NCM 107 Midterm Module 7: Stages of Labor and Delivery 2024-2025 PDF

NCM 107 – Care of the Mother, Child and Adolescent S.Y. 2024-2025 | 1st Semester | Mid Term Module 7 – LABOR AND DELIVERY: Stages of Labor and Delivery Description This module presents the different stages of labor and...

NCM 107 – Care of the Mother, Child and Adolescent S.Y. 2024-2025 | 1st Semester | Mid Term Module 7 – LABOR AND DELIVERY: Stages of Labor and Delivery Description This module presents the different stages of labor and delivery and the important role of the nurse for each stage. Labor and birth require a woman to use all the psychological and physical coping methods she has available. Regardless of the amount of childbirth preparation or the number of times she has been through the experience before, family-focused nursing care is needed to support the family as they mark the beginning of a new family structure. Learning Outcomes LO1 Integrate concepts of the different stages of labor and delivery in the formulation and application of appropriate nursing care to the mother and the fetus. LO3 Assess mother and the fetus in relation to the different stages of labor and delivery. LO4 Formulate nursing diagnosis/es related to different stages of labor and delivery. LO5 Implement safe and quality nursing interventions for mother and fetus related to different stages of labor and delivery. LO7 Evaluate with the mother and family the health outcomes of nurse-client relationship. Module Outline I. Signs of labor II. Stages of labor and delivery III. Maternal Physiologic Effects and Psychological Responses IV. Nursing Diagnoses related to stages of labor and deliver V. Outcome Identification and Planning VI. Evaluating nursing care Module I. Signs of labor Signs of labor may be described as preliminary signs of labor and true signs of labor. Module 7 – LABOR AND DELIVERY: 1 Stages of Labor and Delivery A. Preliminary signs of Labor Before labor, a woman often experiences subtle signs that signal labor is imminent. These signs are usually noted by the primigravid woman at 38 weeks of gestation. In multigravidas, they may not take place until labor begins. It is important to review these during the last trimester of pregnancy so they can more easily recognize beginning signs. These preliminary signs are lightening, increased level of activity, strong Braxton Hick’s contraction, weight loss, ripening of the cervix. 1. Lightening Lightening is the descent of the fetal presenting part into the pelvis. This fetal descent changes a woman’s abdominal contour, because it positions the uterus lower and more anterior in the abdomen. Lightening gives a woman relief from the diaphragmatic pressure and shortness of breath that she has been experiencing and, in this way, “lightens” her load. Lightening probably occurs early in primiparas because of tight abdominal muscles. The downward settling may also lead to the following maternal symptoms: Leg cramps Increased pelvic pressure Increased urinary frequency Increased venous stasis Increased vaginal secretions 2. Increase in Level of Activity A woman may awaken on the morning of labor full of energy, in contrast to the feeling of chronic fatigue she felt during the previous month. This increase in activity, also known as “nesting behavior”, is related to an increase in epinephrine release initiated by a decrease in progesterone produced by the placenta. This additional epinephrine prepares a woman’s body for the work of labor ahead. 3. Slight Loss of Weight As progesterone level falls, body fluid is more easily excreted from the body. This increase in urine production can lead to a weight loss between 1 and 3 pounds. 4. Strong Braxton Hicks Contraction In the last week or days before labor begins, a woman usually notices extremely strong Braxton Hicks contractions. Women having their first child may have great difficulty distinguishing between these and true contractions. A woman may come to the labor unit of a hospital or Module 7 – LABOR AND DELIVERY: 2 Stages of Labor and Delivery  birthing center because false contractions so closely simulate true labor. When this happens, you can assure a woman that misinterpreting labor signals is common. Remind her that if false contractions have become strong enough to be mistaken for true labor, true labor is not far away. 5. Ripening of the Cervix Ripening of the cervix is an internal sign seen only on pelvic examination. Throughout pregnancy, the cervix feels softer than normal to palpation, similar to the consistency of an earlobe (Goodell’s sign). At term, the cervix becomes still softer (described as “butter-soft”), and it tips forward. Cervical ripening this way is an internal announcement that labor is very close at hand. B. Signs of True Labor Signs of true labor are indications that mother will end pregnancy. The mother will experience cervical and uterine changes when labor begins. 1. Uterine Contractions The surest sign that labor has begun is productive uterine contractions. Because contractions are involuntary and come without warning, their intensity can be frightening in early labor. Helping a woman appreciate that she can predict when her next one will occur and therefore can control the degree of discomfort, she feels by using breathing exercises offers her a sense of well-being. 2. Show As the cervix softens and ripens, the mucus plug that filled the cervical canal during pregnancy (operculum) is expelled. The exposed cervical capillaries seep blood as a result of pressure exerted by the fetus. This blood, mixed with mucus, takes on a pink tinge and is referred to as “show” or “bloody show.” Women need to be aware of this event so that they do not think they are bleeding abnormally. 3. Rupture of the Membranes Labor may begin with rupture of the membranes, experienced either as a sudden gush or as scanty, slow seeping of clear fluid from the vagina. Early rupture of the membranes can be advantageous as it can cause the fetal head to settle snugly into the pelvis, actually shortening labor. Two risks associated with ruptured membranes are: a. intrauterine infection and Module 7 – LABOR AND DELIVERY: 3 Stages of Labor and Delivery  b. prolapse of the umbilical cord, which could cut off the oxygen supply to the fetus. If membranes have ruptured, assess the FHR because of risk of cord prolapsed, and assess the amniotic fluid, because meconium-stained can indicate fetal distress. The time when membranes ruptured should be also recorded because if delivery happens 24 hours after, the risk for infection is high. II. Stages of labor Labor is traditionally divided into three stages: 1. Stage 1 – Dilatation stage begins with the initiation of true labor contractions and ends when the cervix is fully dilated. 2. Stage 2 – Expulsion stage extends from the time of full dilatation until the infant is born. 3. Stage 3 - Placental stage lasts from the time the infant is born until after the delivery of the placenta. 4. Stage 4 – Post partum stage is the first 1 to 4 hours after birth of the placenta is sometimes termed the “fourth stage” to emphasize the importance of the close maternal observation needed at this time. This stage will be extensively discussed in the next module. The first three stages of labor can be summarized as: True labor Full dilatation Delivery of the fetus Delivery of the placenta Stage I Stage II Stage III Stage 1(Dilatation Stage) The first stage, which takes about 12 hours to complete is divided into three separate segments: the latent, the active, and the transition phase (Table 1). Table 1. Comparison of Segments/Phases of Stage 1 of labor LATENT ACTIVE TRANSITION Frequency of q15-30 minutes q 3-5 minutes q 2-3 minutes contractions Duration 20-40 seconds 40-60 seconds 60-90 seconds Intensity Mild Moderate Strong Module 7 – LABOR AND DELIVERY: 4 Stages of Labor and Delivery Cervical dilation 0-3 cm 4-7 cm 8-10 cm Feelings of Excited Irritable feeling of loss of Mother control, anxiety, panic, or irritability Assess and record BP, PR, RR q 30-60 min q 30-60 min q 15-30 min FHR q 30-60 min q 15-30 min q 15-30 min Contractions q 30-60 min q 15-30 min q 10-15 min monitoring Perineum q 30-60 min q 30 min q 15 min A. Latent Phase The latent or preparatory phase begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation begins. Contractions during this phase are mild and short, lasting 20 to 40 seconds. Cervical effacement occurs, and the cervix dilates from 0 to 3 cm. Interventions: B. Active Phase During the active phase of labor, cervical dilatation occurs more rapidly, increasing from 4 to 7 cm. Contractions grow stronger, lasting 40 to 60 seconds, and occur approximately every 3 to 5 minutes. This phase lasts approximately 3 hours in a nullipara and 2 hours in a multipara. Show (increased vaginal secretions) and perhaps spontaneous rupture of the membranes may occur during this time. This phase can be a difficult time for a woman because contractions grow strong, last longer, and begin to cause true discomfort. It is also an exciting time, because something dramatic is suddenly happening. It can be a frightening time as a woman realizes labor is truly progressing and her life is about to change forever. C. Transition Phase During the transition phase, contractions reach their peak of intensity, occurring every 2 to 3 minutes with a duration of 60 to 90 seconds and causing maximum cervical dilatation of 8 to 10 Module 7 – LABOR AND DELIVERY: 5 Stages of Labor and Delivery  cm. If the membranes have not previously ruptured or been ruptured by amniotomy, they will rupture as a rule at full dilatation (10 cm). If it has not previously occurred, show occurs as the last of the mucus plug from the cervix is released. By the end of this phase, both full dilatation (10 cm) and complete cervical effacement (obliteration of the cervix) have occurred. During this phase, a woman may experience intense discomfort, so strong that it is accompanied by nausea and vomiting. Because of the intensity and duration of the contractions, a woman may also experience a feeling of loss of control, anxiety, panic, or irritability. Sensations may be so intense it may seem as though labor has taken charge of her. Care of a Woman During the First Stage of Labor Labor and birth are natural processes, so the average woman should be able to complete labor and birth without assistance from medical interventions. Nurses can be instrumental in keeping labor as free of unnecessary interventions as possible, so it remains not only safe but also a joyful and memorable experience. Major concepts to make labor and birth as natural as possible are: 1. Labor should begin on its own, not be artificially induced. 2. Women should be able to move about freely throughout labor, not be confined to bed. 3. Women should receive continuous support during labor. 4. No interventions such as intravenous fluid should be used routinely. 5. Women should be allowed to assume a non-supine such as upright, side-lying position for birth. 6. Mother and baby should be together after the birth, with unlimited opportunity for breastfeeding. 7. Spontaneous rupture of membrane is preferred over amniotomy. 8. Women are allowed light meal during labor. Fluids and ice chips are offered to prevent drying of lips. Because the first stage of labor begins with the start of uterine contractions and takes hours to complete, most women have been having labor contractions for hours before they arrive at a birthing center or hospital. This mean, most likely, they have been experiencing pan and relying on their own or their partner’s judgment that everything is going well for a long time. One or their chief needs when they arrive at a birthing setting, therefore, is reassurance their judgment has been correct – everything is going well and the exhaustion and increasing pain they feel is part of usual labor. Module 7 – LABOR AND DELIVERY: 6 Stages of Labor and Delivery Assessment and monitoring of the progress of labor is vital during stage 1 which includes the following: 1. Monitor maternal vital signs 2. Monitor FHR via ultrasound Doppler, fetoscope, or electronic fetal monitor. 3. Assess FHR before, during, and after a contraction (noting that the normal FHR is 110-160 beats per minute) 4. Monitor uterine contractions by palpation 5. Assess status of cervical dilatation and effacement 6. Assess fetal station presentation and position by Leopold’s maneuver. 7. Assist with pelvic examination. Stage 2 (Expulsion Stage) The second stage of labor is the time span form full dilatation and cervical effacement to birth of the infant. A woman typically feels contractions change from the characteristic crescendo-decrescendo pattern to an uncontrollable urge to push or bear down with each contraction as if to move her bowels. She pushes with such force that she perspires and the blood vessels in her neck become distended. The fetus begins descent and, as the fetal head touches the internal perineum to begin internal rotation, her perineum begins to bulge and appear tense. The anus become everted, and stool may be expelled. As the fetal head pushes against the vaginal introitus, this opens and fetal scalp appears at the opening to the vagina and enlarges form the size of the dime, to a quarter, then a half-dollar. This is termed as crowning. It takes a few contractions of this new type for a woman to realize everything is alright, just different, and to appreciate it feels better and less frightening, to push with contractions (Ferguson reflex). As she concentrates on pushing, she may become unaware of the conversation in the room. Pain may disappear as all of her energy and thoughts are directed toward giving birth. As the fetal head is pushed out of the birth canal, it extends and then rotates to bring the shoulders into the best line with the pelvis. The body of the baby is then born. Care of the Woman During the Second Stage of Labor 1. A support person plays a vital role during this time; because all of the preparations done up to this point may still not be enough to sustain a woman during these final contractions unless she feels well supported. Module 7 – LABOR AND DELIVERY: 7 Stages of Labor and Delivery 2. Assess fetal heart sounds at the beginning of the second stage of labor to be certain that the start of the baby’s passage into the birth canal is not occluding the cord and interfering with fetal circulation. 3. Assist the woman into whatever position she feels will be most effective for pushing (e.g. squatting, sitting upright, leaning forward against her partner) is important to help align the fetal presenting part with the cervix, increase the pelvic diameters, and use the fetal weight to help descent so that a prolonged second stage does not occur. A danger of a prolonged second stage are: a. chorioamnionitis (membrane infection) b. possible caesarean birth c. future urinary incontinence 4. Prepare the place of birth. For a multipara, convert a birthing room into a birth room by opening the sterile packs of supplies on waiting tables when the cervix has dilated to 9 to 10 cm. For a primipara, this can be delayed until the head has crowned to the size of a quarter or half-dollar (full dilatation and descent). 5. Promoting effective second-stage pushing. The woman should wait to feel the urge to push even though a pelvic exam has revealed she is fully dilated. Pushing is usually best done from a semi-Fowler’s with legs raised against the abdomen, squatting, or on all fours rather than lying flat to allow gravity to aid the effort. The woman should push with contractions and rests between them. She can use short pushes or long, sustained ones, whichever feels more comfortable. Holding breath for a prolonged time impairs blood return from the vena cava (a Valsalva maneuver), so this is now discouraged. To prevent this, urge her to grunt or breathe out during a pushing effort. 6. If nuchal cord (cord located around the baby’s neck) is present, which must be removed before the infant is fully born, it may be necessary to prevent the woman form pushing immediately after delivery. 7. Massaging the perineum as the fetal head enlarges the vaginal opening helps to keep it supple and prevent tearing. Clean the perineum with warmed antiseptic from the vagina outward using a clean compress for each stroke. 8. As soon as the head of the fetus is prominent at the vaginal opening apply Ritgen maneuver - place a sterile towel over the rectum and press forward on the fetal chin while the other hand Module 7 – LABOR AND DELIVERY: 8 Stages of Labor and Delivery  presses downward on the occiput to help the fetus achieve extension and allow the smallest head diameter to present. 9. The woman is asked to continue pushing until the occiput of the fetal head is firmly at the pubic arch. The head is then gently born between contractions if possible. This helps to prevent the head form being expelled too rapidly, creating a major pressure change in the skull, which might then rupture cerebral blood vessels. 10. After expulsion of the fetal head, external rotation occurs. Gentle pressure is then exerted downward on the side of the infant’s head by the primary care provider, so the anterior shoulder is born. Slight upward pressure on the side of the head allows the anterior shoulder to nestle against the symphysis pubis and the posterior shoulder is born. The remainder of the body then slides free without any further difficulty. 11. A child is considered born when the whole body is born. This the time that should be noted and recorded as the time of birth, which is the nursing responsibility. 12. The newborn is immediately laid on the mother’s naked abdomen and covered with a warmed blanket and cap to conserve heat and encourage mother-infant bonding. Stage 3 (Placental Stage) The third stage of labor, the placental stage begins with the birth of the infant and ends with the delivery of the placenta. Two separate phases involved: Placental separation and placental expulsion. A. Placental Separation As the uterus contracts down on an almost empty interior, there is such a disproportion between the placenta and the contracting wall of the uterus that folding and separation of the placenta occur. As separation is completed, the placenta sinks to the lower uterine segment or the upper vagina. The following signs indicate that the placenta has loosened and is ready to deliver: Lengthening of the umbilical cord Sudden gush of vaginal blood Change in the shape of the uterus Firm contraction of the uterus Appearance of the placenta at the vaginal opening Module 7 – LABOR AND DELIVERY: 9 Stages of Labor and Delivery There are two types of placental separation: 1. Schultze presentation – The placenta separates at its center and lastly at its edges, it tends to fold on itself like an umbrella and presents at the vaginal opening with at the fetal surface evident. Approximately 80% of placentas separate in this way. It appears shiny and glistening from the fetal membranes. To remember easily: Schutlze = “shiny surface” 2. Duncan presentation - The placenta separates first at its edges; it slides along the uterine surface and presents at the vagina with the maternal surface evident. It looks raw, red, and irregular, with the ridges or cotyledons that separate blood collection spaces showing. To remember easily: Duncan = “dirty surface” After the birth of the infant, the uterus can be palpated as a firm, round mass just below the level of the umbilicus. After a few minutes of rest, uterine contractions begin again, and the organ assumed a discoid shape. It retains the new shape until the placenta has separated, approximately 5 minutes after the birth of the infant. Bleeding occurs as part of the normal consequence of placental separation before the uterus contracts sufficiently to seal maternal sinuses. The normal blood loss is 300 to 500 mL. B. Placental Expulsion After separation, the placenta is delivered either by the natural bearing-down effort of the mother or by gentle pressure on the contracted uterine fundus by a physician or nurse midwife (Credé’s maneuver). Pressure must never be applied to a uterus in a non-contracted state, because doing so may cause the uterus to evert and hemorrhage. This is a grave complication of birth, because the maternal blood sinuses are open and gross hemorrhage could occur. If the placenta does not deliver spontaneously, it can be removed manually. With delivery of the placenta, the third stage of labor is complete. Care of a Woman During the Third Stage of Labor The placenta will deliver spontaneously following most births. Although this is true in most cases, up to 30 minutes is considered normal. The following are interventions during third stage of labor: 1. Assess maternal vital signs 2. Assess uterine fundus 3. After the expulsion of the placenta, uterine fundus remains firm and is located 2 fingerbreadths below the umbilicus. 4. Maintain uterus well contracted by Massage the uterus until it is well contracted. Module 7 – LABOR AND DELIVERY: 10 Stages of Labor and Delivery  Empty bladder. Administer drugs: a. Oxytocin 10 units IM or per 1,000 ml IVF b. Methylergonovine maleate (Methergine) IM c. Carboprost tromethamine (Hemabate) IM - Check any allergies and blood pressure before administering them 5. Examine placenta for cotyledons 6. Assess mother for shivering and provide warmth 7. Promote immediate breastfeeding. III. The Maternal Physiologic Effects and Psychological Responses Pregnancy has effects on many systems of the birthing parent. Knowing and recognizing what is normal and what is not normal can help and ensure safe provision of care. A. Cardiovascular system - Cardiac output increases 40%-50% from prelabor levels. - Blood loss at birth is 300-500 ml on average. - Blood pressure rises by 15 mm Hg with pain response and contractions - Epidural anesthesia may cause hypotension. - Monitor closely for hemorrhage and signs of hypertensive episodes. Position mother on side lying position if they receive epidural anesthesia and administer IVF as necessary. B. Respiratory System - Increased respiratory rate to respond to increased cardiovascular parameters. - Total oxygen needs increase 100% during second stage of labor. - Monitor for any signs of hyperventilation. If it occurs, offer paper bag. C. Temperature regulation - Temperature may increase - Diaphoresis occurs with accompanying evaporation to cool and limit excessive warming. - Monitor for any signs of infection. Offer cool washcloths for the patient’s forehead for comfort if needed. D. Fluid balance Module 7 – LABOR AND DELIVERY: 11 Stages of Labor and Delivery  - Insensible water loss increases due to diaphoresis and the increase in rate and depth of respirations. - Encourage women to sip fluid or ice chips to keep hydrated. E. Urinary system - Pressure of the fetal head as it descends in the birth canal against the anterior bladder reduces bladder tone or the ability of the bladder to sense filling. - Ask mother to void every 2 hours to avoid overfilling can decrease postpartal bladder tone and prevents the descent of fetal head. F. Musculoskeletal system - Relaxin is secreted from the ovaries causing the cartilage between joints to be more flexible. This allow the joints of the pelvis to be able to open as much as 2 cm to allow for fetal passage. - Monitor for appropriate mobility and be mindful of fall risks. G. Gastrointestinal system - GI system is inactive during labor making digestion and emptying of the stomach becomes lengthened. - Some women experience a loose bowel movement as contractions grow strong. - Offer fluids and ice chips. H. Neurological and sensory response - Increased pain and respiratory rate - Epidural anesthesia is administered during first stage, active phase. For birth, it needs block sacral nerves I. Psychological responses - Labor can lead too emotional distress because it is not only painful and fatiguing but it also represents the beginning of a major life change for a woman and her partner. - Continue to encourage her process of labor. Prior to birth, woman can have the support from a doula, who provides physical, emotional, and psychological support to laboring parents. IV. Nursing Diagnoses related to stages of labor and delivery Examples of nursing diagnosis according to stages of labor: Module 7 – LABOR AND DELIVERY: 12 Stages of Labor and Delivery  A. Stage 1 - Powerlessness related to duration of labor - Pain related to uterine contraction - Risk for ineffective breathing pattern related to breathing exercises - Anxiety related to stress of labor - Risk for fluid volume deficit related to prolonged lack of oral intake and diaphoresis form the effort of labor B. Stage 2 - Pain related to uterine contractions and pressure on pelvic structures from labor - Altered cardiac output related to change in vascular resistance - Risk Ineffective individual coping related to inadequate support system - Risk for fatigue related increased energy requirements C. Stage 3 - Acute pain related to tissue trauma - Risk for fluid volume deficit related to laceration of birth canal/uterine atony - Risk for maternal injury related to positioning during transfer V. Outcome Identification and Planning When developing realistic outcomes and planning interventions to manage discomfort during labor, consider the woman’s perceptions about childbirth, her past experiences, and the amount and type of childbirth preparation she and her partner have made. The following are outcome identification related to the identified nursing diagnosis. A. Stage 1 - Patient voices she feels in control of happenings, expresses preferences for positions and techniques to control pain. - Patient will use appropriate techniques to enhance comfort and maintain control of labor process. Rests between contractions - Patient’s respiratory rate returns to normal limits after a contraction; skin is her usual color, cool and dry. No reports of light-headedness or tingling/numbness in extremities - Patient states she feels in control of her situation; she and her support person express confidence in their ability to weather this extraordinary event in their life. Module 7 – LABOR AND DELIVERY: 13 Stages of Labor and Delivery  - Patient drinks at least one glass of selected beverage every hour; states she does not feel thirsty; voids at least 30 ml/hr every 2 to 4 hours. B. Stage 2 - Patient manages her discomfort in labor with nonpharmacologic methods, identifies additional pain relief measures if needed, responds to questions and instructions; states labor and birth were a positive experience for her - Patient will maintain vital signs within normal limits, FHR within normal limit, will use appropriate techniques to sustain/enhance vascular return. - Patient will verbalize feeling congruent with behaviour. Patient will demonstrate effective coping skills by the use of self directed techniques for bearing-down efforts. - Patient will effectively participate in bearing-down activities; will relax/rest between efforts. Stage 3 - Patient will verbalize management/reduction of pain - Patient will display vital signs within normal limits; will demonstrate adequate contraction of the uterus blood loss within normal limit. - Patient will observe safety measures and free of injury. VI. Evaluating nursing care An evaluation during labor should be ongoing to preserve the safety of the woman and her newborn. After birth, an evaluation helps to determine the woman’s opinion of her experience with labor and birth. Ideally, the experience should not only be one she was able to endure but also one that allowed her self-esteem to grow and the family bond to intensify through a shared experience. It is advantageous to talk to women following birth about their labor experience because doing so serves as a means of evaluating nursing care during labor. It also provides a woman the chance to work through the experience and incorporate it into her self-image. References Silbert-Flagg, J. (2022). Maternal and child health nursing: Care of the childbearing and childbearing family (9thed.). Philadelphia, PA: WoltersKluwer. Credits and Quality Assurance Module 7 – LABOR AND DELIVERY: 14 Stages of Labor and Delivery Prepared: Recommending Approval: MELANIE C. TAPNIO, MAN, RN, LPT DENMARK D. GABRIEL, MSN, RN, LPT Assistant Professor Assistant Professor & Chairperson, Nursing Program Reviewed by: Approved by: LEONARDO S. ANGELES, JR., PhD, MAN, RN, LPT Assistant Professor & OBE Facilitator ELMER D. BONDOC, PhD, MAN, RN Dean School of Nursing and Allied Medical Sciences Module 7 – LABOR AND DELIVERY: 15 Stages of Labor and Delivery