrease its capacity to assess the expulsion of the fetus. Premonitory signs of labor: weeks before real labor Lightening: Fetus settles into pelvic cavity occur 10-14 days before labor begins in PG, and occur during labor in multipara. Braxton-Hicks: which are Irregular intermittent contractions or “false labor” which DO NOT initiate true labor. Cervical changes: cervix effaces [thins] & dilates slightly  Burst of Energy: cleans house,. It is due to↑ epinephrine resulting from ↓ progesterone  Signs of true labor Beginning of regular painful uterine contractions. Show is a blood stained mucoid discharge as a result of dilatations Rupture of membranes lead to sudden gush of fluid from the vagina.  Successful labor depend on 4 concepts The passage, the women pelvic. The passenger, the fetus. The power. Psyche of the mother  The passage The pelvis should be adequate in size and shape. Gynecoid pelvis is the female pelvis which is the best because it is round and wide. Two diameters are important in labor ,anterior-posterior diameter and transverse diameter of the pelvis  The passenger The following will pass during labor (fetus, cord, placenta and membranes). The most important to pass is the head and shoulders of the fetus The head is the widest diameter. The fetal skull can pass depending on suture lines and its alignment with the pelvis. The structure of the skull is composed of 8 bones which meet together by their suture lines.  The passenger The suture lines are important during birth because they allow the cranial bones to overlap causing molding this is to decrease the size of the skull during birth. Two fontanels : 1- Anterior fontanel its diameter is 3-4cm, called bregma it closes by 18 months after delivery.  The passenger 2- The posterior fontanel is triangular in shape and is closed after six weeks post delivery. The fontanels help in determine the fetal position during labor.  The Passenger Fontanelles and Sutures  The power The power of contractions. The contraction must be adequate to initiate and continue the labor. The psychology of the mother affects labor also “STAGES of LABOUR” 4 in All !  First Stage Onset of true labor is to complete cervical dilation from 0cm to 10 cm. ~ 6-18 hrs. primipara; 2-10 hrs. multi para. 3 phases: the first stage contractions go into three phases Latent, Active and Transitional. Latent: Dilation 0-3 cms. Contractions are mild but regular. Active: 4-7 cms. Contractions are 5-8 min. apart Lasts 45-60 sec; moderate to strong in their intensity. Transitional: Dilation 8-10 cms. Contractions are every 1-2 min. apart 60 –90 seconds and strong in their intensity.  Second stage of labor “Birthing of Baby” 2-Second stage of labor begins when the cervix reach fully dilatation till the is baby born. Signs of 2nd stage Urge to push. Bulging of the perineum.Everted anus and stool may be expelled. Vaginal introitus open  Second stage of labor Crowning is when the head is on the perineum. 2nd stage may last 1hr in multi Para , 2hrs in PG and 3hrs in case of epidural. Positions uses in 2nd. Stage of labor Sitting, Side Lying, Standing, Squatting, All Fours, Kneeling.  Third stage of labor Starts from the delivery of the baby till the separation and expulsion of placenta and membranes. Delivery of placenta 5 - 30 minutes Signs of placental separation Lengthening of the cord. Sudden gush of blood. Change in the shape of the uterus it becomes hard globular at the level of the umbilicus.  Fourth Stage Lasts ~ 1 hr post delivery of placenta to watch the mother and the fetus unless any complications arise. Then mother is transferred to post partum unit.  Factors that affect length of labor Parity. Birth interval. Psychological status Maternal pelvic shape. Presentation. Contractions. Position of the fetus  Duration of labor Primipara: 18 hrs. Multipara: 6 to 8 hrs. Comparison between true labor & false labor character True labour pain False labour pain contractions regular Irregular Interval between Progressive (increase in Short duration, not contractions and frequency and progressive intensity intensity) Changes in the cervix Associated with Not associated with effacement and dilation effacement and dilation of the cervix of the cervix Membranes Associated with bulging of Not associated with membranes bulging of membranes Response to analgesia Not relieved by sedation Relieved by sedation Labour Followed by labour Not followed by labour  Care in 1st stage labor 1-Emotional support Complete History include medical, obstetric Birth plan such as exercise, position, companion and pain relief. Complete Physical exam. Observations such as BP Q2-4 hr between contractions and pulse Q1-2hr ,Temp Q 4HR Monitor FHR and contractions  Care in 1st stage labor Lab tests ,urine for protein, keton and sugar. Blood for hepatitis, Hb Rh group Abdominal exam-Leopords maneuver. Auscultate the fetal heart Vaginal exam-speculum exam in case of rupture membranes. Bladder care Q 2hr and bowel care. Leopold's maneuver  Care in 1st stage labor Cleanliness and comfort –bathing or shower. Nutrition –low fat and high carbohydrate diet. Monitor progress in labor & record on partograph.  partogram The partograph is a tool for monitoring maternal and foetal wellbeing during the active phase of labour, and a decision-making aid when abnormalities are detected. It is designed to be used at any level of care. Monitoring for fetal well-being: the evidence  Contractions Record the number of contractions present in a 10 minute period.  Interpretation of CTG The normal Base line of fetal heart rate 120- 160 bpm over 10 minutes. The variability is the variations or differing rhymicity in heart rate over time or irregularity (vary 5beats over one minuets). ,  Accelerations:- are due to increase in fetal heart rate 10- 20 beats for seconds it occurs in response to fetal movements  Interpretation of CTG Early decelerations:- is slowing in fetal heart rate due to pressure on the fetal head during contractions. Slowing in FHR begin when the contractions begin and end when the contractions end. Late decelerations is slowing in FHR after beginning of contractions and continue after the end of contractions due to uteroplacental insufficiently  The presence of late decelerations is taken seriously & foetal blood sampling for pH is indicated If foetal blood pH is acidotic it indicates significant foetal hypoxia & the need for emergency C-section  Interpretation of CTG Variable deceleration:- is slowing in FHR that occurs at an unpredictable time in relation to contractions it is due to cord compression.  Care in second stage of labor Prepare for delivery Choose a position for birth that the mother chose. Evaluate for episiotomy. Teach the mother to push during contractions and rest in between. Monitor the FHS and the CTG readings.  Care in second stage of labor Clean the perineum from up to down then inside. Support and explain every procedure to the mother. After delivery ,place the baby on the mother chest in skin to skin contact  Care in second stage of labor Oxytocin 10 IU IM is given at delivery of anterior shoulder or after delivery of the placenta. Note oxytocin increase uterine contractions but may increase B/P, SO base line B/P must be known before giving oxytocin  Care in the 3rd stage Active management of 3rd stage. Delivery of the placenta by CCT. Oxytocin. Uterine massage clamping of the cord  Post Delivery care 1-examine the placenta for its completeness, anomalies, length, and number of vessels in the cord and record the placental weight. 2-Suture the episiotomy or any laceration. 3-Estimate blood loss, count swabs, and take cord blood for Hb, blood group, Rh, bilirubin, and coomb’s test for Rh negative mother. 4-Check BP, P, T, Lochia and firmness of the uterus before transferring the patient. 5-Continue an infusion of syntocinon if necessary..6- Documentation. 7- Breast feeding  Care of the new born 1. -Clearance of mouth and nose. 2. -Determine the Apgar score one and five minutes - heart rate - respiratory rate - muscle tone - color - reflex irritability 3-Care of the umbilical cord stump 4-General assessment of the infant to exclude any seen congenital anomalies. 5-Identification bracelet weight, estimate the gestational age, and keep the baby warm. 6-Protect the baby against cold.