Childbirth Week 4: Labour and Delivery Process PDF

Childbirth Week 4 The Process of Labour and Delivery © 2002 Delmar, a Thomson 1 Learning company  COMPONENTS OF THE BIRTH PROCESS Four P’s # 1 Powers # 2...

Childbirth Week 4 The Process of Labour and Delivery © 2002 Delmar, a Thomson 1 Learning company  COMPONENTS OF THE BIRTH PROCESS Four P’s # 1 Powers # 2 Passage # 3 Passenger # 4 Psyche Chapter 23 © 2002 Delmar, a Thomson 2 Learning company  # 1 The Powers Primary – uterine contractions – Effacement / Dilation – Described by: Frequency Duration Intensity Interval Secondary – maternal pushing © 2002 Delmar, a Thomson Learning company 3  Primary Involuntary uterine contractions are responsible for effacement and dilations of the cervix Contractions cause the cervix to efface and dilate to allow the fetus to descend the birth canal. Contractions at the same time push the fetus downward as they pull the cervix upward. (pushing a ball through a sock) This cause the cervix to become thinner and shorter. Effacement and dilation is determined by a vaginal exam. When the cervix is 4  Secondary Maternal Pushing Combined powers of involuntary uterine contractions and birthing person’s efforts Must be fully dilated and effaced Often strong urge to push © 2002 Delmar, a Thomson 5 Learning company The Powers © 2002 Delmar, a Thomson 6 Learning company  Frequency Frequency (beginning of one contraction the beginning of the next contraction. Measured in minutes or fractions of minutes eg contraction every 4 ½ minutes. Contractions occurring more often than 2 minutes can reduce fetal oxygen supply, needs to be reported. © 2002 Delmar, a Thomson 7 Learning company  Duration Duration is measured by the beginning of a contraction until the end of a contraction. Described as how long the contraction lasts, measured in average number of seconds Eg. Contractions are lasting 45 to 50 seconds. Contraction durations longer than 90 seconds may reduce fetal © 2002 Delmar, a Thomson oxygen supply and must be Learning company 8 Frequency and Duration © 2002 Delmar, a Thomson 9 Learning company  Intensity Is the approximate strength of the contraction which are measured by palpation or level of pain Mild contractions= tip of nose fundus is easily indented with finger tips Moderate contractions = chin, fundus can be indented but with more difficulty Strong contractions = forehead, © 2002 Delmar, a Thomson Learning company 10  Interval Is the amount of time the uterus relaxes between contractions. Blood flow from the mother to the fetus gradually decreases during contractions and resumes during interval. The placenta refills with fresh oxygenated blood and removes fetal waste products. Contraction intervals shorter than 60 seconds may reduce fetal oxygen supplies © 2002 Delmar, a Thomson 11 Learning company Intensity and Interval © 2002 Delmar, a Thomson 12 Learning company  # 2 Passage Bony pelvis composed of 4 bones Pregnancy hormones relaxin and estrogen soften the cartilage and increase the strength and elasticity of the pelvic ligaments. These changes cause pelvic joints to separate False pelvis – shallow upper section true pelvis - lower curved bony canal inlet, cavity, outlet © 2002 Delmar, a Thomson Learning company 13 Types of Pelvises © 2002 Delmar, a Thomson 14 Learning company  Anthropoid Only 1/3 with this type of pelvis can deliver vaginally © 2002 Delmar, a Thomson 15 Learning company  Android 16 % have this Typical male pelvis, not favourable for vag delivery, larger babies often become stuck in birth canal © 2002 Delmar, a Thomson 16 Learning company  Platypelloid Less than 3 % Narrow a/P diameter wide transverse This shape makes it extremely difficulty for the fetus to pass through the bony pelvis usually c-section © 2002 Delmar, a Thomson 17 Learning company Gynecoid Pelvis Most favourable for vaginal delivery, Most common 50% of pregnant people have them © 2002 Delmar, a Thomson 18 Learning company  Passageway The Station Station – refers to the relationship between the ischial spines (narrowest) in the passage and presenting part of fetus Ischial spines are 0 © 2002 Delmar, a Thomson 19 Learning company  # 3 Passenger The Fetus Passenger is the fetus and refers to the ease of passenger through the pelvis and is determined by many fetal factors such as head, size, presentation, lie, attitude and position Fetal head is composed of bony parts the frontal bone, two parietal bones, 2 temperol bones and a occipital bone. Skull bones are united by © 2002 Delmar, a Thomson 20 Learning company  The two most important fontanels are the anterior and posterior The diamond shaped anterior is largest and stays open until 18 months The posterior closes 6 to 8 weeks after birth During labour the vag exam can determine fetal presentation Fontanels allow for molding the fetal head can adapt to size and shape of the pelvis © 2002 Delmar, a Thomson Learning company 21 # 3 Passenger The Fetus © 2002 Delmar, a Thomson 22 Learning company  Fetal Lie Describes how the fetus is orientated to the spine. Most common is the longitudinal lie (99%) in which the fetus is parallel to the spine © 2002 Delmar, a Thomson 23 Learning company  Fetal attitude Relationship of fetal body parts to one another The most common one and most favourable to a vaginal birth is an attitude of flexion. Normal is head flexed forward and arms and legs are flexed. © 2002 Delmar, a Thomson 24 Learning company  Most Common Fetal Presentations The anatomic part of the fetus that enters the pelvis first or is closet to the birth canal 1. Head a) Vertex - fetal head is fully flexed. Most favourable b) Military - chest as normal, and so the widest and hardest part of the top of the head enters the birth canal c) Brow - the neck is not extended as much as in face presentation, and the leading part is the area between the anterior fontanelle and the orbital ridges d) Face - the chin is not tucked and the neck is © 2002 Delmar, a Thomson hyperextended. Learning company 25  Most Common Fetal Presentations 2. Breech a) Frank - Fetal legs are flexed at the hips and extend towars the shoulders. Most common type and buttocks are present at the cervix b) Full - Reversal of cephalic presentation. Both feet and buttocks present at the cervix c) Footling - Single footling - One or both feet are present at the cervix 3. Transverse © 2002 Delmar, a Thomson Learning company 26 Cephalic Presentation © 2002 Delmar, a Thomson 27 Learning company Fetal Presentations © 2002 Delmar, a Thomson 28 Learning company  Right Occiput Posterior (ROP), baby is head down and the back is to the side - the right side. ROP is the most common of the four posterior positions Right Occiput Transverse (ROT), back of baby's head, is on the right side of the mother's body and transverse, or across her pelvis Right Occiput Anterior (ROA), the back of the baby is more on the mother's right side than on her left © 2002 Delmar, a Thomson 29 Learning company  Left Occiput Posterior (LOP), baby is head down and the back is to the side - the left side. Left Occiput Transverse (LOT), back of baby's head, is on the left side of the mother's body and transverse, or across her pelvis Left Occiput Anterior (LOA), the back of the baby is more on the mother’s left side than on her right side © 2002 Delmar, a Thomson 30 Learning company Fetal Positions © 2002 Delmar, a Thomson 31 Learning company  # 4 Pysche Childbirth is more than a physical process Relaxation and positive attitude are crucial Anxiety increases perception of pain and increases secretion of stress compounds from adrenal glands - Adrenal compounds catecholamine's inhibit uterine contraction and divert blood flow © 2002 Delmar, a Thomson Learning company 32  Signs and Symptoms of Impending Labor Braxton Hicks contractions Cervical changes increase discharge Bloody show/mucous plug Rupture of membranes Energy spurt Weight loss Chapter 23 © 2002 Delmar, a Thomson 33 Learning company  http://www.youtube.com/wa tch?v=ze53Ep-gwBQ&featur e=related © 2002 Delmar, a Thomson 34 Learning company Mechanisms of labour Cardinal Movements of Labour © 2002 Delmar, a Thomson 35 Learning company Mechanisms of Labour https://www.youtube.com/w atch?v=Xath6kOf0NE&list= PL74E9C019A2C3DBB6 © 2002 Delmar, a Thomson 36 Learning company  Care and Management of labour Teaching positions and breathing techniques and avoiding pushing until cervix is fully dilated - Eg pushing one deep breath, exhales at the beginning of a contraction then takes another deep breath and pushes with the abdominal muscles while exhaling. Can push with body’s urges, often for 4 to 6 sec at a time, in a position that facilitates an open pelvis, ideally with gravity. Providing encouragement - powerful tool to help people summon their inner strength and strength to continue. Partners needs encouragement as well. Coaching is a demanding job. Some people may use a doula 37 Upright Positions © 2002 Delmar, a Thomson 38 Learning company Electronic Fetal Monitoring © 2002 Delmar, a Thomson 39 Learning company  Electronic Fetal Monitoring The uterine activity sensor is placed on the upper abdomen, over the uterine fundus. The Doppler transducer is placed over the lower abdomen, or wherever the fetal heart rate (FHR) is clearest. Keep everyone informed of progress. Evaluate patterns: baseline Fetal bradycardia when fhr is below 110BPM Fetal tachycardia > 160 © 2002 Delmar, a Thomson Learning company 40  Monitoring fetus before birth the fetal heart rate Determining placement of fetoscope or sensor to assess fetal heart rate (FHR). Approximate the location of the strongest fetal heart sound when the fetus is in various positions and presentations. The fetal heart sounds are heard best in the lower abdomen in a cephalic (vertex) presentation and higher on the abdomen when the fetus is in a breech presentation (E). A, LOA; B, ROA; C, LOP; D, ROP; E, LSA. © 2002 Delmar, a Thomson 41 Learning company  Electronic monitoring Recording of the fetal heart rate (FHR) in the upper grid and the uterine contractions in the lower grid. Note the sawtooth appearance of the FHR tracing that is a result of the constant changes in the rate (variability). Note: The space between each dark black line on the strip represents 1 minute. The small squares, or the space between each light black line, represents 10 seconds © 2002 Delmar, a Thomson 42 Learning company Electronic Fetal Monitoring Normal baseline heartrate: 110-160 beats/min Variability: fluctuations or constant changes (above and below) the baseline © 2002 Delmar, a Thomson 43 Learning company Electronic Fetal Monitoring Accelerations: temporary abrupt rate increase by 15 beats/min lasting 15 seconds to less than 2 min Decelerations: temporary gradual decreases from baseline, during contractions, that return to baseline by the end of the contraction © 2002 Delmar, a Thomson 44 Learning company  The Labour Process and the Nurse First stage (longest) – Latent phase – Active phase – Transition phase – First stage begins with regular contractions and ends when the cervix is completely dilated – Chapter 23 © 2002 Delmar, a Thomson 45 Learning company Latent Phase 4-6 hours + Cervix dilation is 1 – 4 cm Amniotic membranes may be intact May be bloody show Contractions: are Q20 min ↓ to 5 min Duration of contractions: 15 – 40 seconds Intensity: mild to moderate Behaviours: comfortable, alert, talkative © 2002 Delmar, a Thomson Learning company 46 Nursing interventions Establish rapport Encourage ambulation, rest, review breathing Assess fetal heart, contractions, vag discharge, need for health teaching, vital signs q2H Encourage voiding May take shower © 2002 Delmar, a Thomson 47 Learning company  Encourage Walking © 2002 Delmar, a Thomson 48 Learning company  Active Phase 2 – 6 hours Cervix dilation is 4 – 7 cm Amniotic membrane may rupture Effacement of cervix occurs Contractions: 2 – 5 min apart Duration: 40 – 60 seconds Intensity: moderate to firm Behaviours: apprehensive, anxious, introverted, perspires, facial flushing, may request pain relief, may need © 2002 Delmar, a Thomson 49 epidural or analgesia Learning company  Nursing interventions Maternal/fetal assessments Assist in coping strategies Encourage voiding, watch for distension Report colour, odour and any discharge. Watch for meconium staining Provide general comfort measures Coping strategies- breathing relaxation techniques Encourage position©changes 2002 Delmar, a Thomson 50 Learning company  Position Changes © 2002 Delmar, a Thomson 51 Learning company  Anxiety Increases with Pain © 2002 Delmar, a Thomson 52 Learning company  Transition Phase 30 minutes to 2 hours Cervix dilation is 7 – 10 cm full dilation Amniotic membranes rupture if not already have Contractions: q 2 – 3 minutes Duration: 60 – 90 seconds Intensity: firm Behaviours: irritable, may want to give up, restless, tremor of legs, may © 2002 Delmar, a Thomson request medication, nausea, Learning company 53 Nursing Interventions Firm coaching breathing and relaxation exercises. Support coach. Praise and reassure Assess fetal heart rate and contraction EFM Assess colour of vaginal discharge © 2002 Delmar, a Thomson 54 Learning company  Second Stage of Labour Expulsion of Fetus Cervix dilation is 10 cm Contractions: q 1 1/2- 3 mins apart Duration: 60 – 80 seconds Intensity: firm Episiotomy may be performed if needed Second stage ends with expulsion of the fetus Behaviours: bulging perineum. May pass stool, uncontrollable urge to push, states baby is coming. © 2002 Delmar, a Thomson 55 Exhaustion after each contraction. May find it Learning company Nursing Interventions Assist with open glottis pushing technique Monitor contractions and FHR q 5 min Report bulging or crowning Prepare supplies for delivery Assess bladder distension © 2002 Delmar, a Thomson 56 Learning company  Urge to push At the beginning of a contraction take 2 deep breaths and push on second exhalation © 2002 Delmar, a Thomson 57 Learning company  Examining presence of head © 2002 Delmar, a Thomson 58 Learning company  Crowning © 2002 Delmar, a Thomson 59 Learning company  Head is born © 2002 Delmar, a Thomson 60 Learning company  External rotation © 2002 Delmar, a Thomson 61 Learning company  Preparing to deliver the shoulder © 2002 Delmar, a Thomson 62 Learning company  Delivery © 2002 Delmar, a Thomson 63 Learning company  Third Stage of Labour Expulsion of Placenta Duration: 5 – 30 minutes Contractions – intermittent Intensity – mild to moderate Umbilical cord is cut Placenta is delivered Uterus contracts to size of grapefruit Episiotomy/laceration is sutured Behaviours: Elation, relief, tremors, tears © 2002 Delmar, a Thomson 64 Learning company © 2002 Delmar, a Thomson 65 Learning company The maternal side of the placenta, which is dull and rough, fetal side of the placenta, which is shiny and smooth © 2002 Delmar, a Thomson 66 Learning company Nursing Interventions Observe blood loss Massage uterus Vital signs q 15 min Administer oxytocin as needed Apply proper ID to birthing person, infant and partner Newborn care © 2002 Delmar, a Thomson 67 Learning company  Fourth Stage of Delivery Recovery Uterus remains midline, firmly contracted at or below umbilicus Lochia rubra saturates perineal pad (no more than one pad per hour) Cramping may occur Birthing person may have shaking chills related to thermoregulation response Behaviours: get acquainted period between birthing person, infant, partner First period of reactivity Learning-company breastfeed infant © 2002 Delmar, a Thomson 68 Nursing Interventions Vital signs/pain Q15 min Assess maternal voiding Monitor newborn vital signs Assess fundus and massage to maintain firm contraction Assess lochia Encourage breastfeeding and bonding © 2002 Delmar, a Thomson 69 Learning company Forceps Delivery © 2002 Delmar, a Thomson 70 Learning company Suction Delivery © 2002 Delmar, a Thomson 71 Learning company https://www.youtube.com/watch?v=x yN48VnRYUY&list=PLD8C569116E48F 504 © 2002 Delmar, a Thomson 72 Learning company  Cesarean Delivery C-Section Role Play activity or description of what to expect with a c-section. -monitor dressing, pain, output, gas pain common, monitor for blood clots in calf, up to bathroom when possible (one to one assistance). © 2002 Delmar, a Thomson 73 Learning company  Maternal Adaptations to Labor Hematologic and cardiovascular system Respiratory system Renal system Gastrointestinal system Chapter 23 © 2002 Delmar, a Thomson 74 Learning company  Hematologic and cardiovascular system Increased demand for oxygen during labour, similar to mother engaging in vigorous aerobic activity Moderate increase in cardiac output throughout first stage. During second stage (pushing) cardiac output can increase 40 to 50% above prelabour Pulse is often high, dehydration and exhaustion also contribute to increased pulse Blood pressure does not change © 2002 Delmar, a Thomson Learning company 75  Respiratory system Respirations increase related to pain of uterine contractions. The increased demand for oxygen increase risk for hyperventilation, dry mouth and dehydration Renal system - Pressure on urethra from presenting part may cause over filling of the bladder, decreased sensation to void and edema. Full bladder slows the progress of labour, Sometimes in and out catheterization © 2002 Delmar, a Thomson Learning company 76 Gastrointestinal system Labour prolongs the gastric emptying time, this can lead to N & V Current recommendations allow clear fluids © 2002 Delmar, a Thomson 77 Learning company  Fetal Adaptations to Labor Fetal heart rate - Watch for decelerations FHR During pregnancy is 140 to 160. During contractions can slow heart rate, placental blood flow can diminish Fetal respiratory system - Passing through birth canal is beneficial to fetus As fetus descends maternal tissues help to compress the body and expel respiratory passage of mucous. Chapter 23 © 2002 Delmar, a Thomson Learning company 78 TEACHING POINTS – LABOUR & DELIVERY When should I come to hospital? when contractions are regular and painful – lasting 30-60 secs - in five min intervals or your water breaks What are my pain management options? Medical – nitrous oxide, injection of pethidine or 79 TEACHING POINTS – LABOUR & DELIVERY What is an – Episiotomy – surgical cut at opening of vagina during childbirth – Amniotomy – intentional rupture of amniotic sac Can I eat or drink while I am in labour? Ice chips © 2002 Delmar, a Thomson 80 Learning company