Labor Phenomena OB PDF

The Labor Phenomena Also known as parturition, childbirth, birthing Fetal head – is the largest presenting part – common presenting part – ¼ of its length Is the process by which the fetus and the placenta...

The Labor Phenomena Also known as parturition, childbirth, birthing Fetal head – is the largest presenting part – common presenting part – ¼ of its length Is the process by which the fetus and the placenta are expelled from the uterus and the vagina into the external environment Bones – 6 bones A parturient is a woman in labor S – sphenoid P – parietal 2x Toco- and toko- (Gr) are combining forms meaning childbirth F – frontal-sinciput T – temporal Eutocia – normal labor E – ethmoid O – occipital/occiput Dystocia – difficult labor The trigger that converts the random, painless Braxton-Hicks contraction, into strong coordinated labor contractions is unknown Normally labor begins when the fetus is sufficiently mature, yet not too large to cause difficulties in delivery In some instances, labor begins before the fetus is mature (premature birth); in others labor is delayed (postmature birth). It is unknown why this occurs Theories proposed why Labor begins: 1. Uterine Stretch Theory. Any hollow body organ when Measurement of fetal head: stretched to capacity will necessarily contract and empty 1. Transverse diameter – 9.25 cm because of pressure on nerve endings and increased irritability -biparietal –largest transverse of the uterine musculature. 2. Bimastoid 7 cm – smallest transverse 2. Oxytocin Stimulation Theory. Because labor is considered a stressful event, the hypophysis is stimulated to initiate SUTURES – intramembranous spaces that allow molding production of oxytocin by the posterior pituitary gland. Oxytocin ▪ Sagittal suture – connects 2 parietal bones (sagitna) is known to stimulate uterine contractions. ▪ Coronal suture – connect parietal & frontal bone 3. Progesterone Deprivation Theory. Progesterone is (crown) believed to inhibit uterine motility. A decrease in the amount of ▪ Lambdoidal suture – connects occipital & parietal the hormone, therefore, results in uterine contractions. bones 4. Prostaglandin Theory. The relative progesterone MOLDINGS – the overlapping of the sutures of the skull to deprivation and estrogen predominance set off production of permit passage of fetal head during delivery cortical steroids which act on lipid precursors to release arachidonic acid and, in turn, increase the synthesis of prostaglandins. 5. Theory of Aging Placenta. The decrease of nutrients and blood supply in the aging placenta causes uterine contractions. (By 260 days the placenta began to age; life span of placenta is 42 weeks. At 36 weeks, degenerates leading to contraction- onset of labor) Factors affecting Labor & Delivery (5 P’s) 1. Passenger 2. Passageway Fontanels: 3. Power 1. Anterior fontanel – bregma, diamond shape, 3x4 cm (> 5 cm- 4. Person (Psyche) hydrocephalus) 12-18 mos. After birth, close 5. Placenta 2. Posterior fontanel or lambda (vertex) – triangular shape; 1x1 cm; 2-3 months, close ⬛ PASSENGER ▪ Anteroposterior diameter ▪ suboccipitobregmatic, 9.5 cm, complete flexion, The passage of the fetus through the birth canal is influenced: smallest AP -size of the fetal head and shoulder -fetal presentation ▪ occipitofrontal 12 cm, partial flexion -dimensions of the pelvic girdle -fetal position ▪ occipitomental 13.5 cm hyperextension ▪ submentobregmatic – face presentation Shapes of Pelvis Pelvic Outlet 1. Gynecoid – round shape a. Antero posterior – lower border of the symphysis pubis 2. Android – describe as male pelvis; heart shape to the acro coccygeal points. Diameter: 13 cm b. Transverse diameter – between the 2 ischial spines. 3. Anthropoid – apelike pelvis; diamond shape; narrowed Diameter: 10-11 cm. transverse diameter - Narrower diameter is much important than the wider diameter 4. Platypelloid – widen transverse; narrow antero-posterior; flat in front & back; oval shape/pear shape Fetal lie – relationship of the long axis of the fetus to the long axis of the mother If the two are parallel, then the fetus is said to be PREMONITORY/PRELIMINARY/PRODROMAL longitudinal lie SIGNS OF LABOR If the two are at 90- 1. Lightening. This is defined as the settling of the degree angle to each fetal head into the pelvic brim which occurs 2-3 other, the fetus is said to weeks before labor onset. Lightening causes relief of be in transverse lie abdominal tightness and diaphragmatic pressure so that respiration becomes easier. - Lightening should not be confused with engagement, since engagement is defined as that ⬛ PASSAGES point when the biparietal diameter of the fetal head has passed the pelvic inlet. Pelvis = 4 bones 2. Loss of weight. There is loss of weight of about 2 hip bones (innominate) 2-3 lbs. one to two days before labor onset, due to 1 sacrum; 1 coccyx loss of appetite and decrease in progesterone level. Pelvic brim – False pelvis; supports the uterus Progesterone is known to cause fluid retention. Its decrease, therefore is known to cause fluid excretion, True pelvis – lower part of the pelvis thus causing loss of weight. Linea Terminalis – imaginary line that separates the false & 3. Increase level of activity (“nesting behavior”). true pelvis The sudden burst of energy is believed to be due to increase in epinephrine in response to the stress Pelvic Inlet - where the baby passes first brought about by the approaching delivery. The pregnant woman should be cautioned not to use this a. Diagonal conjugate – posterior border of the pubis – energy to carry out household chores because it is anterior portion of sacral promontory. Ave. 12.5 – 13 meant to prepare the body for the “labor” ahead. cm 4. Braxton Hicks Contraction. these are painless, b. Conjugate vera (true) – anterior border of the pubis – irregular ad intermittent uterine contractions are also anterior portion of sacral promontory. 11.0 cm. Can be known as practice contractions. measured only thru radiographic films c. Obstetric conjugate – shortest. Estimating by 5. Ripening of the cervix. The cervix becomes subtracting 1.5 to 2 cm ˂ the diagonal conjugate. even softer, now described as “butter-soft”. Measures 10 cm or more 6. Rupture of the membranes. Also known as the a. Ex.: DC = 12.5 cm – 1.5 = 11 cm bag of waters, its rupture may be seen as a sudden d. Transverse diameter – line between the points farthest gush, or a scanty, slow sleeping, of amniotic fluid from the iliopectineal line from the vagina. The color of the amniotic fluid – 13 cm. should always be noted. 6. Rupture of the membranes (contd.) Dilatation. This is the process by which the external cervical - At term, it is clear, almost colorless, and contains is enlarges from a few millimeters wide to 10 cm full dilatation. white specks of vernix caseosa. Green staining means the - In primigravidas- effacement occurs before dilatation; amniotic fluid has been contaminated with meconium, a sign of in multigravidas, however, dilatation may precede fetal distress if the fetus is in non-breech presentation. Yellow effacement staining may mean blood incompatibility, while pink staining Effacement. Thinning/shortening of the cervical canal may indicate bleeding. Cervix = 1 inch thick; during 7. Show. This is the blood-tinged mucus discharged from the labor, paper thin vagina because of pressure of the descending fetal part on the cervical capillaries, causing their rupture. ½ inch cervix = 50% effaced ¼ inch cervix = 75 % effaced ¾ inch cervix = 25 % effaced SIGNS OF TRUE LABOR True labor is said to occur when the following signs are observed: Uterine contractions. The surest sign that labor has begun is the initiation of effective, productive, and involuntary uterine contractions. Three phases of uterine contractions: ▪ Crescendo/Increment – intensity of the contraction increases. This phase is longer than the other two phases combined. ▪ Acme/Apex – the height or peak of the contraction. Uterine Changes. The uterus is gradually differentiated into ▪ Decrescendo/Decrement – intensity of the two distinct portions. These are distinguished by a ridge formed contraction decreases. in the inner uterine surface, the physiological retraction ring. Show. Capillary blood mixes with mucus when operculum is 1. Upper uterine segment is the portion from the isthmus (or released, that is why show is no more than a pinkish vaginal the physiological retraction ring) up to the fundus. discharge. Show should be distinguished from bright red vaginal bleeding because the latter is a danger sign during this phase of 2. Lower uterine segment is the portion from the isthmus (or pregnancy. the physiological retraction ring) down to the cervix. DIFFERENCE BETWEEN FALSE AND TRUE LABOR PAINS False Labor Pains True Labor Pains LENGTH OF LABOR In general multigravidas deliver 6 hours earlier than 1. Remain irregular 1. May be slightly irregular at primigravidas. Labor which is completed in more than 18 hours first nut become regular and in primigravidas or more than 12 hours in multigravidas is predictable within a matter of hours. called prolonged labor. Labor which is completed in less than 3 hours is termed 2. Generally confined to the precipitate delivery. 2. First felt in the lower back abdomen and sweep around to the abdomen in a girdle-like Comparison Of Length of Labor in Primigravidas and fashion. Multigravidas Stage of Labor Primigravidas Multigravidas 3. No increase in duration, 3. Increase in duration, frequency and intensity. frequency and intensity. First Stage 12 ½ hours 7 hours, 20 minutes 4. Often disappear if the 4. Continue no matter what Second Stage 80 Minutes 30 minutes woman ambulates. the woman’s level of activity Third Stage 10 Minutes 10 minutes 5. Absent cervical changes. 5. Accompanied by cervical effacement and dilatation. TOTAL 14 hours 8 hours STAGES OF LABOR Transition Phase. This phase begins when the cervix is dilated STAGES DURATION START-END from approximately 8 cm and continues until full dilation at 10 cm. STAGE CERVICAL P - 10-14 Hrs TRUE LABOR– -Intense uterine contractions I DILATATION M - 6-8 Hrs FULL DILATION -Occur at 1.5–3-minute intervals and last 60–90 STAGE FETUS P – 1.5 Hrs FULL DILATION– seconds. The woman experiences significantly II M – 30-45 Min. FETAL increased EXPULSION -Pain and pressure, often accompanied by a strong urge to push. She may feel overwhelmed, irritable, and STAGE PLACENTA 5 – 30 Min. FETAL exhausted, with an increased sense of loss of control. III EXPULSION– PLACENTAL DELIVERY NURSING MANAGEMENT STAGE RECOVERY/ 1 – 2 Hrs. Watch out for Nursing care of the woman in her first stage of labor includes IV IMMEDIATE signs of the following considerations: POSTPARTUM hemorrhage ▸ Hospital Admission. Privacy and reassurance are both very important at this time and throughout the other stages of labor. Establishing the maintaining rapport with the woman in labor will go a long way towards alleviating fear and apprehension. THE FIRST STAGE OF LABOR Keeping her informed of the progress of labor is the best way of The first stage of labor, otherwise known as the Stage of giving emotional support. Dilatation, is a very important stage - Such important data as the expected date of In so far as assessment of fetal and maternal well- confinement (EDC), the condition of the membranes, and the being is concerned. The following are discussions of this stage show should be elicited at the onset on order to determine the of labor. kind of management to be given to the particular patient. ▸ Physical Assessment. General physical examination. PHASES OF THE 1ST STAGE OF LABOR Leopold’s maneuvers and/or internal examination are done to determine the following: PHASES DILATION DURATION INTERVAL INTENSITY ▪ Effacement, dilatation, and condition of the membranes. LATENT 0-4 CM 30-45 SEC. 15 MIN. MILD ▪ Lie or presentation – the relation of the long axis of the fetus to the long axis of the mother. ACTIVE 4-8 CM 45-60 SEC. 5 MIN. MOD- ▪ Lie may either be vertical or horizontal. STRONG ▪ Location of the fetal heart tone in relation to the presentation. TRANSIT 8-10 CM 60-90 SEC. 2-3 MIN. VERY ION STRONG Outline of Various Presentation And Their Presentations Parts Latent Phase. The phase begins with onset of regular I. VERTICAL LIE contraction and ends with complete effacement (100%) and Cephalic Presentation – head is the presenting part cervical dilatation of about 4 cm. 1. Vertex – head is sharply flexed, making the parietal bones the presenting part -Mild uterine contractions occur regularly 10-20 2. Face minutes apart and are of short duration (10-30 3. Brow seconds). The woman usually experiences low 4. Chin backaches and abdominal cramps and is generally excited, alert, talkative, and in control. Breech Presentation – buttocks are the presenting parts 1. Complete breech – thighs are flexed on the abdomen and legs are on thighs Active or Accelerated Phase. This begins with complete 2. Frank breech – thighs are flexed and legs are extended, effacement and cervical dilatation of about 2-3 cm and ends resting on the anterior surface of the body with cervical dilatation of approximately 8 cm. 3. Footling -Moderate uterine contractions a. Double – legs unflexed and extended; feet are presenting parts -Occur at 2–5-minute intervals and last 30-45 seconds. b. Single – one leg unflexed and extended; one foot is the The woman experiences moderately increased pain, presenting part may be more apprehensive and fears losing control. II. HORIZONTAL LIE – shoulder presentation  ▪ Station the relation of the fetal presenting part to the OUTLINE OF POSSIBLE FETAL POSITIONS: level of the ischial spines are explained below. Vertex Presentation Face Presentation ▻ Station 0 – when the fetal presenting part is at the level of LOA – left occipitoanterior LMA – left mentoanterior the ischial spines. Station 0 is synonymous to engagement. LOP – left occipitoposterior LMP – left mentoposterior ▻ Station –1 or 2 – when the fetal presenting part is above LOT – left occipitotransverse LMT – left mentotransverse the level of the ischial spines. ROA – right occipitoanterior RMA – right mentoanterior ROP – right occipitoposterior RMP – right mentoposterior ▻ Station +1 or +2 – when the fetal presenting part is 1cm ROT – right occipitotransverse RMT – right mentotransverse or 2 cm below the level of the ischial spines. ▻ Station +3 or +4 – is synonymous to crowning. Crowning is defined as the encirclement of the largest diameter of the fetal Breech Presentation Shoulder Presentation head by the vulvar ring. LSA – left sacroanterior LADA – left acromiodorsoanterior ▻ Station +3 or +4 – is synonymous to crowning. Crowning LSP – left sacroposterior LADP – left acromiodorsoposterior is defined as the encirclement of the largest diameter of the fetal LST – left sacrotransverse RADA – right acromiodorsoabterior head by the vulvar ring. RSA – right sacroanterior RADP – right RSP – right sacroposterior acromiodorsoposterior RST – right sacrotransverse ▸ Bath. is advisable if contractions are still tolerable or are not too close to one another. Bathing will not only ensure cleanliness but will also provide comfort and relaxation. ▸ Perineal Preparation. The perineum is cleansed from front to back using the No. 7 stroke in order to disinfect the area surrounding the vagina, this procedure helps to prevent contamination of the birth canal and reduce possibilities of ▪ Position – the relation of the fetal presenting part of a postpartum infection. specific quadrant of the woman’s pelvis. -Perineal shaving is no longer a routine procedure The woman’s pelvis is divided into four quadrants: nowadays but if and when it is ordered, the techniques vary 1. right anterior from one hospital to the other. The basic steps are as follows: 2. right posterior 1. The perineal hair is first lathered well. 3. left anterior 2. The skin from above is stretched and kept taut and with 4. left posterior the use of a safety razor, hair is shaved downward from Four parts of the fetus have been chosen as points of the mons veneris, using long single strokes running direction: along the growth of the hair. occiput – in vertex presentations 3. The perineum is again washed thoroughly after chin (mentrum) – in face presentations shaving. sacrum – in breech presentations 4. The woman is instructed not to touch the genitals scapula (acromion) – in shoulder presentations. The afterwards to keep the area as clean as possible during word “dorso” is added to indicate the position of the labor. fetal back. The most common and favorable position is the loccipito- anterior position. (LOA). In the ROA position, the occiput of the fetus is the right side of the mother and is directed towards her front; in such position, the fetus, therefore, is facing the mother’s right buttock. ▸ Ambulation. is advised during the latent phase of labor in order to help shorten the first stage of labor. ▸ Diet. Solid or liquid foods are avoided for the following reasons: ▪ Digestion is delayed during labor. ▪ A full stomach interferes with proper bearing down. ▪ Aspiration may occur during the reflex nausea and vomiting of the transition phase or when anesthesia is used. ▸ Enema Administration. Enema is not a routine procedure Frequency – from the beginning of one contraction to the for all women in labor but may be done for the following beginning of the next contraction (A to C of Fig. 3). A woman in reasons: labor should seek hospital admission when her contractions are already occurring every 5-10 minutes. ▪ A full bowel hinders labor progress; enema increases the space available for passage of the fetus and - The nurse should time 3-4 contractions at a time to improves frequency and intensity of uterine have a good picture of the frequency of contractions. contractions. The effectiveness of Intensity – prolonged and sustained uterine contractions can enema administration is therefore, shown by lead not only to fetal distress but also to rupture of the uterus. evaluating the change in uterine tone and the amount of show. ▪ Enema decreases the possibility of fecal contamination ▸Vital Signs. Blood Pressure (BP) and Fetal Heart Rate (FHR) of the perineum during the second stage of labor. are taken every hour during the latent phase and every 30 ▪ A full bowel can add to the discomfort of the immediate minutes during the active phase. Definitely, BP and FHR should postpartum period. never be taken during contraction. The procedure of enema administration during labor consists -During uterine contractions, no blood goes to the of the following considerations: placenta. The blood is pooled to the peripheral blood vessels ▪ Soapsuds or Fleet enema is usually given which results in increased blood pressure. Therefore, the blood ▪ The optimal temperature of the solution is 105 -115o1 pressure should be taken in between contractions and whenever (40.5 -5.46.1oC). the mother in labor complains of a headache. ▪ The patient is placed on side –lying position - FHR, on the other hands, tends to decrease during a contraction because of the compression of the fetal head. When ▸ Voiding. The woman in labor should be encourage to empty her bladder every to 2-3 hours because full bladder the fetal head is compressed by the contracting uterus, the retards fetal descent. vagus nerve is stimulated, thus causing bradycardia, FHR - Urinary stasis can lead to urinary tract infection. normally 120-160 per minute. It should not be mistaken for the - A full bladder may be traumatized during delivery. uterine soufflé the sound which results when the uterine blood vessels refill with blood. Uterine soufflé synchronizer with ▸ Breathing Technique. The woman in the first stage of maternal heartbeat. For any abnormality in FHR the initial labor should be instructed not to push or beat down during nursing action is to change the mothers in position because the contractions because it will not only lead to maternal abnormality may just be due to Supine Hypotensive Syndrome. exhaustions but, more importantly, unnecessary bearing down If the rate does not change despite positioning the attending can lead to cervical edema because of the excessive pounding physician should be informed. of the fetal presenting part on the pelvic floor, thus interfering with labor progress. ▸Danger Signals. The nurse must be aware of the following -To minimize bearing down, the patient should be danger signals labor and delivery. advised to do abdominal breathing during contractions. Signs fetal and maternal distress are given below. ▸ Position. Encourage the woman in labor to assume Sim’s position because the inferior vena cave is caught between the gravid uterus and the spinal column, causing a drop in arterial Signs of Fetal Distress: blood pressure, which leads the woman to complain of dizziness. ▪ Tachycardia (FHR more than 180) - It favors anterior rotation of the head ▪ Bradycardia (FHR less than 100) ▪ Meconium-stained amniotic fluid in non-breech - It promotes relaxation between contractions. presentation - It prevents Supine Hypotensive Syndrome ▪ Fetal thrashing or hyperactivity due to feta struggling for more oxygen. ▪ ▸ Contractions. Uterine contractions are monitored every hour during the latent phase of labor and every 30 minutes during Signs of Maternal Distress: the active phase by spreading the fingers lightly over the fundus. ▪ BP over 140 /90, or failing BP associated with clinical signs of shock (pallor, restlessness or apprehension, increased respiratory and pulse rates) Duration – from the beginning of one contraction to the end of ▪ Bright red vaginal bleeding or hemorrhage (blood loss the same contraction. of more than 500 cc) Interval- from the end of one contraction to the beginning of the ▪ Abnormal abdominal contour (may be due to uterine next contraction. rupture of Band’s pathological ring, a condition wherein -Early in labor interval is 40-45 minutes; late in labor, the muscles at the physiological retraction ring become interval is only 2 minutes. very tense, gripping the fetus causing possible fetal distress. ▸ Administration of Analgesics. Narcotics are the most THE SECOND STAGE OF LABOR commonly used analgesics, specifically Demeerol (meperidine The second stage begins with complete dilatation of the cervix hydrochloride). Its dosage is based on the patient’s weight the and ends with delivery of the infant. status of labor, and the size and stage of gestation. Demerol acts to suppress the sensory portion of the cerebral cortex. A dose of 25-100 mg is given and it takes effect within 20 minutes MECHANISMS OF LABOR/FETAL POSITION CHANGES when the patient experiences a sense of well-being and As the fetus passes through the birth canal for delivery, it goes euphoria. Demerol, being also an antispasmodic, should not be through different position changes so that the smallest diameter given very early in labor because it will retard labor progress. It of the fetal head (in cephalic presentation) will fit through the should not also be given when delivery is less than an hour away pelvic inlet and outlet. because it can cause respiratory depression in the newborn. It is, therefore, preferably given when cervical dilatation is around Descent - The fetus goes down the birth canal. Descent either 5-8cm. follows or includes engagement. ▸ Administration of Anesthetics. Regional anesthesia is Flexion - As the fetus descends down the birth canal, pressure from the pelvic floor causes he fetal heard to be flexed, so that preferred over any other form because it does not enter the chin touches the chest. This brings the smallest diameter of maternal circulation and therefore does not retard labor contractions nor cause respiratory depression in the newborn. the fetal head into a good position, which is termed attitude. Attitude, therefore, is the degree of flexion that the fetus The patient is completely awake and aware of what happening, assumes prior to delivery. but since there is loss of coordination between contractions and pushing, the baby will have to be delivered with the aid of Internal Rotation - The wider anteroposterior (AP) diameter forceps. One of the more commonly used anesthesia is the low of the fetal head enters the wider transverse diameter of the spinal, specially saddle block. Xylocaine is injected into the 5th pelvic inlet and will rotate so that fetal head is positioned at the lumbar space, causing anesthesia into the parts of the body that wide AP diameter of the pelvic outlet. come in contract with a saddle, e.g., the perineum, the upper Extension - As the head comes out, the back of the neck stops thighs, and lower pelvis. Post spinal headaches, however, may beneath the public arch. The head then extends and the head, occur because of leakage of cerebrospinal fluid (CSF) or air at face, and chin are born. the time of needle insertion. The patient should be kept flat on External Rotation- After the head has been delivered, it bed for 13 hours and her fluid intake increased to prevent post rotates 45 to the left so that the anterior shoulder is just below spinal headaches. the public arch. Local anesthesia in the following forms may also be administered: NURSING MANAGEMENT ▪ Paracervical – transvaginal injection into either side of the cervix. The care of the woman during the second stage of labor, which ▪ Pudendal block – injection through the sacrospinous is focused on the delivery of the baby, consists of the following: ligament into the posterior areolar tissues to reduce ▸ Positioning on the Delivery Table. When positioning the perception of pain during the second stage of labor. woman on lithotomy on the delivery table, the legs should be put up slowly at the same time on the stirrups in order to prevent trauma to the uterine ligaments and back aches or leg cramps. ▸ Transfer of Patients. A sure sign that the baby is about to be born is the bulging of the perineum. ▸ Bearing Down Techniques. This is the best time to encourage strong pushing with contractions. At the beginning of a contraction, the woman is asked to take two short breaths, THE TRANSITION PHASE OF LABOR then to hold her breath and bear down at the peak of the Nursing Management contraction. ▸ Care of the Episiotomy Wound ▸ Breathing Technique. The patient should be assisted in Episiotomy, a perineal incision done to facilitate the birth of controlled chest (costal) breathing during the baby is made by the doctor primarily to prevent lacerations. contraction of the transitional phase. Other reasons for doing episiotomy are to: ▸ Avoidance of Bearing. The patient is discouraged from ▪ Prevent prolonged and serve stretching of the muscles supporting the bladder or rectum, which can later lead bearing down until cervical dilatation is complete to prevent to stress incontinence of urine or even vaginal cervical edema. prolapse. ▸ Emotional Support. The patient should be helped to relax ▪ Reduce duration of the second stage of labor in cases between contractions. of maternal hypertension of fetal distress. ▸ Comfort Measures. Effleurage (slight stroking on the ▪ Enlarge the vaginal outlet in breech presentation or abdominal skin surfaces), back rubs, and sacral pressure (the forceps delivery. heel of the hand is placed against the sacrum) during ▪ Spare the infant’s head from having brain damage contractions provide relief. prolonged pressure which may result in brain damage, especially in the premature baby. The two types of episiotomies are: NURSING MANAGEMENT ▪ Median – begun in the midline of the perineum and ▸ Method of Placental Delivery. Do not hurry the delivery directed toward rectum of the placental by forcefully pulling out the cord or by vigorous ▪ Mediolateral – begun in the midline of the perineum fundal push as this can lead to uterine inversion. but directed laterally away from the rectum. ▸ Time of placental delivery. 10 minutes immediately notified as it could be a sign of uterine atony. Uretent “atony” ▸ Breathing Technique. As soon as the head crowns, woman never contact to massage Õ uterus is instructed not to push any longer because it causes rapid ▸ Care after placental delivery expulsion of the fetus. The following aspects are important: ▸ Ritgen’s Maneuver. The basic steps are applying this a. Inspection of placenta for completeness of cotyledons. method of delivery are as follows. b. The initial nursing action for a non-contracted or boggy ▪ Time of delivery: uterus is gentle massage of the fundus. An ice cap may Take note of the time the baby is delivered. also help. ▪ Handling of the Newborn: c. Oxytocic agents may be administered as ordered to Immediately after delivery, the newborn should be held ensure uterine contractions, thus preventing below the level of the mother’s vulva so that blood from hemorrhage. the placenta can enter the infant’s body on the basis of ▪ Methergin (0.2mg) and gravity flow. ▪ Syntocinon (10 U) are two of the ▪ Cutting of the cord: more commonly given oxytocics. Cutting of the cord is postponed until pulsations have ▪ Common side effect of oxytocins in stopped because it is believed that 50-100 ml of blood hypertension. Monitor the blood is flowing from the placenta to the newborn at this pressure. time. It is then clamped twice, an inch apart, and cut d. Lacerations are rugged edged which heal more slowly in between. and therefore predispose infection, if healing process ▪ Initial Contact: is prology. Maternal-infant bonding is initiated as soon as the ▪ First-degree – vaginal mucous skin. mother has eye-to-eye contact with her baby. The ▪ Second-degree – vagina, perineal skin, fascia, mother is informed of her baby’s sex and helped to hold levator ani muscle and perineal body. and inspect her baby if she wished. ▪ Third-degree – entire perineum. ▪ Fourth-degree – entire perineum rectal sphincter and some of the mucous membrane for the rectum. THE THIRD STAGE OF LABOR The third stage, also known as the Placenta Stage, begins with ▸ Care during and after Perineal Repair. A local anesthetic, the delivery of the infant and ends with the delivery of the placenta. usually Xylocaine, is given in order to minimize pain during episiorrhaphy. In vaginal episiorrhaphy, packing is done to maintain pressure on the suture line and, therefore, prevent PHASES bleeding. The nurse should be aware that this packing is usually Placental Separation Phase. Separation of the placenta results removed after 24 or 48 hours. from the disproportion between the size of the placenta and the Estimation of blood loss: 250-300cc – N 500cc hemorrhage. reduced size of the site of placental attachment after the delivery of the baby. THE FOURTH STAGE OF LABOR The signs of placental separation are the following: Fourth stage first one- or two-hours vital signs of the mother are ▪ The uterus becomes firmer and rounder in shape again quite unstable. and rising high to the level of the umbilicus. NURSING MANAGEMENT Placental Expulsion Phase. This phase is affected by the mother’s bearing down or by gentle pressure on the fundus. Nursing interventions during the fourth stage of labor are focused mainly: There are two mechanisms by which the placenta is separated and expelled from uterus: ▸ Assessment. ▪ Schultz – clear type of placenta, “aw” – separation in a. Fundus – should be palpated every 15 minutes during the “center” shiny, reddish in color. first hour postpartum and then every 30 minutes for the next 4 ▪ Duncan – dark, dirty “dweg” – edges (separation) hours. b. Bladder – checked every 2 hours during the first 8 hours postpartum and then every 8 hours for 3 days. Suspect a full urinary bladder if the fundus is not well contracted and is shifted to the right. A full urinary bladder prevents good contraction of the uterus and therefore may cause hemorrhage. c. Vaginal discharge – the amount of blood flow should be Glucose - Normal = Negative or + I. High levels of glucose may checked every 15 minutes and should be moderate. It is said be one indicator of high blood sugar, gestational diabetes or that if a newly-delivered woman saturates a sanitary napkin diabetes mellitus. Always ask what woman has recently eaten if more often than every 30 minutes, the flow is excessive her BS is high. necessitating immediate referral to the doctor. Ketones - Normal = Negative. Ketones are products of the d. Blood pressure and pulse rate – should be checked every 15 breakdown of fatty acids caused by fasting. The body breaks minutes during the first hour postpartum and then every 30 down fats because there are not enough carbohydrates and minutes until stable. BP and pulse rate are slightly increased proteins available. Ketones may be deleterious to fetus. from excitement and the effort of delivery but normally stabilizes within one hour. Techniques to be Used in Performing a Physical e. Perineum – should be inspected every 8 hours for 3 days. Examination: Take note of the condition of the episiorrhaphy: ▪ Inspection d. Bladder Assessment - ▪ Palpation - Voiding pattern, complete emptying, pain burning on ▪ Auscultation urination - Record first three voids with the amount and times General appearance: voided - A full bladder displaces the uterus upwards and Edema, skin color, hygiene, pain, distress, mood laterally and prevents contraction of the uterus = UTERINE ATONY = > risk of postpartum hemorrhage. Measure vital signs: Blood pressure, pulse, respiration, temperature ▸ Comfort Measures. Helping the mother feel comfortable after delivery can be effective by the following measures: a. Perineal care gently Blood pressure b. Position her flat on bed without pillows to prevent Take blood pressure with woman in sitting or side lying position dizziness due to sudden release of intraabdominal Compare blood pressure with prenatal blood pressure pressure. c. Mother a soothing sponge bath change her soiled gown/dress and dirty linens. Pulse d. Additional blankets if the mother suddenly complains Rate: 60 - 90 of chilling. e. Mother initial nourishment of coffee, tea or milk. Increased pulse can be dehydration, anxiety. f. Mother to sleep in order to regain lost energy. Always question possibility of cardiac problems. PHYSICAL EXAMINATION OF THE LABORING WOMAN Respiration Steps you should take to prepare for the examination: Don’t count during a contraction ▪ Ask woman to empty bladder (collect urine for testing). ▪ Prepare to follow a logical order. Temperature ▪ Prepare to chart logically immediately after exam Think about infection and dehydration (make notes). ▪ Remember to use all your senses during assessment. Abdominal examination ▪ Remember to explain everything you are doing. An abdominal examination should include a ▪ Exam should be carried out immediately and as quickly measurement of fundal height as well as an assessment of fetal as possible. size (estimated fetal weight), presentation and position using Leopold's maneuvers. Urine Tests Used During Intrapartum Inspect: Scars, linea, striae, symmetry Ph - Measures acidity/alkalinity of the urine, Levels below normal Palpate: fundal height, fetal position indicate high fluid intake, levels above the norm indicate Osculate: fetal heart tones inadequate fluids & dehydration. Determine and palpate contractions Protein - Normal = Negative, Small amounts may be in urine from vaginal secretions & dehydration, amounts of 2+ to 4+ may indicate be one indicator of possible UTI, Kidney Infection or PIH. Inspect and palpate lower extremities The progress of labor is followed by abdominal or vaginal ✓ Press firmly with thumbs about 5 seconds over shin examination to note the position of the baby, the station of the ✓ If any signs of elevated blood pressure, elicit DTR presenting part, and the dilatation of the cervix. These ✓ If reflexes are hyperactive, check for clonus examinations should be done only often enough to ensure the safe conduct of labor, i.e., to determine that the rate of dilatation is within the normal range or to evaluate the patient Measuring fundal height if she is requesting medication. ✓ Place the zero line of the tape measure on the anterior Over distension of the bladder is obviated by urging the patient border of the symphysis pubis and stretch tape over to void every few hours. If she is not able to do so, midline of abdomen to top of fundus. catheterization may be necessary, since a full bladder impedes ✓ The tape should be brought over the curve of the progress. fundus. ✓ The height of the fundus in centimeters equals the Adequate amounts of fluids and nourishment are essential. If number of weeks gestation plus or minus 2. the patient is unable to take enough orally, a intravenous of ✓ After 32 weeks the relationship is less accurate. Lactated Ringers solution may be given. ✓ Perform Leopold maneuver. During the first stage, the patient should be impressed with the important of relaxing with the contractions. Help the couple as much as possible to work with the contractions and Leopold's Maneuver compliment them for a good job. Abdominal Examination for Position and Presentation and Size The passage of meconium-stained fluid in a cephalic 1. Palpation of the uterine fundus to determine which presentation is a possible sign of fetal distress and if present, fetal pole "head or breech" is present in the fundus. the patient should be continually monitored during active labor. Using two hands and compressing the maternal abdomen, a sense of fetal direction is obtained (vertical or transverse). Abdominal Examination for Contractions 2. The lateral sides of the fundus are palpated to An initial abdominal examination is carried out on determine the position of the fetal back and small admission by laying a hand on the uterus and palpating, noting parts. The fetal spine will palpate as firm, flat and the degree of hardness during a contraction and timing its linear. The fetal extremities are palpable by their length. This should be repeated at intervals throughout labor in varying contour and movements. The purpose of this order to assess the length, strength and frequency of maneuver is to determine whether the fetal back is left contractions and the descent of the presenting part. The uterus or right. should always feel softer between contractions. 3. The purpose of this maneuver is to determine the pelvic position of the presenting part. The presenting part (head or breech) is palpated above the symphysis The monitor should never be relied on; and degree of engagement determined. The examiner the mother’s uses the thumb the fingers of one hand in the suprapubic region (similar to palming a basketball) and abdomen should be regularly palpated attempts to move the presenting part from side to side. by hand. If little movement occurs or only the fetal neck is palpable the presenting part is engaged. 4. The fetal occipital prominence and flexion of the vertex is determined. If the fetal vertex is flexed, the cephalic Uterine Contractions prominence may be palpable on a same side as the fetal small parts. If a distinct cephalic prominence is noted on the same side as the spine and head the vertex is not very well flexed. Monitoring the Mother and Fetus During Labor A 20-minute fetal monitor strip is done for all patients on admission. As long as the patient is healthy, the presentation normal, the presenting part well engaged, and the fetus in good condition, the woman may walk about or be in bed as she wishes. The patient's condition and progress are checked periodically. FHT's are checked q 30 min in latent phase, q 15min. in active phase, and q 5min. in second stage. The maternal temp is taken q 4 hrs., q 2 hours if ROM. Variations to this timing depend on the maternal-fetal situation. “There is no place for routine vaginal examinations in Speculum examination any labor.” A speculum examination will be necessary in cases of Vaginal examination should only be done when there is doubt suspected "leaking" or ruptured membranes. The presence of about the clinical situation or symptoms, and the information "leaking" or ruptured membranes can be confirmed by gathered is necessary or likely to be of use in making a clinical performing a nitrazine test, inspecting the posterior fornix for decision. pooling of fluid and by obtaining a sample of the fluid with a (1) Significant vaginal bleeding of unknown etiology (delay sterile applicator and applying the fluid to a glass slide. The glass examination until placenta previa has been ruled out by slide is allowed to air dry and is subsequently inspected for an ultrasonography), arborization pattern ("ferning"). (2) Presence of placenta previa, (3) Ruptured membranes in patients who are not in labor and THE SIX STEPS OF LABOR PROGRESSION for whom immediate induction of labor is not anticipated, - Labor can be defined as regular, painful uterine (4) Presence of active HSV lesions in a patient with ruptured contractions that result in progressive cervical change. The membranes. diagnosis of labor progression may be dependent upon the patient's history of uterine contractions as well as information gathered from abdominal palpation and vaginal examination. Evidence of progressive cervical effacement and/or dilation is necessary in order to distinguish true labor from false labor. - Labor progresses in six ways and all are equally important. Frequency, duration and intensity of contractions cannot be relied upon as measures of progression in labor. Cervical dilatation and fetal descent are the only indicators that labor is progressing. How to Palpate Presenting Part Cervical Ripening. The cervix ripens or softens. As a Palpate the hard skull; palpate for sagittal suture; follow to woman’s body gets ready to labor it produces prostaglandin. anterior or posterior fontanel This causes the cervix to soften from the consistency of rubber to something that feels like a marshmallow. If what you feel is soft it may be breech or face. Cervical Position. The cervix moves from a posterior to an anterior position. During most of the pregnancy, the cervix points toward the back (posterior), but during the last few weeks of pregnancy or in early labor, it moves forward (anterior). The uterus may contract for several days intermittently before true labor begins to accomplish these first two things, softening the cervix and bringing the cervix from the back of the vagina to the front of the vagina. Cervical Effacement. The cervix effaces About two inches in length is average size, but in early labor, the cervix begins to get shorter and thinner (effacement). By the active part of labor, the cervix will be completely effaced and be paper-thin. -It is vital to understand that when the cervix has not Assessing Cervical Effacement undergone the first three steps (ripening, effacement, and Cervical effacement: Palpate degree of thickness; normal anterior movement of the cervix), significant dilation (beyond 3- cervix about 1 inch thick 4 cm in the nullipara, more in the multipara) rarely occurs), but that pre-labor contractions are accomplishing the important job of pre-paring the cervix to dilate. Cervical Dilatation. The cervix dilates and active labor begins. Not much dilatation can occur until the cervix has completed the above three processes. Remember the cervix needs to get very soft, move to an anterior position and get paper-thin before it will dilate much past 3-4 centimeters.  Fetal Head Rotation, Flexion and Molding. The fetal head rotates, flexes, and molds. The head begins to change Crowning and birth of the baby and placenta shape to fit through the pelvis. Remember, this is called molding. Rotation, flexion, molding, and descent of the fetal head take place in active labor and second stage Fetal Descent and Birth. The fetus descends and is born. Descent occurs as the baby lowers itself into your pelvis. Remember, descent is measured in terms of "stations." STAGES OF LABOR CHART The first stage of labor begins when uterine contractions of sufficient frequency, intensity and duration result in effacement and dilation of the cervix. The first stage is completed when the cervix reaches 10 cm. The second stage involves descent of the fetus and its eventual expulsion from the vagina. It begins with complete cervical dilation (10 cm) and ends with delivery of the infant. The third stage of labor involves delivery of the placenta. It begins with the completion of the infants' delivery and ends with delivery of the placenta and membranes. Hand baby to mom: if baby is stable Father or SO Cuts the Cord