Labor 2024-2025 Lecture Notes PDF

Topic: labor Dr.Wafaa Ahmed University of Babylon / College of Nursing Year: 2024-2025  After this chapter, you should be able to:  1. Describe common theories explaining the onset of labor  2.role of passenger, passage, and powers in labor.  3. Identify the fou...

Topic: labor Dr.Wafaa Ahmed University of Babylon / College of Nursing Year: 2024-2025  After this chapter, you should be able to:  1. Describe common theories explaining the onset of labor  2.role of passenger, passage, and powers in labor.  3. Identify the four components of labor (4 p’s)  4. Describe the physiological changes during the four different stages of labor  5. Explain how false labor differs from true labor  6. The nursing management in each stage of labor. Dr.Wafaa Ahmed Ameen 2024-2025  Normal childbirth  The onset of labor remains unknown. . Many factors play a part in initiating labor include  Labor normally begins when the fetus is mature enough to adjust easily to life outside the uterus yet still small enough to fit through the mother’s pelvis..  usually reached between 39 and 40 weeks, or approximately 280 days after the woman’s last menstrual period. Dr.Wafaa Ahmed Ameen 2024-2025 THEORIES OF LABOR ONSET (progesterone withdrawal begins) 1- Uterine muscle stretching, which results in release of prostaglandins 2. Pressure on the cervix, which stimulates the release of oxytocin from the posterior pituitary Dr.Wafaa Ahmed Ameen 2024-2025 3. Oxytocin stimulation, which works together with prostaglandins to initiate contractions  4.Change in the ratio of estrogen to progesterone (increasing estrogen in relation to progesterone, which is interpreted as progesterone withdrawal) Dr.Wafaa Ahmed Ameen 2024-2025  Placental age, which causes contractions at a set point  Rising fetal cortisol levels, which reduces progesterone formation and increases prostaglandin formation  Fetal membrane production of prostaglandin, which stimulates contractions(stretching of uterine and softening of the cervix). Dr.Wafaa Ahmed Ameen 2024-2025  Preliminary Signs of Labor  Before labor, a woman often experiences subtle signs that signal labor is imminent. It is important to review these with women during the last trimester of pregnancy so they can more easily recognize beginning signs. Dr.Wafaa Ahmed Ameen 2024-2025  Lightening  In primiparas, lightening, or descent of the fetal presenting part into the pelvis, occurs approximately 10 to 14 days before labor begins.  In multiparas, it is not as dramatic and usually occurs on the day of labor or even after labor has begun. As the, a woman may experience shooting leg pains from the increased pressure on her sciatic nerve, increased amounts of vaginal discharge, and urinary frequency from pressure on her bladder. Dr.Wafaa Ahmed Ameen 2024-2025  Increase in Level of Activity  A woman may awaken on the morning of labor full of energy, in contrast to the feeling of chronic fatigue she felt during the previous month. This increase in activity is related to  an increase in epinephrine release initiated by a decrease in progesterone produced by the placenta. Dr.Wafaa Ahmed Ameen 2024-2025  Slight Loss of Weight  As progesterone level falls, body fluid is more easily excreted from the body. This increase in urine production can lead to a weight loss between 1 and 3 pounds. Dr.Wafaa Ahmed Ameen 2024-2025  Braxton Hicks Contractions  In the last week or days before labor begins, a woman usually notices extremely strong Braxton Hicks contractions. )False contractions so closely simulate true labor. true labor is not far away.( Dr.Wafaa Ahmed Ameen 2024-2025  False labor (prodromal labor or True labor prelabor) Contractions are irregular or do Contractions gradually develop a not increase in frequency, duration, regular pattern and become more and intensity. frequent,longer, and more intense Walking tends to relieve or Contractions become stronger and decrease contractions more effective with walking. Discomfort is felt in the abdomen Discomfort is felt in the lower and groin. back and the lower abdomen; often feels likemenstrual cramps at first Bloody show is usually not present Bloody show is often present, especially in women having their first child. There is no change in effacement Progressive effacement and or dilation of the cervix. dilation of the cervix occur Dr.Wafaa Ahmed Ameen 2024-2025  Ripening of the Cervix  Ripening of the cervix is an internal sign seen only on pelvic examination. Throughout pregnancy, the cervix feels softer  than normal to palpation, similar to the consistency of an  earlobe (Goodell’s sign).  At term, the cervix becomes still softer (described as “butter-soft”), and it tips forward.  Cervical ripening )labor is very close at hand(. Dr.Wafaa Ahmed Ameen 2024-2025  Signs of True Labor  Signs of true labor involve uterine and cervical changes.  Uterine Contractions  Because contractions are involuntary and come without warning, their intensity can be frightening in early labor.  Helping a woman appreciate that she can predict when her next one will occur and therefore can control the degree of discomfort she feels by using breathing exercises offers her a sense of well-being Dr.Wafaa Ahmed Ameen 2024-2025  Show  As the cervix softens and ripens, the mucus plug that filled the cervical canal during pregnancy (operculum) is expelled.  The exposed cervical capillaries seep blood as a result of pressure exerted by the fetus.  This blood, mixed with mucus, takes on a pink tinge and is referred to as “show” or “bloody show.” Dr.Wafaa Ahmed Ameen 2024-2025  Rupture of the Membranes  Labor may begin with rupture of the membranes, experienced either as a sudden gush or as scanty, . Early rupture of the membrane scan be advantageous as it can cause the fetal head to settle the pelvis, actually shortening labor  Two risks associated with ruptured membranes are intrauterine infection , prolapse of the umbilical cord, if labor has not spontaneously occurred by 24 hours after membrane rupture and the pregnancy is at term, labor will be induced to help reduce these risks. Dr.Wafaa Ahmed Ameen 2024-2025  Nada did not recognize for over an hour that she was in labor. A sign of true labor is:  a. Sudden increased energy from epinephrine release.  b. “Nagging” but constant pain in the lower back.  c. Urinary urgency from increased bladder pressure.  d. “Show” or release of the cervical mucus plug. Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  COMPONENTS OF LABOR 4Ps  A successful labor depends on four integrated concepts: 1. A woman’s pelvis (the passage) is of adequate size  2. The passenger (the fetus) is of appropriate size and in an advantageous position and presentation.  3. The powers of labor (uterine factors) are adequate. (The powers of labor are strongly influenced by the woman’s position during labor.)  4. A woman’s psychological outlook is preserved, so that afterward labor can be viewed as a positive experience. Dr.Wafaa Ahmed Ameen 2024-2025  Passage  The passage refers to the route a fetus must travel from the uterus through the cervix and vagina to the external perineum. Because the cervix and vagina are contained inside the  pelvis, a fetus must also pass through the bony pelvic ring. Dr.Wafaa Ahmed Ameen 2024-2025  the adequacy of the pelvic size: the diagonal conjugate (the anteroposterior diameter of the inlet) and the transverse diameter of the outlet. At the pelvic inlet, the anteroposterior diameter is the narrowest diameter; at the outlet, the transverse diameter is the narrowest Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025 Note:  The measurements of the maternal bony pelvis must be adequate to allow the fetal head to pass through, or cephalopelvic disproportion will occur, and a cesarean birth may be indicated Dr.Wafaa Ahmed Ameen 2024-2025  women who have had previous vaginal births deliver more quickly than women having their first births because their soft tissues yield more readily to the forces of contractions and pushing efforts Dr.Wafaa Ahmed Ameen 2024-2025  Passenger  The passenger is the fetus.  the widest diameter is the head, so this is the part least likely to be able to pass through the pelvic ring. Whether a fetal skull can pass depends on both its structure (bones,  fontanelles, and suture lines) and its alignment with the  pelvis. Dr.Wafaa Ahmed Ameen 2024-2025  Passengers  The passengers are the fetus, placenta (afterbirth), amniotic membranes, and amniotic fluid.  Because the fetus usually enters the pelvis head first (cephalic presentation), the nurse should understand the basic structure of the fetal head. Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  The Fetus  Fetal head is composed of several bones separated by strong connective tissue, called sutures  A wider area, called a fontanelle, is formed where the sutures meet.  The following two fontanelles are important in obstetrics: Dr.Wafaa Ahmed Ameen 2024-2025  1. The anterior fontanelle, a diamond-shaped area formed by the intersection of four sutures (frontal, sagittal, and two coronal)  2. The posterior fontanelle, a tiny triangular depression formed by the intersection of three  sutures (one sagittal and two lambdoid) Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  The sutures and fontanelles of the fetal head allow it to change shape as it passes through the pelvis (molding).  They are important landmarks in determining how the fetus is oriented within the mother’s pelvis during birth.  The main transverse diameter of the fetal head is the biparietal diameter, ) the two parietal bones(  The anteroposterior diameter of the fetal head can vary depending on how much the head is flexed or extended. Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  overlap, molding or diminishing the size of the skull so that it can pass through the birth canal more readily  anterior fontanelle closes when the infant is 12 to 18 months of age  posterior fontanelle closes when an infant is about 2 months of age.  The space between the two fontanelles is referred to as the vertex Dr.Wafaa Ahmed Ameen 2024-2025  The anteroposterior diameter of the pelvis, a space approximately 11 cm wide, is the narrowest diameter at the pelvic inlet so to be born most easily, a fetus must present a biparietal diameter, the narrowest fetal head diameter (approximately 9.25 cm). Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  Molding  a change in the shape of the fetal skull produced by the force of uterine contractions pressing the vertex of the head against the not-yet-dilated cervix. Because the bones of the fetal skull are not yet completely ossified and therefore do not form a rigid structure, pressure causes them to overlap and molds the head that facilitates passage through the rigid Dr.Wafaa Ahmed pelvis. Ameen 2024-2025 Powers  The powers of labor are forces that cause the cervix to open and that propel the fetus.. The two powers are uterine contractions and the mother’s pushing efforts.  Uterine contractions  Uterine contractions are the primary powers of labor during the first of the four stages of labor  (from onset until full dilation of the cervix).  Uterine contractions are involuntary smooth muscle  contractions; the woman cannot consciously cause them to stop or start. . Dr.Wafaa Ahmed Ameen 2024-2025  Effect of contractions on the cervix  efface (thin) and dilate (open) to allow the fetus to descend in the birth canal  Before labor begins, the cervix is a tubular structure about 2 to 3.8 cm long.  Contractions simultaneously push the fetus downward as they pull the cervix upward (an action  similar to pushing a ball out the cuff of a sock).  This causes the cervix to become thinner and shorter.  Dr.Wafaa Ahmed Ameen 2024-2025 NOTE:Before labor begins, the cervix is a tubular structure about 2 to 3.8 cm intensity and effectiveness are influenced by a number of factors, such as walking, drugs, maternal anxiety, and vaginal examinations 1. Effacement: shortening and thinning of the cervix during the first stage of labor When the cervix is 100% effaced, it feels like a thin, smooth membrane over the fetus. Dr.Wafaa Ahmed Ameen 2024-2025  2. Dilation: enlargement of the cervical canal from an opening a few millimeters wide to one large enough (approximately 10 cm)  Both dilation and effacement are estimated by touch (vaginal examination )rather than being precisely measured Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  Phases of contractions Each contraction has the following three phases  1. Increment: The period of increasing strength  2. Peak, or acme: The period of greatest strength  3. Decrement: The period of decreasing strength Dr.Wafaa Ahmed Ameen 2024-2025  Characteristics of contraction  Frequency  is the time from the beginning of one contraction until the beginning of the next contraction.  described in minutes and fractions of minutes, such as “contractions every 4:5 minutes.”  Contractions occurring more often than every 2 minutes may reduce fetal oxygen supply and should be reported. Dr.Wafaa Ahmed Ameen 2024-2025  Duration  is the time from the beginning of a contraction until the end of the same contraction.  described as the average number of seconds contractions last, such as “duration of 45 to 50 seconds.”  Persistent contraction durations longer than 90 seconds may reduce fetal oxygen supply and should be reported. Dr.Wafaa Ahmed Ameen 2024-2025  Intensity  approximate strength of the contraction.  described in words such as “mild,” “moderate,” or “strong,”  : Mild contractions: Fundus is easily indented with the fingertips; the fundus of the uterus feels similar to the tip of the nose.  Moderate contractions: Fundus can be indented with the fingertips but with more difficulty; the fundus of the uterus feels similar to the chin.  Sever contractions: Fundus cannot be readily indented with the fingertips; the fundus of the uterus feels similar to the forehead. Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  Interval  The interval is the amount of time the uterus relaxes between contractions. Blood flow from the mother into the placenta gradually decreases during contractions and resumes during each interval. The placenta refills with freshly oxygenated blood for the fetus and removes fetal waste products.  Persistent contraction intervals shorter than 60 seconds may reduce fetal oxygen supply. Dr.Wafaa Ahmed Ameen 2024-2025 NOTE  Report to the registered nurse any contractions that occur more frequently than every 2 minutes, last longer than 90 seconds, or have intervals shorter than 60 seconds. Dr.Wafaa Ahmed Ameen 2024-2025  Maternal Pushing When the woman’s cervix is fully dilated, she adds voluntary pushing to involuntary uterine contractions.  The combined powers of uterine contractions and voluntary maternal pushing in stage 2 of labor propel the fetus downward through the pelvis.  Most women feel a strong urge to push or bear down when the cervix is fully dilated and the fetus begins to descend. Dr.Wafaa Ahmed Ameen 2024-2025  However, factors )such as maternal exhaustion or sometimes epidural analgesia may reduce or eliminate the natural urge to push(.  Some women feel a premature urge to push before the cervix is fully dilated because the fetus pushes against the rectum.  This should be discouraged, as it may contribute to maternal exhaustion and fetal hypoxia and tearing of maternal soft tissues. Dr.Wafaa Ahmed Ameen 2024-2025 NOTE  Provide emotional support to the laboring woman so that she is less anxious and fearful. Excessive anxiety or fear can cause greater pain, inhibit the progress of labor, and reduce blood flow to the placenta and fetus. Dr.Wafaa Ahmed Ameen 2024-2025  Lie  Lie describes how the fetus is oriented to the mother’s spine.The most common orientation is the longitudinal lie (greater than 99% of births), in which the fetus is parallel to the mother’s spine.  The fetus in a transverse lie is at right angles to the mother’s spine. The transverse lie may also be called a shoulder presentation.  In an oblique lie, the fetus is between a longitudinal lie and a transverse lie Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  Attitude  The fetal attitude is normally one of flexion, with the head flexed forward and the arms and the legs flexed. The flexed fetus is compact and ovoid and most efficiently occupies the space in the mother’s uterus and pelvis. Extension of the head, arms, or legs sometimes occurs, and labor may be prolonged Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  Presentation  Presentation refers to the fetal part that enters the pelvis first. The cephalic presentation is the most common. Any of the following four variations of cephalic presentations can occur, depending on the extent to which the fetal head is flexed Dr.Wafaa Ahmed Ameen 2024-2025  1.Vertex presentation: The fetal head is fully flexed. This is the most favorable cephalic variation because the smallest possible diameter of the head enters the pelvis. It occurs in about 96% of births.  2. Military presentation: The fetal head is neither flexed nor extended.  3. Brow presentation: The fetal head is partly extended. The longest diameter of the fetal head is presenting. This presentation is unstable and tends to convert to either a vertex or a face presentation.  4. Face presentation: The head is fully extended and the face presents Dr.Wafaa Ahmed Ameen 2024-2025  The next most common presentation is the breech, which can have the following three variations  1. Frank breech: The fetal legs are flexed at the hips and extend toward the shoulders; this is the most common type of breech presentation. The buttocks present at the cervix . 2. Full or complete breech: A reversal of the cephalic presentation, with flexion of the head and extremities. Both feet and the buttocks present at the cervix.  3. Footling breech: One or both feet are present Dr.Wafaa Ahmed Ameen 2024-2025 first at the cervix.  breech presentation have cesarean births because the head, (largest single fetal part), is the last to be born and may not pass through the pelvis easily because flexion of the fetal head cannot occur.After the fetal body is born, the head must be delivered quickly so the fetus can breathe; at this point, part of the umbilical cord is outside the mother’s body and the remaining part is subject to compression by the fetal head against the bony pelvis. Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  When the fetus is in a transverse lie, the fetal shoulder enters the pelvis first. A fetus in this orientation must be delivered by cesarean section because cannot safely pass through the pelvis. Dr.Wafaa Ahmed Ameen 2024-2025 Position: relationship of assigned area of the presenting part or landmark to the maternal pelvis..  In a vertex presentation, the occiput (O) is used. For a face presentation,  the chin (M for mentum) is used.  In a breech presentation, the sacrum (S) is used,. Dr.Wafaa Ahmed Ameen 2024-2025 Fetal Positions ROA: Right occiput anterior LOA: Left occiput anterior ROP: Right occiput posterior LOP: Left occiput posterior ROT: Right occiput transverse LOT: Left occiput transverse RMA: Right mentum anterior LMA: Left mentum anterior RMP: Right mentum posterior LSA: Left sacrum anterior LSP: Left sacrum posterior Abbreviations that designate brow, military, and shoulder presentations are not included here because they occur infrequently. Dr.Wafaa Ahmed Ameen 2024-2025 Psyche . A woman’s perception of the process and her mental state can influence the course of her labor. For example, the woman who is relaxed and optimistic during labor is better able to tolerate discomfort and work with the physiological processes. By contrast, marked anxiety can increase her perception of pain and reduce her tolerance to it. Anxiety and fear also cause the secretion of stress compounds from the adrenal glands. (Ineffective labor) Dr.Wafaa Ahmed Ameen 2024-2025 instrumental delivery Dr.Wafaa Ahmed Ameen 2024-2025  Mechanisms of labor are also called cardinal movements. The positional changes allow the fetus to fit through the pelvis with the least resistance. (A) Descent, engagement, and flexion. (B) Internal rotation. (C) Beginning extension. (D) Birth of the head by complete extension. (E) External rotation, birth of shoulders and body. (F) Separation of placenta begins. (G) Complete separation of placenta from uterine wall. (H) Placenta is expelled and uterus contracts. Dr.Wafaa Ahmed Ameen 2024-2025  Descent  Descent is required for all other mechanisms of labor to occur and for the infant to be born. Descent occurs as each mechanism of labor comes into play. Station describes the level of the presenting part (usually the head) in the pelvis. Dr.Wafaa Ahmed Ameen 2024-2025  Station refers to the relationship of the presenting part(head ) of a fetus to the level of the ischial spines 1. The measurement of the progress of descent in centimeters above or below the mid plane from the presenting part to the ischial spine 2. Station 0: at ischial spine 3. Minus station: above ischial spine 4. Plus station: below ischial spine Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  Engagement  Engagement occurs when the presenting part (usually the biparietal diameter of the fetal head) reaches the level of the ischial spines of the mother’s pelvis )presenting part is at 0 station or lower).  Engagement often occurs before the onset of labor in a woman who has not previously given birth (a nullipara); if the woman has had previous vaginal births (a multipara), engagement may not occur until well after labor begins Dr.Wafaa Ahmed Ameen 2024-2025  Flexion The fetal head should be flexed to pass most easily through the pelvis. As labor progresses, uterine contractions increase the amount of fetal head flexion until the fetal chin is on the chest. Dr.Wafaa Ahmed Ameen 2024-2025  Internal Rotation When the fetus enters the pelvis head first, the head is usually oriented so that the occiput is toward the mother’s right or left side. As the fetus is pushed downward by contractions, the curved, cylindrical shape of the pelvis causes the fetal head to turn until the occiput is directly under the symphysis pubis (occiput anterior [OA]). Dr.Wafaa Ahmed Ameen 2024-2025  Extension As the fetal head passes under the mother’s symphysis pubis, it must change from flexion to extension so that it can properly transfer the curve. To do this, the fetal neck stops under the symphysis, which acts as a spindle. The head swings anteriorly as it extends with each maternal push until it is born Dr.Wafaa Ahmed Ameen 2024-2025  External Rotation When the head is born in extension, the shoulders are crosswise in the pelvis and the head is twisted in relation to the shoulders. The head spontaneously turns to one side as it realigns with the shoulders (restitution). The shoulders then rotate within the pelvis until their transverse diameter is aligned with the mother’s anteroposterior pelvis. The head turns farther to the side as the shoulders rotate within the pelvis. Dr.Wafaa Ahmed Ameen 2024-2025  Expulsion  The anterior shoulder followed by the posterior shoulder are born, quickly followed by the rest of the body. Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025   When to go to the hospital  1. Contractions: contractions have a pattern of increasing frequency, duration, and intensity.  The woman having her first child is usually advised to enter the facility when contractions have been regular (every 5 minutes) for 1 hour.  Women having second or later children should go sooner, when regular contractions are 10 minutes apart for a period of 1 hour. Dr.Wafaa Ahmed Ameen 2024-2025  2 Ruptured membranes: The woman should go to the facility if her membranes rupture or if she thinks they may have ruptured.  3 Bleeding other than bloody show: Bloody show is a mixture of blood and thick mucus. Active bleeding is free flowing, bright red, and not mixed with thick mucus.  4.Decreased fetal movement: The woman should be evaluated if the fetus is moving less than usual. Many fetuses become quiet shortly before labor, but decreased fetal activity can also be a sign of fetal compromise Dr.Wafaa Ahmed Ameen 2024-2025 . The three major assessments performed promptly on admission are  (1) fetal condition,  (2) maternal condition, and  (3) impending (nearness to) birth. Dr.Wafaa Ahmed Ameen 2024-2025  Fetal Condition  The fetal heart rate (FHR) is assessed with  a fetoscope (stethoscope for listening to fetal heart  sounds), a  handheld Doppler transducer, or  an external fetal monitor.  When the amniotic membranes are ruptured, the  color, amount, and odor of the fluid are assessed,  and the FHR is recorded. Dr.Wafaa Ahmed Ameen 2024-2025  When to Auscultate and Document the Fetal Heart Rate  Low-risk women (no risk factor identified)  Every hour in the latent phase  Every 30 minutes in the active phase  Every 15 minutes in the second stage Dr.Wafaa Ahmed Ameen 2024-2025  High-risk women (a risk factor is identified)  Every 30 minutes in the latent phase  Every 15 minutes in the active phase (Every 5 minutes in the second stage, before and after contractions) Dr.Wafaa Ahmed Ameen 2024-2025  Maternal Condition  The temperature, pulse, respirations, and blood pressure are assessed for signs of infection or hypertension.  Impending Birth  The nurse continually observes the woman for behaviors that suggest she is about to give birth  Bulging of the perineum or the fetal presenting part becoming visible at the vaginal Opening Dr.Wafaa Ahmed Ameen 2024-2025  The FHR can be assessed by  intermittent auscultation, by using a fetoscope or Doppler transducer, or continuous by(electronic fetal monitoring). Dr.Wafaa Ahmed Ameen 2024-2025  To assess and document the fetal heart rate (FHR)  Steps  1. Determine best location for assessing FHR.  2. Identify where the clearest fetal heart sounds will most likely be found, over the fetal back  and usually in the mother’s lower abdomen Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025   Routine auscultations  When the membranes rupture (spontaneously or artificially)  Before and after ambulation  Before and after medication or anesthesia administration or a change in medication  After a vaginal examination  After catheterization  If uterine contractions are abnormal or excessive Dr.Wafaa Ahmed Ameen 2024-2025 Pregnancy and delivery is symptomatic and not disease Characteristic of normal delivery: 1- Fetal pass through the birth canal. 2- Full term, that’s mean 37weeks or more. 3- The process of labor is complete spontaneous. 4- Fetus present by cephalic. 5- The maximum time of delivery is 24hours. 6- It occur without surgical interference [except episiotomy]. 7- It occur without complication for fetus and mother. Dr.Wafaa Ahmed Ameen 2024-2025 V. FETAL MONITORING 1. The fetal monitor displays the fetal heart rate (FHR). 2. The device monitors uterine activity. 3. The monitor assesses frequency, duration, and intensity of contractions. 4. The monitor assesses FHR in relation to maternal contractions. 5. Baseline FHR is measured between contractions; the normal FHR at term is 120 to 160 beats per minute. Dr.Wafaa Ahmed Ameen 2024-2025 External fetal monitoring 1. External fetal monitoring is noninvasive and is performed using a tocotransducer or Doppler ultrasonic transducer. 2. Perform Leopold's maneuvers to determine on which side the fetal back is located, and place the ultrasound transducer over this area (fasten with a belt). Dr.Wafaa Ahmed Ameen 2024-2025 3. Place the tocotransducer over the fundus of the uterus where contractions feel the strongest (fasten with a belt). 4. Allow the client to assume a comfortable position, avoiding vena cava compression. Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025 C. Internal fetal monitoring 1. Internal fetal monitoring is invasive and requires rupturing of the membranes and attaching an electrode to the presenting part of the fetus. 2. Mother must be dilated 2 to 3 cm to perform internal monitoring. Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  Evaluating fetal heart rate patterns be evaluated together for accurate interpretation of FHR patterns. The FHR is evaluated for baseline rate, baseline variability, episodic changes, and periodic changes. Dr.Wafaa Ahmed Ameen 2024-2025  Episodic changes  are transient changes in the FHR that are not associated with uterine contractions.  Periodic changes are transient  and brief changes in the FHR that are associated with uterine contractions such as accelerations and  decelerations Dr.Wafaa Ahmed Ameen 2024-2025  Baseline fetal heart rate  is the average FHR that occurs for at least 2 minutes during a 10- minute period and is averaged over 30 minutes.  It is assessed while there are no uterine contractions. The baseline FHR should be 110 to 160 beats/min for at least a 2-minute period.  Dr.Wafaa Ahmed Ameen 2024-2025  Fetal bradycardia  occurs when the FHR is less than 110 beats/min for 10 minutes or longer.  Causes of fetal bradycardia can include  fetal hypoxia,  maternal hypoglycemia,  Maternal hypotension,  or prolonged umbilical cord compression.  When bradycardia is accompanied by a loss of baseline variability or by late decelerations,  immediate intervention is required for a favorable outcome. Dr.Wafaa Ahmed Ameen 2024-2025  Fetal tachycardia is  a baseline FHR greater than 160 beats/min that lasts 2 to 10 minutes or longer.It can be caused by  maternal fever or  maternal dehydration.  When fetal tachycardia occurs along with loss of baseline variability or with late decelerations,  immediate intervention is required.  Dr.Wafaa Ahmed Ameen 2024-2025  Baseline variability  describes fluctuation or constant changes in the baseline FHR above and below the baseline in a 10-minute.Variability causes a recording of  the FHR to have a sawtooth appearance with larger, undulating,  Baseline variability is a reflection of an intact central nervous system and cardiac status of the fetus Dr.Wafaa Ahmed Ameen 2024-2025  Moderate variability,  defined as changes of 6 beats/min to 25 beats/min from the baseline FHR, is desirable because it indicates good oxygenation of the central nervous system and  fetal well-being.  Marked variability occurs when there are more than 25 beats of fluctuation over the FHR baseline, and it can indicate cord prolapse or maternal hypotension.  , Dr.Wafaa Ahmed Ameen 2024-2025  Absent variability  is less than 6 beats/min change from baseline for a 10-minute period and is typically caused by  uteroplacental insufficiency  Maternal hypotension,  cord compression,  or fetal hypoxia.  Nursing interventions for marked or absent variability include positioning the mother on her side,  increasing regular IV fluid flow rate to improve maternal circulation,  administering oxygen at 8 to 10 L/min by mask Dr.Wafaa Ahmed Ameen 2024-2025  Episodic changes  are changes in the FHR that are not associated with uterine contractions. They are brief and quickly return to baseline  Periodic changes  are temporary changes in the baseline rate associated with uterine contractions that quickly return to baseline. Periodic changes include accelerations (rate  increases) and any of three types of deceleration Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025. Accelerations. Brief temporary increases in the FHR of at a least 15 beats greater than thebaseline and lasting at least 15 seconds. b. A reassuring sign, reflecting a responsive, non acidotic fetus. c. occur with fetal movement.with uterine contractions, vaginal examinations, or mild cord compression, or when the fetus is in a breech presentation. Dr.Wafaa Ahmed Ameen 2024-2025. decelerations a. Early decelerations are decreases in FHR below baseline; the rate at the lowest point of the deceleration usually remains greater than 100 beats per minute. b. Early decelerations occur during contractions as the fetal head is pressed against the woman's pelvis or soft tissues, such as the, Dr.Wafaa Ahmed Ameen 2024-2025 c. Tracing shows a uniform shape and mirror image of uterine contractions, d. Early decelerations are not associated with fetal compromise and require no intervention. Dr.Wafaa Ahmed Ameen 2024-2025  5. Late decelerations non reassuring patterns that reflect impaired placental exchange or utero placental insufficiency. b. The patterns look similar to early decelerations but begin well after the contraction begins and return to baseline after the contraction ends. c. Interventions include improving placental blood flow and fetal oxygenation. Dr.Wafaa Ahmed Ameen 2024-2025  6. Variable decelerations a. Variable decelerations are caused by conditions that restrict flow through the umbilical cord. b. Variable decelerations do not have the uniform appearance of early and late decelerations. c. Their shape, duration, and degree of fall below baseline heart rate are variable; they fall and rise suddenly with the onset and relief of cord compression. Dr.Wafaa Ahmed Ameen 2024-2025 d. Variable decelerations also may be nonperiodic,) occurring at times unrelated to contractions(.. Variable decelerations are significant when the FHR repeatedly decreases to less than 70 beats per minutes and persists at that level for at least 60 seconds before returning to the baseline. Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  Nursing interventions  Identify the cause (assess for cord prolapse).  Implement position changes to relieve the pressure on the fetal umbilical cord (knee-chest position OR trendelenburg position ) or pressure on the inferior vena cava (left-lateral position)  Administer oxygen via facemask at 10 L/min for 30 minutes to increase fetal oxygenation  Administer IV fluids such as a saline solution to improve cardiac output, circulatory volume, and uteroplacental perfusion. The nurse should observe for fluid volume overload and pulmonary edema Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  Correct hypotension, which is often caused by dehydration or response to analgesic drugs.  Implement measures to reduce uterine activity. Excess uterine activity is more than five contractions in 10 minutes, averaged over 30 minutes (the normal is five contractions or fewer in 10 minutes) . (Discontinuing oxytoxin or administering tocolytic)  Implement amnioinfusion, which involves instilling a saline infusion by catheter into the uterine cavity to restore amniotic fluid volume to relieve umbilical cord compression that can interrupt fetal oxygenation Dr.Wafaa Ahmed Ameen 2024-2025  Uterine Activity  Tachysystole is more than five uterine contractions within 10 minutes, observed over 30 minutes.  Contractions last more than 90 seconds with less than 60 seconds between contractions.  Tachysystole must be reported promptly. Corrective action, such as oxygen or position change,  may be indicated. Dr.Wafaa Ahmed Ameen 2024-2025  f. Notify the physician or nurse midwife as soon as possible,  g. Prepare to initiate continuous electronic fetal monitoring with internal devices if not contraindicated.  i. Prepare for cesarean delivery if necessary Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  STAGES OF LABOR Stage (1) Latent phase approximately 6 hours in a nullipara and 4.5 hours in a multipara Cervical dilation is 0 to 3 cm.. Cervical effacement occurs, Uterine contractions occur (lasting 20 to 40 second) and of mild intensity. d. Mother is talkative & cooperative and eager to be in labor. is completed at home. During the latent phase MM may be intact, Show may be present Dr.Wafaa Ahmed Ameen 2024-2025  Measuring the length of the latent phase is important because a reason for a prolonged  latent phase is cephalopelvic disproportion disproportion  that could require a cesarean birth  should not be denied analgesia at this point, analgesia given too early may prolong this phase Dr.Wafaa Ahmed Ameen 2024-2025  B. Stage 1 active phase 3 hours in a nullipara and 2 hours in a multipara a. Cervical dilation is 4 to 7 cm. effacement from 40% to 80% c. Frequency: 3–5 min , Duration: 40–60 sec Intensity: moderate.MM( Intact or ruptured) d. Mother may experience feelings of weakness. e. Mother becomes restless and anxious as contractions become stronger. Dr.Wafaa Ahmed Ameen 2024-2025  C. Stage 1 transition phase(30-2hrs) 1. Assessment Cervical effacement from 80% to 100% –a. Cervical dilation is) 8 to 10 (cm. b. Frequency: 2–3 min Duration: 60–90 sec Intensity: strong, (If the membranes have not previously ruptured or been ruptured by amniotomy) c. Mother becomes tired, is restless ,refused support, irritable, and feels out of control. Dr.Wafaa Ahmed Ameen 2024-2025 D. Interventions throughout stage I. 1. Monitor maternal vital signs. 2. Monitor FHR via ultrasound Doppler, fetoscope, or electronic fetal monitor. 3. Assess FHR before, during, and after a contraction, noting that the normal FHR is 120 to 160 beats per minute. 4. Monitor uterine contractions by palpation or monitor, determining frequency, duration, and intensity. Dr.Wafaa Ahmed Ameen 2024-2025 5. Assess status of cervical dilation and effacement. 6. Assess fetal station presentation and position by Leopold's maneuvers. 7. Assist with pelvic examination and prepare for a Nitrazine test and a fern test. 8. Assess the color of the amniotic fluid if the membranes have ruptured because meconium- stained fluid can indicate fetal distress. Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025  E. Stage 2 (30- 2hrs) a. Cervical dilation is complete. b. Progress of labor is measured by descent of fetal head through the birth canal (change in fetal station). c. Frequency: 1,1/2–3 min ,Duration: 60–80 sec. Intensity: strong(firm), urge to push during the later perineal phase (Expulsive), Membranes Ruptured. Increase in bloody show occurs. e. Mother feels urge to bear down; assist mother in pushing efforts. Dr.Wafaa Ahmed Ameen 2024-2025 2. Interventions a. Perform assessments every 5 minutes, b. Monitor maternal vital signs, person support c. Monitor FHR via ultrasound Doppler, fetoscope, d.Assess FHR before, during, and after contraction, noting that normal fetal heart rate is 120 to 160 beats per minute. e. Monitor uterine contractions by palpation or monitor, determining frequency, duration, and intensity or electronic fetal monitor. Dr.Wafaa Ahmed Ameen 2024-2025 g. Keep mother and partner informed of progress. h. Maintain privacy. i. Provide ice chips and ointment for dry lips. f. Provide mother with encouragement and provide for rest between contractions. Assess perineum and vaginal discharge Observe bladder distension Dr.Wafaa Ahmed Ameen 2024-2025 j. Assist mother into a position that promotes comfort and assists pushing efforts, such as lithotomy, semisitting, kneeling, side-lying, or squatting. l.Episiotomy may needed m.prepare sterile supply and infant resucitation k. Monitor for signs of approaching birth, such as perineal bulging or visualization of the fetal head.  Prolonged second stages of labor are associated with chorioamionitis (uterine infection) and an increased rate of cesarean birth Dr.Wafaa Ahmed Ameen 2024-2025  E. Episiotomy(seminar) 1. An episiotomy is an incision made into the perineum to enlarge the vaginal outlet and facilitate delivery. 2. Check episiotomy site. 3. Institute measures to relieve pain. 4. Provide ice packs during the first 24 hours. 5. Instruct the client in the use of sitz baths. 6. Apply analgesic spray or ointment as prescribed. Dr.Wafaa Ahmed Ameen 2024-2025  Cutting and Clamping  The newborn is held with his or her head in a slightly dependent position, to allow secretions to drain from the nose and mouth. The mouth may be gently aspirated by a bulb syringe to remove additional secretions. The infant is then laid on the abdominal drape of the mother while the cord is cut. Dr.Wafaa Ahmed Ameen 2024-2025  The cord continues to pulsate for a few minutes after birth, and then the pulsation ceases  The cord is clamped with two Kelly hemostats placed 8 to 10 inches from the infant’s umbilicus and then is cut between them. A cord blood sample is obtained to provide a ready source of infant blood typing Dr.Wafaa Ahmed Ameen 2024-2025  Introducing the Infant After the cord is cut, it is time for the new parents  Take the infant and covering the infant in a sterile blanket.  An infant sucking at the breast stimulates the  release of oxytocin, encouraging uterine contraction and involution, )the return of the uterus to its prepregnant state( Dr.Wafaa Ahmed Ameen 2024-2025 1. Prepare for birth of placenta Stage 3 Assessment a. Contractions intermittent ,intensity mild or moderate b. occur until the placenta is born. b. Placental separation and expulsion occur. c. Birth of placenta occurs 5 to 30 minutes after birth of the baby. d. Schultze mechanism: Center portion of placenta separates first, and its shiny fetal surface emerges from the vagina. e. Duncan mechanism: Margin of placenta separates, and the dull, red, rough maternal surface emerges from the vagina first. Dr.Wafaa Ahmed Ameen 2024-2025  Signs of placenta seperation  Lengthening of the umbilical cord  Sudden gush of vaginal blood  Change in the shape of the uterus  Firm contraction of the uterus  Appearance of the placenta at the vaginal opening Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025 2. Interventions a. Assess maternal vital signs. b. Assess uterine status. c. Provide parents with an explanation. d. Following birth of the placenta, uterine fundus remains firm and is located 2 fingerbreadths below the umbilicus. e. Examine placenta for cotyledons and membranes to verify that it is intact. f. Assess mother for shivering and provide warmth. g. Promote parental-neonatal attachment. h. Dry infant and put in radiant warmer, apgar score Dr.Wafaa Ahmed Ameen 2024-2025  Once the placenta is delivered, oxytocin is usually ordered to be administered intramuscularly or intravenously to the mother Dr.Wafaa Ahmed Ameen 2024-2025 G. Stage 4 1. Description: the period of time from 1 to 4 hours after delivery 2. Assessment a. Blood pressure returns to prelabor level, b. Pulse is slightly lower than during labor. c. Fundus remains contracted, in the midline, below or at the umbilicus. d. Lochia is moderate or scant and is red. No more than one pad should be saturated in an hour Dr.Wafaa Ahmed Ameen 2024-2025 3. Interventions a. Perform maternal assessments every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 2 hours, b. Provide warm blankets. c. Apply ice packs to the perineum. d. Massage the uterus if needed and teach the mother to massage the uterus, e. Provide breast-feeding support as needed,. Dr.Wafaa Ahmed Ameen 2024-2025  Location and firmness of the uterine fundus (see Amount and color of lochia  IV infusion and medications  Fullness of the bladder or urine output from a catheter  Condition of the perineum for vaginal birth  Condition of dressing for cesarean birth Dr.Wafaa Ahmed Ameen 2024-2025  Vaginal bleeding should be dark red (lochia rubra).  A continuous of bright red blood suggests a bleeding laceration . Dr.Wafaa Ahmed Ameen 2024-2025 Amniotomy a woman’s cervix must be dilated at least 3 cm. 1. Artificial rupture of membranes is performed by the physician to stimulate labor. 2. Amniotomy is performed if the fetus is at 0 or a plus station. 3. Amniotomy increases risk of prolapsed cord and infection. 4. Monitor FHR before and after amniotomy. 5. Record time of amniotomy, FHR, and characteristics of the fluid. amniohook (a long, thin instrument) Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025 6. Meconium-stained amniotic fluid may be associated fetal distress. 7. Bloody amniotic fluid may indicate abruptio placenta , fetal trauma. 8. An unpleasant Cloudy or yellow amniotic fluid with an offensive odor may indicate an infection and should be reported immediately. odor to amniotic fluid is associated with infection. 9. Polyhydramnios is (maternal diabetes and certain congenital disorders. 10. Oligohydramnios is (intrauterine growth restriction and congenital disorders. 11. Expect more variable decelerations after rupture of the membranes as a result of possible cord compression during contractions. 12. Limit client activity ifDr.Wafaa prescribed. Ahmed Ameen 2024-2025  Nursing responsibilities  The registered nurse who cares for the woman during labor usually continues to do so during delivery.  Typical delivery responsibilities include the following:  wear Gown ,mask, cap,slipper,gloves  Preparing the delivery instruments  infant equipment  Doing the perineal scrub is performed just before birth. Administering drugs to the mother or infant .  Dr.Wafaa Ahmed Ameen 2024-2025  Providing initial care to the infant suchas  suctioning secretions from the airway with a bulb syringe,  drying the skin,  and placing the infant in a radiant warmer to maintain body heat  Assessing the infant’s Apgar score. Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025 Dr.Wafaa Ahmed Ameen 2024-2025