Cebu Normal University Recognizing Normal Labor Process PDF

Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines...

Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph Self-Instructional Module 1: Unit 2: The Birth Experience RECOGNIZING NORMAL LABOR PROCESS Course Code: NCM 106 Course Name/Title: Care of the Mother, Child and Adolescent (Well) Course Credit: 4 untis (lec) (5 units lab: 2 units Skills lab, 3 units clinical) Level Offering and Academic Year: BSN 2, First Semester, AY: 2024-2025 Name/s of Faculty: Prof. Jillian A. Bejoc Pre-Requisite Courses: HA 2, NCM 102 & NCM 103 MODULE OVERVIEW & INTRODUCTION Each woman’s labor and birth experience is uniquely shaped by a myriad of factors. Throughout this journey, the actions of nurses play a vital role in supporting the woman, her fetus and the family. This module is intended for students who have no online/offline access. The learning session is good for 2 hours and is aimed at helping you in recognizing the process of labor as springboard for you to make accurate decisions, render appropriate care and feel confident when you attend births. DESIRED LEARNING OUTCOMES Apply appropriate nursing concepts and actions holistically and comprehensively in the care of mothers during the intrapartal period. ENABLING LEARNING OUTCOMES When you have studied this module, you should be able to: 1. Discuss theories causing labor to begin. 2. Describe signs and symptoms of impending labor. 3. Explain factors affecting progress of labor. 4. Distinguish between true and false labor. 5. Describe the characteristic features and mechanisms of the four stages of labor. 6. Describe the seven cardinal movements as the baby descends the birth canal in a normal labor. 7. Apply the concepts learned in a given scenario. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph In the majority of cases, 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. Labor is the term for the changes in anatomy and physiology in the female reproductive tract that prepare the fetus and the placenta for delivery. Yet, only about 2% of deliveries occur on the expected date even among women who know their last menstrual period (LMP) date exactly. A woman in labor is known as a parturient. Wondering what initiates labor to begin? Suffice it to know that a number of theories regarding the origin of labor have emerged, but no single theory can establish for the onset of labor in all women. Hence, in this module, you will have a grasp of a variety of interacting factors that bring about initiation of labor along with the processes that the woman and the fetus have to undergo onwards to their birthing journey. What causes labor to begin? Theories regarding the onset of labor have been attributed to the woman and that of the fetus 1.1 Maternal factors: a. Uterine muscle stretching: The uterus stretches with the baby to the maximum and this causes the uterus muscles to start contracting so that the uterus regains its normal size and shape. It is a law of physics wherein a uterus is a hollow organ and when you are pregnant this organ becomes full. Therefore, the fullness must be emptied. Basically, stretching of the uterine muscles causes a release of prostaglandins to activate uterine contractions. b. Progesterone deprivation theory: As term approaches, biochemical changes cause a decreased availability of progesterone (relaxes smooth muscle) to the uterine myometrial cells. With rising estrogen levels, the uterus becomes more excited and contractions begin. c. Pressure on the cervix: stimulates the release of oxytocin by the maternal posterior pituitary gland d. Oxytocin stimulation: oxytocin, increases significantly during labor and works together with prostaglandins to activate uterine contractions. 1.2 Fetal factors a. Placental aging: As a pregnancy progresses, the placenta begins to age and this results in insufficient nutrients reaching the fetus triggering the initiation of contractions. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph b. Fetal cortisol concentration: Increase in fetal cortisol results in a decrease in the production of placental progesterone and an increase in the release of prostaglandins, which aid in the stimulation of uterine contractions. Before proceeding to the next lesson, accomplish the self-check at your right by sketching a heart shape beside the emoji that symbolizes the breadth of your understanding of the theories that explain why labor begins. At the outset, I greatly believe that you can discuss each theory pretty well. Meanwhile, although gestational age can predict to a certain extent when the signs of labor and pre-labor will develop, there is no proven way to predict precisely when labor will begin. But not without clues. What are the signs and symptoms of impending labor? Remarkably, before the onset of labor, a number of physiological changes occur that signal the readiness for labor and birth. The changes listed below are usually noted by the primigravid woman at about 38 weeks of gestation. In multigravidas, they may not take place until labor begins).  Lightening: settling of the fetal head into the birth canal causing the uterus to move downward as well with the woman reporting that her baby has “dropped.” The woman may further report changes in the appearance of her abdomen such as flattening of the upper area and an enhanced protrusion of the lower area. This will result to the following maternal symptoms: - leg cramps or pains, increased pelvic pressure, increased urinary frequency - increased venous stasis causing edema in the lower extremities - increased vaginal secretions, due to congestion in the vaginal mucosa (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph  Braxton-Hicks Contractions: irregular contractions usually felt in the groin region or abdomen, often called as false labor as these do not lead to dilatation and effacement of the cervix.  Weight loss: changes in the levels of estrogen and progesterone can lead to electrolyte shifts and may result in a reduction in fluid retention. The increased fluid loss can lead to a weight loss of up to 3 pounds (0.5 to 1.5 kg).  Cervical changes: the cervix softens (“cervical ripening’), stretches and thins. These changes are collectively called cervical effacement.  Bloody Show: with cervical effacement, there may be rupture of the small cervical capillaries. The added pressure created by the engagement of fetal head may result to expulsion of a blood-tinged mucus plug, called bloody show. Its presence often indicates that labor will begin within 24 to 48 hours.  Rupture of the membranes: About 12% of pregnant women experience spontaneous rupture of the amniotic sac (“ruptured membranes” or “ruptured bag of waters”) prior to the onset of labor. In the majority of pregnancies, the amniotic membranes rupture once labor is well established. 1. It is important for the woman to note the color, amount, and odor of the amniotic fluid. - The fluid should be clear and odorless. - Often it contains white specks (vernix caseosa) and fetal hair (lanugo). 2. Urinary incontinence (frequently associated with urgency, coughing, and sneezing) is sometimes confused with ruptured membranes.  Energy spurt: also known as “nesting” wherein some women experience a sudden increase in energy coupled with a desire to complete household preparations for the new baby. The energy spurt may be related to an increase in the hormone adrenaline, which is needed to support the woman during the work of labor. Women should be cautioned not to overexert themselves doing household chores and instead to “store up” their energy for the childbirth process.  Gastrointestinal Disturbances: Some women experience gastrointestinal disturbances (diarrhea, nausea, vomiting or indigestion) as a sign of impending labor. The etiology of the gastrointestinal disturbances is generally unknown. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph Now, let’s check what you have learned so far. F L A T T E N I N G Locate the answers in the puzzle. S I L C L E A R L U 1. sudden increase in energy: T G A L L O P O E B ____________ O H N E S T I N G L 2. fetal hair: ___________ R T U F F E R A G O 3. acronym for ruptured bag of E E G T H R O M I O ___________ U N O I G E S T G D 4. ruptured cervical capillaries causes P S N V E R N I X Y ___________ show O R I P E N I N G E 5. gastrointestinal disturbance N A U S E A V O M T 6. white particulate in amniotic fluid is called ________ caseosa. Before you proceed to 7. normal color of amniotic fluid: the next lesson, kindly ___________ accomplish the self- 8. health teaching to women check at your right by experiencing energy spurt: ticking (/) the emoji __________ indicating the extent that 9. softening of cervix in known you can describe the signs of impending as cervical ______________ delivery. 10. appearance of upper part of abdomen when lightening occurs: _____________ I bet it took you sooner to accomplish the puzzle. Keep the enthusiasm. (Refer to Appendix A for the Answers) On a personal note, particularly, for those who have siblings, you may have heard from your mother telling you that her birthing experience in bringing you out is uniquely different from your brother/s or sister/s, whereas, your friends may have shared that their mother, sister or relatives had it pretty easy. Why is this so? Well, a number of forces or factors affect the progress of labor and facilitate childbirth. The coordination of the various factors is significant for the labor and birth to progress successfully. What are the factors that affect the progress of labor? These critical factors are often referred to as the 5 “P’s” of labor: Powers (physiological forces): strength, duration and frequency of the contractions as well as the woman’s voluntary bearing-down or “pushing” efforts (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph Passageway (maternal pelvis or birth canal): configuration and diameters of the maternal pelvis, distensibility of the lower uterine segment, cervical dilation or dilatation, and introitus or dimensions of the pelvic girdle. Passenger (fetus and placenta) 1. fetus: size of head and shoulders, presentation and position 2. placenta: site of insertion Position of the mother: enhances comfort and facilitate labor and birth Psychosocial influences: readiness for labor and birth, level of educational preparedness, previous experience with labor and birth, emotional readiness, cultural influences and ethnicity. Considering that this course tackles normal labor and delivery process, a detailed discussion on the effects of the 5 P’s will be reserved in the next semester when we deal on the complications of labor and delivery. But this does not preclude you to learn them independently though. SELF-CHECK: In 2-3 sentences, scribble down your thoughts explaining how a woman’s readiness for childbirth influences labor and delivery Before proceeding to the next lesson, accomplish the self-check at your right by sketching a diamond shape beside the emoji that symbolizes the breadth of your understanding of the factors that explain why labor and delivery process is unique for every woman. on the theories that explain why labor begins. Doing so far? Keep it up!!! (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph Moving on, note that uterine contractions are considered the primary force of labor. Contractions are a rhythmic tightening of the uterus that occurs intermittently. Over time, this action shortens the individual uterine muscle fibers and aids in the process of cervical effacement and dilation or dilatation, birth, and postpartal involution (the reduction in uterine size after birth). When would you say then that a contraction is of good quality? What are the characteristics of uterine contractions? Each contraction consists of three distinct components: the increment (building of the contraction), the acme (peak of the contraction) and the decrement (decrease in the contraction). Between contractions, the uterus normally 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 to avoid exhaustion (Figure 1). Figure 1. Components of a contraction and counting contractions (Source: Ward, S. and Hisley, S. 2009, p. 358) (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph In addition, uterine relaxation between contractions is important for fetal oxygenation as it allows for blood flow from the uterus to the placenta to be restored. Furthermore, contractions bring about changes in the uterine musculature. The upper portion of the uterus becomes thicker and more active. The lower uterine segment becomes thin-walled and passive. The boundary between the upper and lower uterine segments becomes marked by a ridge on the inner uterine surface, known as the “physiological retraction ring.” (See Figure 2 and Figure 3) Figure 2. Mechanism of effacement, dilation or dilatation Figure 3. Physiologic and labor. retraction ring Source: BrainKart.com Source:nursekey.com (https://www.brainkart.com/article/Maternal-Changes- https://nursekey.com/giving- Before-the-onset- of-Labor_25650/) birth/ With each contraction, the uterus elongates. 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. Then as the uterus elongates, the longitudinal muscle fibers are stretched upward over the presenting part. This force, along with the hydrostatic pressure of the fetal membranes, causes the cervix to dilate or open.. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph What to assess in a uterine contraction? Contractions are often described in terms of their frequency, duration, and intensity. The frequency of a contraction is measured from the beginning of one contraction to the beginning of the next contraction. The duration of a contraction is measured from the start of one contraction to the end of the same contraction. The intensity of a contraction is most frequently measured by uterine palpation and is described in terms of mild, moderate, and strong. The interval of each contraction is measured from the end of one contraction to the beginning of the next contraction. How to assess a uterine contraction? Assessing a uterine contraction is done through palpation. To do this, you need to perform the following steps to assess each uterine contraction: a. Place the fingertips of your one hand on the fundus of the uterus where most contractions can be felt. b.Apply gentle pressure and keep your hand in the same place. Rationale: Moving your hand over the uterus may stimulate additional contractions, therefore interfering with the ability to accurately assess labor progress. c. Determine the firmness of the uterus and whether there is an ability to indent the uterus at the acme (peak) of the contraction. Palpating the intensity of contractions is often compared to palpating one’s nose (mild intensity), chin (moderate intensity), or forehead (strong intensity). When the uterine fundus remains soft at the acme of a contraction, the contraction intensity is described as “mild.” Conversely, when there is an inability to indent the uterus at the acme of a contraction, the contraction intensity is described as “strong.” “Moderate” contraction intensity falls somewhere in between and is characterized by a firm fundus that is difficult to indent with the fingertips. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph Additionally, between contractions, that is, when the uterus is relaxed and the muscular wall is soft, you will be able to palpate the fetal parts. But 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 if you apply deep pressure with your fingers. Meanwhile, in most birthing facilities, contractions may also be measured via electronic monitoring. Monitoring may be external or internal, and this modality can provide a continuous assessment of uterine activity. External contraction monitoring uses a tocodynamometer, which is a pressure-sensitive device that is applied against the uterine fundus. When the uterus contracts, the pressure that is exerted against the “toco” is measured and recorded on graph paper. Figure 4. Application of electronic fetal monitor sensors Source: https://blog.frontiersin.org/2017/ 09/20/ frontiers-in- bioengineering- biotechnology- fetal-health-pregnancy/ External monitoring may be continuous or intermittent. It provides information about the frequency and duration of contractions, but may not give accurate data regarding the intensity of contractions because there are many variables (i.e., maternal position, obesity, and the placement of the monitor on the uterus) that can affect the tracing. Contraction intensity is best assessed with palpation. What are the characteristics of a normal labor? Uterine contractions during early labor are characteristically weak and irregular. They usually last for about 30 seconds and occur every 5 to 7 minutes. As the labor pattern becomes established, the uterine contractions typically become regular in frequency, longer in duration, and increased in intensity. The duration of contractions increases to about 60 seconds, and they occur every 2 to 3 minutes. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph Uterine contractions are involuntary and are most efficient when there is a regular, rhythmic, coordinated labor pattern. In other words, the woman in labor is unable to control contraction frequency, duration, or intensity. Uterine contractions also bring about changes in the pelvic floor musculature. The forces of labor cause the levator ani muscles and fascia of the pelvic floor to draw the rectum and vagina upward and forward. During descent, the fetal head exerts increasing pressure and causes thinning of the perineal body from 5 cm to less than 1 cm in thickness. Continued pressure causes the maternal anus to evert and the interior rectal wall is exposed as the fetal head descends forward. The coordinated efforts of the contractions help to bring about effacement and dilatation of the cervix. Effacement is the process of shortening and thinning of the cervix. As contractions occur, the cervix becomes progressively shorter until the cervical canal eventually disappears. The amount of cervical effacement is usually expressed as a percentage related to the length of the cervical canal, as compared to a non-effaced cervix. For example, if a cervix has thinned to half the normal length of a cervix it is considered to be 50% effaced and fully effaced if 100%. Dilatation or dilation is the opening and enlargement of the cervix that progressively occurs throughout the first stage of labor. Cervical dilation is expressed in centimeters and full dilation is approximately 10 cm. With continued uterine contractions, the cervix eventually opens large enough to allow the fetal head to come through. At this point, the cervix is considered fully dilated or completely dilated and measures 10 cm. See Figure 2 & Figure 5.. Figure 5. Cervical effacement and dilatation. A. Membranes are intact before labor. B. Early effacement C. Complete effacement D. Complete dilatation Source: Ward, S. and Hisley, S. 2009, p. 359 (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph Basically, a normal labor occurring at term pregnancy has the following characteristics - spontaneous onset (it begins on its own, without medical intervention) - rhythmic and regular uterine contractions - vertex or cephalic presentation (baby’s head or ‘crown’ is at the birth canal) - vaginal birth occurs without active intervention in less than 12 hours for a multigravida woman and less than 18 hours for a primigravida - no maternal or fetal complications Any labor that deviates these conditions is considered abnormal and usually requires more intensive care. SELF-CHECK: In 2-3 sentences, scribble down your thoughts explaining why must the nurse monitor the uterine contraction pattern of a client in labor. Before proceeding to the next lesson, accomplish the self-check at your right by sketching a star shape beside the emoji that symbolizes the breadth of your understanding of the characteristics of normal uterine contractions and why the nurse needs to monitor them. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph Now, remember the Braxton Hicks contractions, often called as false labor? Women may report feelings of irregular contractions usually felt in the groin region or abdomen. These do not lead to dilatation and effacement of the cervix. Contractions that lead to cervical dilation/dilatation and effacement take place when true labor contractions occur. Determining whether labor is true or false is an important assessment. How does false labor differ from true labor contractions? Depending upon the findings, the nurse can help validate the next steps the woman should take. Distinguishing features of true and false labor are summarized in Table 1. Table 1. Distinguishing True from False Labor True Labor False Labor  Contractions are occurring at regular intervals  Contractions occur at irregular intervals  Contractions increase in frequency, duration and  Usually there is no increase in intensity. frequency, duration and intensity of contractions.  Pains usually begin in lower back, radiating to  Pains usually occur in abdominal the abdomen. region.  Dilation or dilatation and effacement of the cervix  Cervix does not dilate, remains are progressive. less than 2 cm  Activity such as walking usually increases labor  Walking may lessen the pain. pains What are the characteristics of each stage of labor? Labor is traditionally divided into four (4) stages: 1. First stage of labor (cervical opening or dilatation stage): begins with onset of regular uterine contractions and ends with complete cervical dilatation. Contractions often start slowly and are fairly tolerable. Over time, contractions tend to increase in frequency, duration, and intensity as the first stage of labor progresses. The first stage of labor is most often the longest stage and its duration can vary considerably among women. The first stage of labor is divided into three distinct phases: Latent phase: begins with establishment of regular contractions typically about 5 minutes apart, last 30 to 45 seconds, accompanied by low back pain and abdominal cramping which are considered to be mild. At this time, the woman is usually excited about labor commencing and remains chatty and sociable. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph Latent phase can last as long as 10 to 14 hours as the contractions are mild and cervical changes occur slowly. Often this phase of labor is completed at home. Cervical effacement and early dilation or dilatation will be from 0 to 3 cm. Active phase: characterized by more active contractions. The contractions become more frequent (every 3 to 5 minutes), last longer (60 seconds), and are of a moderate to strong intensity. At this time, the woman becomes more focused on each contraction and tends to draw inward in an attempt to cope with the increasing demands of the labor. Cervical dilatation during this phase advances more quickly as the contractions are often more efficient. While the length of the active phase is variable, nulliparous women generally progress at an average speed of 1 cm of dilation per hour and multiparas at 1.5 cm of cervical dilation per hour. Transition phase: most intense phase of labor, characterized by frequent, strong contractions that occur every 2 to 3 minutes and last 60 to 90 seconds on average. Often, this phase does not take long because dilation usually progresses at a pace equal to or faster than active labor (1 cm/hr for a nullipara and 1.5 cm/hr for a multipara). During the transition phase, the laboring woman may feel: - she can no longer continue - rectal pressure - an increased urge to bear down They will also experience increase in bloody show and spontaneous rupture of the membranes (if they have not already ruptured), and may question her ability to cope. 2. Second stage of labor (pushing stage): commences with full dilatation of the cervix and ends with the birth of the infant. Often the woman experiences the urge to push or have involuntary bearing down efforts. The contractions continue to occur frequently and are very intense. The woman may exhibit varying emotions during the second stage. Some patients may get a spurt of energy or a “second wind” to help them get through the second stage. Others may be nervous or fearful of the new sensations that they are feeling. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph For nulliparous women, the second stage often involves 1 to 2 hours of pushing. Multiparous women typically experience a much shorter second stage and childbirth may occur within minutes following full dilatation. Now, did you ever wonder how the fetus is able to get out of the mother’s womb? This mystery will be unlocked in the succeeding section. How does the fetus pass through the birth canal? Well, the cardinal movements, or mechanisms of labor, have been used to describe 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 (Figure 6) as follows: 1. Descent: Four forces facilitate descent, which is the progression of the fetal head into the maternal pelvis: (1) pressure of the amniotic fluid; (2) direct pressure of the uterine fundus on the fetal breech; (3) contraction of the maternal abdominal muscles; and (4) extension and straightening of the fetal body. The fetal head enters the maternal inlet in the occiput transverse or the oblique position because the pelvic inlet is widest from side to side. The sagittal suture is equidistant from the maternal symphysis pubis and sacral promontory. The degree of fetal descent is measured by stations. 2. Flexion: occurs as the fetal head descends and comes into contact with the soft tissues of the pelvis, the muscles of the maternal pelvic floor, and the cervix. The resistance encountered with these structures causes the fetal chin to flex downward onto the chest. This position allows the smallest fetal diameters to enter the maternal pelvis. 3. Internal Rotation: To fit into the maternal pelvic cavity, which is widest in the anteroposterior diameter, the fetal head must rotate. As the occiput of the fetal head comes into contact with the levator ani muscles and surrounding fascia, it meets with resistance. This causes the occiput to rotate, usually from left to right, and the sagittal suture aligns with the long axis of the maternal pelvis (the anteroposterior pelvic diameter). 4. Extension: As the fetal head passes under the maternal symphysis pubis, it meets with resistance from the pelvic floor. The head pivots and extends with each maternal pushing effort. The head is born in extension as the occiput slides under the symphysis and the face is directed toward the rectum. The fetal brow, nose, and chin then emerges. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph 5. Restitution: Internal rotation causes the fetal shoulders to enter the maternal pelvis in an oblique position. After the head is delivered in the extended position, it rotates briefly to the position it occupied when it was engaged in the inlet. This movement is termed restitution. The 45-degree turn of the fetal head facilitates realignment with the long axis of the body. 6. External Rotation: As restitution continues, the shoulders align in the anteroposterior diameter, causing the head to continue to turn farther to one side (external rotation). The 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. Lateral flexion of the shoulder and head occurs and the anterior, then posterior, shoulder is born. Once the shoulders are delivered, the rest of the body quickly follows. Figure 6. Cardinal Movements of the Fetus Source: Alanazi, Y. 2015. https://twitter.com/doctor_you sif/status/638671726709096 Watch each birth closely to see how babies in different positions move down the birth canal. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph 3. Third stage of labor: period of time from birth of the baby to the delivery of the placenta. This stage usually takes place within 5 to 10 minutes though may last up to 30 minutes. Once the baby is born, the uterine cavity immediately becomes smaller. The change in the interior dimension of the uterus results in a reduction in the size of the placental attachment site. This event leads to the separation of the placenta from the uterus. Clinical indicators of placental separation are: There is lengthening of the umbilical cord. The uterus becomes spherical or globular in shape. The uterus rises upward in the abdomen due to the descent of the placenta into the vagina. The umbilical cord descends further through the vagina, absence of backflow pressure A gush of blood occurs once the placenta detaches from the uterus. The placenta (Figure 7) is expelled or delivered in either the Schultze or Duncan manner. The Schultze mechanism (“shiny Schultze”) occurs when the placenta separates from the inside to the outer margins with the shiny, fetal side of the placenta presenting first. It is the most common method of placental expulsion. The Duncan mechanism occurs when the placenta separates from the outer margins inward, rolls up, and presents sideways. Since the placental surface is rough, the Duncan mechanism is commonly called “dirty Duncan.” Figure 7. Placental Presentation A. Schultze B. Duncan Source: A - Pillitteri, 2010, p. 362 A B As the placenta separates from the uterine wall, it is important that the uterus continues to contract. The contractions minimize the bleeding that results from the open blood vessels left at the placental attachment site. Failure of the uterus to contract adequately with separation of the placenta can result in excessive blood loss or hemorrhage. 4. 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. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph SELF-CHECK: Using the matrix below, describe the characteristic features and mechanisms of the four stages of labor. PARAMETERS FIRST STAGE SECOND STAGE Description Contractions Dilatation Physical Discomforts Maternal Behaviors Reference: Ward & Hisley, 2009. p. 373 PARAMETERS THIRD STAGE FOURTH STAGE Description Contraction Assessment Dilatation Physical Discomforts Maternal Behaviors Reference: Ward & Hisley, 2009.p. 389. Come to think of it, we are done discussing the nitty-gritty of normal labor and delivery. Finally, you now have a better grasp of the birthing process. It is with great hope that having recognized the uniqueness of this experience, you now have an anchor in making accurate decisions as well as in rendering appropriate care and most importantly feel confident when you attend births. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph LEARNING OUTCOMES ASSESSMENTS Now that you have completed this study session, you are directed to accomplish 2 sets of graded tasks. Part 1: Think-Pair-Share is accomplished with a partner. Kindly refer to the list provided for your respective partner/s. Part 2: 20-item Quizlet is to be accomplished individually after completing/submitting Part 1. Part 1. Think-Pair-Share Directions: 1. Choose a partner. 2. Answer the questions based on the given scenario below together with your partner/s. 3. Time Allotment to accomplish the tasks: 15 minutes 4. Brainstorm on a given scenario and apply the concepts and theories about labor and delivery process. 5. Write down your answers on the spaces provided. 6. Cite at least 2 references following APA 7th edition format. 7. Only one (1) output per partner is required. Prior to submission, ensure that your output bears your names. 8. You are expected to have submitted your output on or before 11:59PM (August 28, 2024) 9. Maximum rating for this activity: 15 points (Refer to rubrics found below) SCENARIO: Mrs. XAL is 27 years of age and is having her first baby. She has come to the labor room at 8:00AM because she began to feel regular cramping pains about 3 hours ago. She says that the pains start in her back and move forward to the front of her abdomen, each pain lasts about 50 seconds, and they occur 2–3 times in every 10 minutes. When the attending physician examined her, it was found that her cervix is 70% effaced and the diameter is 4 cm. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph Name: __________________________________________________ Date: ________________________ 1. What are the signs suggesting true labor from Mrs. XAL’s description and the physical examination? 2. What stage of labor has she reached and how do you know this? Support your answer with evidences. 3. What will you tell to Mrs. XAL to help her recognize that she is really in labor? (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph WRITTEN OUTPUT RUBRICS Best Work Good Work Could do better CRITERIA (15) (11) (8) Content Very substantial, concrete and Information provided are Some details (70%) logical details are provided comprehensive and provided are loosely that clearly match the task. clearly match the task related Organization Ideas presented are very Ideas presented are Confusing (10%) organized organized but could still organization of ideas be improved presented Citation of Sources Reference/s cited were more Cited 2 references; Reference/s cited (10%) than what is required; correctly follows APA 7th does not follow APA correctly follows APA 7th edition guidelines 7th edition format edition guidelines Timeliness Submitted at least day before Submitted on due Submitted beyond (10%) due date/time date/time due date Part 2. 20-Item Quizlet: Schedule to be arranged LEARNING ENHANCEMENT Additional learning such as additional readings materials and video links are provided below for you to learn through. This is intended to give you an opportunity to dig more on other “must know” and “need to know” of the labor and delivery process. This 4 minutes & 49-seconds video demonstrates the mechanism of labour (stages of labour) and the various fetal positions you may need to describe during an obstetric abdominal examination in an OSCE scenario. Source: Geeky Medics. 2018. Link: https://www.youtube.com/watch?v=ruIa1bC4tsw (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph Pillitteri. A. 2010. Maternal & Childhealth Nursing: Care of the Childbearing and Childrearing Family. 6th ed. https://drive.google.com/file/d/1lWX-vJNjUGSEi6- ZwKYRdk7utz997oJ_ /view?fbclid=IwAR06BLt4z9s8pWmypM-la5qzrrh5bsH- zQdM7gvI4EO-kcNeM9jP1y5iFNc pp.343-414. Ward, S. and Hisley, S. 2009. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children & Families. https://alraziuni.edu.ye/uploads/pdf/book1/ nursing/maternal-child%20nursing.pdf?fbclid=IwAR0dwlkYi_gtnB_LWVpP9 EUK7IW3sGLPCMHXnyf5I9zFK2UEzXPgkxpnF9o. pp. 355-426. REFERENCES Alanazi, Y. 2015. Cardinal Movements. Date Accessed: August 12, 2020 from: https://twitter.com/doctor_yousif/status/638671726709096 BrainKart.com. Nd. Mechanism of effacement, dilation and labor. Date Accessed: July 15, 2020 from; https://www.brainkart.com/article/Maternal-Changes-Before-the-onset-of- Labor_25650/ https://blog.frontiersin.org/2017/09/20/frontiers-in-bioengineering-biotechnology-fetal-health- pregnancy/ Nursekey.com. Nd. Physiologic retraction ring. Date accessed: August 12, 2020 from: https://nursekey.com/giving-birth/ Pillitteri. A. 2010. Maternal & Childhealth Nursing: Care of the Childbearing and Childrearing Family. 6th ed. Date accessed: July 15, 2020. from https://drive.google.com/file/d/1lWX-vJNjUGSEi6-ZwKYRdk7utz997oJ_ /view?fbclid=IwAR06BLt4z9s8pWmypM-la5qzrrh5bsH-zQdM7gvI4EO- kcNeM9jP1y5iFNc The Open University.nd.Labor Delivery and Care Module: 1. Recognition of Normal Labour. Date Accessed: July 15, 2020 from: https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=269&printab le=1& fbclid=IwAR2qjQJ6JuHvW4UT3vAcJTf_fYFldtDAI405uqaHEfyOcNAFN57i TAzdh1Q The Open University. 2017. Labour and Delivery Care. Date accessed: July 15, 2020 from: https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=273&section =20.5. 6&fbclid=IwAR1aH71Kx4qMZTYCorpNXF9FJtLVvywRyN31zzy- vTTi7CbuHAGcAp ZM46g (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph USAID. 2004. Basic Maternal and Newborn Care: Basic Childbirth, Postpartum and Newborn Care (Course Handbook for Participants). Date accessed: July 15, 2020 from: http://reprolineplus.org/system/files/resources/cpnc_handbook_0.pdf?fbclid=IwA R0zZ2 h4ObYQyhAmQdGNP_lY7uMusV4S9sszfCfChlDzASvvsWvom0O6I4Q Ward, S. and Hisley, S. 2009. Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children & Families. Date accessed: July 15, 2020 from https://alraziuni.edu.ye/uploads/pdf/book1/nursing/maternal-child%20nursing.pdf? fbclid=IwAR0dwlkYi_gtnB_LWVpP9EUK7IW3sGLPCMHXnyf5I9zFK2UEzXPgkxpn F9o. (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)  Republic of the Philippines Cebu Normal University Osmeña Blvd. Cebu City, 6000 Philippines College of Nursing Center of Excellence (COE) | Level IV Re-Accredited (AACCUP) Telephone No.: (+63 32) 254 4837 Email: [email protected]; [email protected] Website: www.cnu.edu.ph Appendix A ANSWER TO THE PUZZLE F L A T T E N I N G S I L C L E A R L U T G A L L O P O E B O H N E S T I N G L R T U F F E R A G O E E G T H R O M I O U N O I G E S T G D P S N V E R N I X Y O R I P E N I N G E N A U S E A M E N T Prepared by: JILLIAN A. BEJOC, RN, MSN Facilitator (Document Code) Page 1 of Registration No. 52Q18778 29 Certification Date: 6 August 2018 Recertification due date: 24 January 2021 For verification of the certificate please access www.globalgroup.net (Certification check and type the registration number)