Week 5 Normal Labor PDF

Types of Labor ▪ Prolonged labor: a labor that lasts more than 24hrs. ▪ Precipitate labor: a labor that lasts less than 3hrs. ▪ Premature labor: a labor that results in a premature fetus and occurs at gestational age ranged between 28-37 weeks of gestation....

Types of Labor ▪ Prolonged labor: a labor that lasts more than 24hrs. ▪ Precipitate labor: a labor that lasts less than 3hrs. ▪ Premature labor: a labor that results in a premature fetus and occurs at gestational age ranged between 28-37 weeks of gestation. PAGE 5 Components of Birth Process Factors Affecting Labor Process (4Ps) 1. Power: Primary force (uterine contractions); Secondary force (maternal bearing down/pushing efforts) 1. Passage: maternal pelvis (bony pelvis) and soft tissue. 2. Passenger: Fetal size, Fetal lie, Attitude, Presentation, Position 3. Psyche: Psychological status of the mother which is influenced by many factors such as culture, age…etc. Ch12 P. 302 PAGE 6 Normal Labor Characteristics Spontaneous expulsion A single Mature fetus (38-42 weeks) Presented by vertex Through the birth canal (vaginal delivery) Within a reasonable time (> 3 to < 18 hours) Without complications to the mother Without complications to the fetus. PAGE 8 Premonitory Signs of labor ▪ Premonitory Signs – impending signs that take place last weeks or days of pregnancy ▪ Braxton Hicks Contractions ▪ Lightening ▪ Increased Vaginal Mucous Secretions ▪ Cervical Ripening and Bloody Show ▪ Energy Spurt ▪ Weight Loss PAGE 9 Premonitory Signs of labor 1- Braxton Hicks Contractions Irregular, mild uterine contractions that occur throughout pregnancy & become stronger in the last trimester 2- Lightening ▪ Descent of the fetus toward the pelvic inlet 2 to 3 weeks before the natural onset of labor. ▪ Pressure of the fetal head in the pelvis. ▪ Frequency of urination. ▪ Mother notices breaths easily PAGE 10 Premonitory Signs of labor 3- Increased Vaginal Mucous Secretions ⁎ Due to fetal pressure  congestion of the vaginal mucosa. 4- Cervical Ripening and Bloody Show ⁎ Hormone Relaxin  the cervix softens. ⁎ As the fetal head descends  pressure on the cervix, starting the effacement and dilation. ⁎ Bloody show: mixture of blood and mucus, often precedes labor > expulsion of the mucus plug PAGE 11  Premonitory Signs of labor 5. Energy Spurt A nesting …..sudden increase in energy 6. Weight Loss 2.2 to 6.6 kg Altered estrogen-to-progesterone ratio causes excretion of some extra fluid that accumulates during pregnancy. PAGE 12 True Labor Vs False Labor True Labor False Labor (Prodromal Labor) Contractions Regular frequency Irregular frequency Increase in duration & intensity Irregular duration Begin in lower back & abdomen Walking Increase with walking May decrease with walking Discomfort Menstrual cramps like pain Abdomen and groin Not relieved by sedation Relieved by sedation Cervix Progressive effacement & Dilation No cervical effacement or dilation most important feature Ch 12 p. 310 PAGE 15 Stages and Phases Of Labor Ch 12 p. 312 PAGE 20 Factors affecting birth process Additional factors: (+P) ⁎ Philosophy (touch base) ⁎ Partners (Support) ⁎ Patience (birth time) ⁎ Patient (Preparation & knowledge) ⁎ Pain management 35 4Ps- Passenger Fetal Head: Skull The fetus enters the birth canal in the cephalic/vertex presentation 96% of the time. The fetal shoulders are also important because of their width, usually can be moved to adapt to the diameter of the pelvis.. 36  1.Fetal Skull Bones, Sutures, Fontanels & landmarks Bones 2 frontal bones 2 parietal bones (crown of skull) 1 occipital bone (back of head) These bones are not fused but are connected by sutures: narrow areas of flexible tissue Fontanels: The wider spaces at the intersections of the sutures. 37 1. Fetal Skull Bones, Sutures, Fontanels & landmarks Allow the bones to move slightly, changing the shape of the fetal head Molding adapt to the size and shape of the pelvis It provides important landmarks to determine fetal position and head flexion during vaginal examination 38  Fontanels The anterior fontanel: has diamond shape formed by the intersection of The 4 sutures: (2 coronal,1 frontal, & 1 sagittal) The 4 bones: (2 frontal and 2 parietal bones). The posterior fontanel small shape formed by the intersection of The 3 sutures: (1 sagittal and 2 lambdoid) The 3 bones: (2 parietal and 1 occipital bone). 39  Landmarks of Fetal Skull Anterior fontanelle (bregma) Posterior fontanelle (lambda) Mentum – chin (M-Mentum) Sinciput – brow Vertex – space between fontanels Occiput – occipital bone (O) The major transverse diameter is the biparietal diameter averages 9.5 cm. The most favorable condition the head becomes fully flexed during labor-and the anterior posterior diameter is (suboccipitobergmatic averaging 9.5 cm) 40  Variations in the Passenger (Relationship between fetus & Pelvis) Refers to the relationship between the longitudinal axis of the baby with respect to the longitudinal axis of the mother. ▪ longitudinal lie (normal) The fetal spine (long axis) runs in the same direction (parallel) to the mother’s spine. ▪ Transverse lie The fetal spine runs transverse or perpendicular to the mother spine ▪ Oblique lie The fetal long axis is at angle to the bony inlet and no palpable fetal part is presenting. 2. Fetal Lie 42  3. Fetal Attitude Definition: The relation of fetal head to fetal back or extremities (the relation of fetal body parts to anther one). The normal fetal attitude is flexion (Anterior) of the head toward the chest and the arms and legs flexed over the thorax. The back is curved in a convex “C” shape. Universal flexion 43 3. Fetal Attitude 44 4. Presentation/ Presenting part - Three categories of Presentation: Definition: Fetal part that enters the maternal pelvis first (1) cephalic (2) breech (3) shoulder - The most common is cephalic/ vertex presentation. Other presentations are associated with prolonged labor and other problems. 45 Cephalic Presentation Variations of Cephalic Presentation 1. Vertex/ occiput presentation the most common type “favorable” because the smallest sub-occipito-bregmatic (9.5cm) diameter is presenting. 46 Cephalic Presentation 2. Military: 3. Brow: The fetal head is partly The head is neither flexed nor extended. extended. The longer occipitofrontal diameter is Unstable, usually converting to a presenting. vertex if the head flexes or to a face presentation if it extends. The longest supraoccipitomental diameter is presenting 47 Cephalic Presentation 4. Face: The head is extended, near to fetal spine. Submentobregmatic diameter is presenting. 48 Cephalic Presentation 49  Breech Presentation A breech presentation occurs when the fetal buttocks enter the pelvis first, in about 3% to 4% of births. Occurs due to Fetal abnormality as hydrocephalus Abnormalities of the maternal uterus and pelvis and with placenta Previa. 50  Breech Presentation Frank breech Full (complete) Footling This is the most The head, knees, and breech: common (fetal legs hips are flexed, the This occurs when are extended across buttocks are one or both feet the abdomen toward presenting. are presenting. the shoulders). 51 Shoulder Presentation The shoulder presentation is a transverse lie and accounts for only 0.3% of births. Occurs more often with Preterm birth High parity Prematurely ruptured membranes Hyramnios, placenta previa. 52  5. Position Fetal position: describes the location of a fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvis. 53 5. Position Position cont.. ▪ The following abbreviations describes the relationship between fetus and mother pelvis: 1. Right (R) or Left (L) (fetal reference is right or left to the mother ‘s pelvis) 2. Occiput (O), Mentum (M), or Sacrum (S) (fetal reference point) 3. Anterior (A), Posterior (P) or Transverse (T) (anterior or posterior quadrant of mother’s pelvis) 4 Quadrants: Right (R) & Left (L) anterior Right & Left posterior 54  Left Occiput Anterior (LOA) The fetal occiput is directed towards the mother's left, anterior side Right Occiput Anterior (ROA) The fetal occiput is directed towards the mother's right, anterior side.  Left Occiput Posterior Baby's back favors mother's left and the back of baby's head is towards mother's posterior.  Right Occiput Posterior ▪ Baby's back favors mother's right and the back of baby's head is towards mother's posterior. Fetal heart tone positions 59 4Ps- Passage The linea terminals (pelvic prim) divide the bony pelvis into: False pelvis (top) True pelvis (bottom) consist of the following:  Inlet (upper pelvic opening)  Mid-pelvis (cavity)  Outlet (lower pelvic opening) 60  True Pelvic Structure I-Inlet (brim): is slightly transverse, oval shape. ▪ Anteroposterior diameter of inlet (Obstetric diameter) 10.5cm ▪ middle of the sacral promontory to the most prominent point symphysis pubis. ▪ Oblique diameter 12.5 cm ▪ Transverse diameter of inlet 13.5 cm. 61  True Pelvic Structure II-The pelvic Cavity ▪ The midpelvis is the narrowest part of the pelvis which fetal enters through birth canal. ▪ midpelvic diameters are measured at the level of ischial spines. ▪ Averages 12 cm. 62  True Pelvic Structure III. Outlet Three important diameters of pelvic outlet: The anterior posterior (9.5-11cm) The transverse biischial (11cm) The posterior sagittal (7.5cm) 63 Four Types of Pelvis Gynacoid Anthropoid Android Platypelloid 64  Fetal Station Is a measurement of the fetal descent of the fetal presenting part in relations to the level of ischial spins of the mother’s pelvis Imaginary line between ischial spines of maternal pelvis It’s measured in centimeters (cm) 0 Station: from right ischial spine to the left ischial spine Therefore, we are assessing 5 cm from the top of the ischial spine line to 5 cm below the ischial spine line. Crowning: fetal head can be seen at vaginal opening (+5 Station) 65  Fetal Station The fetus is at -2 station signifying that the leading bony edge of the presenting part is 2 centimeters above the ischial spines. The head is engaged at 0 station. References Cleveland Clinic. (2021). Breech Baby. (2021). Retrieved from, https://my.clevelandclinic.org/health/diseases/21848- breech-baby Cleveland Clinic. (2020). Fetal Positions for Birth. Retrieved from, https://my.clevelandclinic.org/health/articles/9677- fetal-positions-for-birth. Pilliod RA, Caughey AB. Fetal malpresentation and malposition: diagnosis and management. Obstet Gynecol Clin North Am. 2017;44:631–43. Murray, S. & Mckinney , E. (2019). Foundations of Maternal-Newborn and Women’s Health Nursing. (7th Ed). Elsevier. Saunders. 67  Part III Pharmacological & Non-Pharmalogical Management During Labor Antenatal Care 68 Objectives 1- Explain how the pain of labor and birth differs from other types of pain. 2- Describe sources of labor pain. 3- List factors influencing the woman’s experience of labor pain. 4- Discuss principles of labor pain management. 5- Illustrate the non-pharmacologic interventions to manage labor pain. 6- Explain various relaxation techniques that help a woman to cope with labor. 7- Describe labor analgesic techniques 8- Describe the complications of regional techniques 69  Introduction Pain is a universal experience but is difficult to define. It is an unpleasant sensation resulting from stimulation of sensory nerves. Pain components: A physiologic is reception by sensory nerves and transmission to the central nervous system A psychological is recognizing the sensation, interpreting it as painful, and reacting to the interpretation Pain is subjective and personal. No one can feel another’s pain. 70 The Pain of Labor and Childbirth Unique ▪ Different from other types of pain (usually pain is warning sign of injury) ▪ Increased intensity desired and positive (greater intensity is associated with approaching birth) ▪ Occurs in predictable pattern (begins without warning, but once established it is predictable) 71 General concepts of pain Pain Threshold ▪ The level of pain necessary for an individual to perceive pain Pain tolerance ▪ The ability of an individual to withstand pain once it is recognized 72 Discomfort during labor A Distribution of labor pain during first stage. B Distribution of labor pain during transition and early phase of second stage. C Distribution of pain during late second stage and actual birth 73 Sources of Pain During Labor Physical sources:  Tissue ischemia (Due to decreased blood supply to uterus during contractions, lead to hypoxia).  Cervical dilatation.  Pressure and pulling of pelvic structures (stretching and pulling of ligaments, uterine tubes, ovaries, bladder and peritoneum. This is felt as referred pain in back and legs).  Distension of vagina and perineum (It is felt as sensation of burning, tearing or splitting). 74 Causes of Pain in Labor Stretching of the cervix during dilation & effacement Stage One Uterine Anoxia Stretching of the uterine ligaments 75 Causes of pain in labor Distention of the vagina and Perineum Compression of the nerve Stage ganglia in cervix & lower uterus Two Pressure on urethra, bladder, rectum during fetal descent Traction on and stretching of the perineum 76 The Physiology of Pain in Labor 1st stage of labor – mostly visceral (is pain that results from the activation of nociceptors [organs]. Visceral pain comes from the internal organs)  Dilation of the cervix and distention of the lower uterine segment  Dull, aching and poorly localized  Slow conducting, visceral C fibers, enter spinal cord at T10 to L1 2nd stage of labor – mostly somatic (comes from the skin, muscles, and soft tissues)  Distention of the pelvic floor, vagina and perineum  Sharp, severe and well localized  Rapidly conducting A-delta fibers, enter spinal cord at S2 to S4 77 Gate control Theory Transmission of nerve impulses is controlled by a neural mechanism in the dorsal horn of the spinal cord that acts like a gate to control impulses transmitted to the brain. Pain …..small-diameter sensory nerve fibers. Stimulation of large-diameter fibers in the skin blocks conduction of Pain. Closing the “gate” & the amount of pain felt. 78 Techniques of Pain management Non-Pharmacological Based on gate-control theory Pharmacological Regional Anesthesia/Analgesia 79 Factors affecting Mothers Response to Pain in Labor Physiologic Psychosocial Physical condition of the woman The level of the woman’s fear and Use of pharmacologic methods anxiety Age of the woman The woman’s culture Length of labor experience The circumstances surrounding the birth experience (planned or unplanned, wanted or not wanted, preterm or term) Preparation - Knowledge and confidence gained through childbirth classes 80 Factors influencing Tolerance of Pain Intervention of caregivers: Intravenous lines cause pain. Fetal monitoring equipment causes discomfort by limiting movement. Vaginal examinations and procedures such as amniotomy are uncomfortable as they cause stretching. Induced or augmented labor is more painful. 81 Non-Pharmacologic Pain Interventions Relaxation techniques-helps to facilitate labor process. Birthing ball Patterned breathing Movement and Position Changes Listening to music; subdued lighting Imagery Applying heat and cold Massage (lower back); Counterpressure https://www.youtube.com/watch?v=dRpfPOLMX3Y https://www.youtube.com/watch?v=yZ85g9MLfR8 82 Non-Pharmacologic Pain Interventions Advantages: Labor not delayed / slow No side effects or risk of allergy. Eliminate labor pain without extra techniques. A realistic option for a woman who in advanced, rapid labor. No time needed to for effective action on birth. No risk for newborn respiratory effort as analgesic Limitations: Women do not always achieve the desired level of pain control using these methods alone 83 Breathing Exercise Slow, deep breathing is particularly effective. There are no rules related to how many breaths per minute, whether to breathe through the mouth or nose, or whether to make sounds. The key here is that the breathing is conscious, not automatic. As labor contractions get stronger and the work of labor gets harder, speeding up the breathing and making it shallower is sometimes, but not always, more effective. 84 Breathing Techniques – First stage Modified-Paced Breathing chest breathing at a faster rate allows oxygen intake to remain the same. Patterned-Paced Breathing Patterned-paced breathing a certain number of breaths, exhales with a slight blow. Breathing to Prevent Pushing Blowing prevents closure of the glottis to overcome the urge to push Hyperventilation ….. “Carpo pedal spasm” due to decreased levels of calcium in tissues & blood 85 Breathing Methods Basic principles Comfortable position Chest breathing Focal point Verbal and non-verbal cues Cleansing breath Rhythmic chest Shallow chest Pant-blow Exhalation pushing 86 Breathing Methods Focusing on something, either with eyes closed or open, can help maintain the rhythm of the breathing. Women move, change position, slow dance, sway on birth balls, learn massage, and identify the countless other ways they normally relax and find comfort. Each of these comfort strategies can be used in combination with breathing. 87 Non-Pharmacologic Pain Interventions Movement and Position Changes (relieve pain by shifting pressure and allowing the baby to move). 88  Non-Pharmacologic Pain Interventions Aromatherapy Use of essential oils such as lavender, rose, and chamomile. These can be administered in oil during a massage, in hot water as a bath or footbath, a drop in the palm or on the forehead of the laboring woman or a drop on a warm face cloth. Aromatherapy reduces stress and tension during labor. Beware, however, that pregnant and laboring women are highly sensitive to smell. 89  Non-Pharmacologic Pain Interventions Imagery: ▪ Dissociate herself from the painful aspects of labor. Focal Point: ▪ close eyes or may want to concentrate on an external focal point. To be away from the pain of contractions. A picture of a relaxing scene Hydrotherapy: ▪ Water therapy is a relaxation technique. ▪ The resistance afforded by immersion. ▪ Equalizes pressure on the body, & aids muscle relaxation. Major concern ▪ Newborn and postpartum maternal infections caused by microorganisms in the water. 90 Non-Pharmacologic Pain Interventions Massage 1. Self-Massage: The woman may rub her abdomen, legs, or back during labor (effleurage). 2. Massage by Others: By support person or nurse. Counter pressure: Sacral pressure for back pain, (occiput posterior position). Using the palm of the hand, the fist /a firm object 91 Non-Pharmacologic Pain Interventions Touch Holding her hand, stroking her hair, or similar actions convey caring, comfort, affirmation, and reassurance Thermal Stimulation Warmth applied to the back, abdomen, or perineum Increases local blood flow, relaxes muscles, raises the pain threshold. Massage is more comfortable after the skin is warmed. A warm shower, tub bath, or whirlpool bath is relaxing and provides thermal stimulation. 92 Non-Pharmacologic Pain Interventions Acupressure. The support person applies pressure to specific pressure points using hands, rollers, balls. Effective in relieve nausea & vomiting Morning sickness of pregnancy. 93 Pharmacological Pain Interventions Regional Anesthesia/Analgesia Narcotic Analgesics ▪ Timing ▪ Effect on labor ▪ Common medications used ▪ Stadol ▪ Nubain 94 Pharmacological Pain Interventions Criteria for administering an ▪ Analgesia and sedation analgesic: ▪ The use of medication to reduce the sensation of pain ▪ Needs to be in active phase of ▪ Sedatives given to promote labor sedation and relaxation ▪ If give in latent phase – it may ▪ Anesthesia slow labor ▪ The use of medication to partially ▪ If give in transition phase – can or totally block all sensation to an area of the body lead to neonatal respiratory ▪ Local, regional, general depression 95 Types of anesthesia Local anesthesia ▪ Used to numb the perineum just before birth to allow for episiotomy and repair Regional anesthesia ▪ Involves blocking a group of sensory nerves that supply a particular organ or area of the body (Epidural anesthesia-pain relief during labor) General anesthesia ▪ Not used frequently in obstetrics because of the risks involved 96 Regional Anesthesia ▪ Epidural ▪ Spinal ▪ Pudendal ▪ Side effects ▪ Hypotension ▪ Bladder distention 97  Epidural Analgesia Provides excellent pain relief reducing maternal catecholamines Ability to extend the duration of block to match the duration of labor Blunts hemodynamic effects of uterine contractions: beneficial for patients with preeclampsia. 98 Epidural Block. ▪ An injection of local anesthetic and/or upload into epidural space. ▪ Epidural space: is outside the dura mater, between the dura and the spinal canal (L3-L4) interspace ▪ Indications:  Patient request.  Slow dilatation with unbearable pain.  Premature bearing down with cervical edema. 99 Regional Pain Management Techniques Major advantage of Epidural Block: -Woman can participate in birth & good pain control. Adverse Effects of Epidural Block: Maternal Hypotension Sympathetic block results in hypotension because vasodilatation of the lower limb has limited capacitance for blood volume. Non-reassuring signs of FHR monitoring Bladder Distention. Prolonged Second Stage Catheter Migration Maternal Fever reduced hyperventilation and decreased heat dissipation. 100 Contraindications for Lumbar epidural analgesia ABSOLUTE RELATIVE Patient refusal Systemic maternal infection Inability to cooperate Preexisting neurological deficiency Increased intracranial pressure Mild or isolated coagulation Infection abnormalities Severe coagulopathy Relative (and correctable) hypovolemia Severe hypovolemia Inadequate training 102  Spinal Anesthesia/Analgesia Used mainly for very late in labor because it has limited duration of action Faster onset than Epidural Amount of local anesthetic used is much smaller Combined spinal-epidural (CSE): A CSE is a combination of two injections: a spinal injection (spinal block) and an epidural. 103 104  Spinal Anaesthesia Epidural Anaesthesia Level: below L1/L2, where the spinal cord ends Level: at any level of the vertebral column. Injection: subarachnoid space i.e. puncture of the dura Injection: epidural space (between Ligamentum mater flavum and dura mater) i.e. without puncture of the dura mater Identification of the subarachnoid space: When CSF Identification of the Peridural space: Using the Loss of appears Resistance technique. Doses: 2.5- 3.5 ml bupivacaine 0.5% heavy Doses: 15- 20 ml bupivacaine 0.5% Onset of action: rapid (2-5 min) Onset of action: slow (15-20 min) Density of block: more dense Density of block: less dense Hypotension: rapid Hypotension: slow Headache: is a probably complication Headache: is not a probable. 105  Effect of Pharmacologic pain management Effects on the Fetus Maternal physiologic Alterations Decreased FHR variability 1. Cardiovascular Changes (aortocaval Decreased blood flow to the placenta compression) Fetal hypoxia and acidosis due to Use - left uterine displacement (LUD) maternal hypotension. 2. Respiratory Changes. 3. Gastrointestinal Changes “regurgitation & aspiration” 4. Nervous System Changes 106 Systemic Labor Pain drugs Opioid analgesic/narcotic: “Pethidine”, which is similar to morphine. IM / 1st stage. Narcotic Antagonists: Naloxone (Narcan): 0.4-2mg IV Side effect: Nausea, vomiting, dizziness Respiratory depression Reverse action cause respiratory depression 107 Nursing Management Assessment of: Preferences for pain management Previous surgeries, anesthesia, & anesthesia-associated problems Maternal vital signs FHR and electronic fetal monitor patterns Allergies, to opioid analgesics Oral intake—time and type of last intake Evidence of pain Verbal: requests for pain-relief measures, crying, moaning; Nonverbal evidence: tense, guarded posture or facial expression 108  Nursing Care during Epidural Preparation Assess platelet count – must be normal Empty bladder Assess vital signs for baseline ▪ Assessing the maternal B.P. & FHR Q5 min. > first 15 min after injection. ▪ Repeat at 30 min at1 hour. IV access and fluids Assist her in remaining still while the block is completed. Following Assess V/S – especially the B/P because the main side effect is hypotension Rotate position between right and left side-lying Assess bladder and catheterize as needed Observe for signs associated with catheter migration. Assess the nausea and vomiting and pruritus. Assess for other side effects and intervene 109  Nursing Care during Epidural Observe for: Hypotension, Reduced respiratory effort, Bradycardia, Sensory loss, Maternal fever, Shivering, Pruritus. Nursing Care Administer oxygen. Keep patient well hydrated. Have emergency tray ready. 4 hourly vital signs. Fetal heart rate monitoring 110 References Murray, S. & Mckinney , E. (2019). Foundations of Maternal-Newborn and Women’s Health Nursing. (7th Ed). Elsevier. Saunders. 111 PRESENTATION TITLE 112