Lesson 2 Stages of Labor PDF

LESSON 2 STAGES OF LABOR LEARNING CONTENTS Let’s start… STAGES OF LABOR A. First Stage (Stage of Dilatation) – begins with true labor pains and ends with complete dilatation of the cervix. 1. Power/Forces: Involu...

LESSON 2 STAGES OF LABOR LEARNING CONTENTS Let’s start… STAGES OF LABOR A. First Stage (Stage of Dilatation) – begins with true labor pains and ends with complete dilatation of the cervix. 1. Power/Forces: Involuntary uterine contractions 2. Phases: a. Latent – early time in labor  Cervical dilatation is minimal because effacement is occurring  Cervix dilates 3-4 cm. only  Contractions are of short duration and occur regularly 5-10 minutes apart (during which time the pregnant woman may seek admission to the hospital)  Mother is excited, with some degree of apprehension but still with ability to communicated  Takes up 8 of the 12-hour first stage b. Active/accelerated  Cervical dilatation reaches 4-8 cm.  Rapid increase in duration, frequency and intensity of contractions  Mother fears losing control of herself 3. Nursing Care a. Hospital admission – provide privacy and reassurance from the very start  Personal data – name, age, address, civil status  Obstetrical data – determine EDC; obstetrical score; amount and character of show; and whether or not membranes have ruptured  b. General physical examination, internal exam and Leopold’s maneuvers are done to determine:  Effacement and dilatation Station – relationship of the fetal presenting part to the level of the ischial spines  Station 0 – at the level of the ischial spines; synonymous to engagement  Station -1 – presenting part above the level of the ischial spines  Station +1 – presenting part below the level of the ischial spines \  Station +3 or +4 – synonymous to crowning (= encirclement of the largest diameter of the fetal had by the vulvar ring)  Presentation – relationship of the long axis of the fetus to the long axis of the mother; also known as lie Presenting part – the fetal part which enter the pelvis first and covers the internal cervical os Types of Presentation I. VERTICAL A. Cephalic – he is the presenting part 1. Vertex – head sharply flexed, making the parietal bone the presenting part 2. Face) 3. Brow) if in poor flexion 4. Chin ) B. Breech – buttocks are the presenting parts 1. Complete – thighs flexed on the abdomen and legs are on thighs 2. Frank – thighs are flexed and legs are extended, resting on the anterior surface of the body 3. Footling a. Single – one leg unflexed and extended; one foot presenting b. Double – legs unflexed and extended; feet are presenting II. HORIZONTAL – Transverse lie – Shoulder presentation  In vertex and breech presentations, fetal heart sounds are best heard, at the area of the fetal back; in face presentations, at the area of the fetal chest  In vertex presentations, FHS are usually located in either the left or right lower quadrant (RLQ or LLQ); in breech presentation, at or above the level of the umbilicus (RUQ or LUQ)  Hazards of breech delivery: o Cord compression o Abruptio placenta o Erb-duchenne paralysis  Horizontal lie is very rare (1%) and maybe due to a relaxed abdominal wall because of multiparity, pelvic contraction or placenta previa  Position – relationship of the fetal presenting part to a specific quadrant of the mother’s pelvis  The pelvis is divided into four quadrants o Right anterior o Right posterior o Left anterior o Left posterior o Posteriors positions result in more backaches because of pressure fetal presenting part on the maternal sacrum  Points of direction in the fetus: o Occiput – in vertex presentations o Chin (mentum) – in face presentations o Buttocks/feet – in breech presentations o Scapula (acromic) – in horizontal presentation  Possible fetal positions o Vertex  LOA – left occipitoancetior (most common and favorable position at birth)  LOP – left occipitoposterior  LOT – left occipitoetransverse  ROA – right occipitoanterior  ROP – right occipitoposterior  ROT – right occipitotransverse o Breech  LSA – left sacroanterior  LSP – left sacroposterior  LST – left sacrotransverse  RSA – right sacroanterior  RSP – right sacroposterior  RST – right sacrotransverse o Face  LMA – left mentoanterior  LMP – left mentoposterior  LMT – left mentotransverse  RMA – right mentoanterior  RMP – right mentoposterior  RMT – right mentotransverse  o Shoulder  LADA – left acromiodorsoanterior  LADP – left acromiodorsoposterior  RADA – right acromiodorsoanterior  RADP – right acromiodorsotransverse c. Monitoring and evaluation of important aspects  Uterine contractions – fingers should be spread lightly over the fundus o Duration – from the beginning of one contraction to the end of the same contraction (A to B)  Duration during early labor – 20-30 seconds  Duration late in labor – 60 to 70 seconds (SHOULD NEVER BE LONGER) o Interval – from the end of one contraction to the beginning of the next contraction (B to C)  Interval early in labor – 40-45 minutes  Interval late in labor – 2-3 minutes o Frequency – from the beginning of one contraction to the beginning of the next contraction (A to C) Time 3-4 contractions to have a good picture of the frequency of contractions o Intensity – strength of contractions. May be mild, moderate or string. Intensity is measured by the consistency of the fundus at the acme of the contraction. When estimating intensity, check fundus at the end of contractions to determine whether it relaxes. o Blood pressure – should not be taken during a contraction as it tends to increase. Because no blood supply goes to the placenta during a contraction, all of the blood is in the periphery that is why there is increased BP during uterine contractions.  BP readings should be taken at least every half hour during active labor  When a woman in labor complains of a headache, the first nursing action is to take the BP. If it is normal, it is only stress headache; if the BP is increased, refer immediately to the doctor (it could be a sign of toxemia) o Fetal heart rate – should not be mistaken for uterine soufflé (synchronizes with maternal pulse rate)  Normally 120-160 per minute  Should not be taken also during a uterine contraction because it tends to decrease. Compression of the fetal head when the uterus contracts stimulates the vagal reflex which, in turn, caused bradycardia  Should be taken every hour during the latest phase of labor; every half hour during the active phase and every 15 minutes during the transition phase   For any abnormality in FHR, the initial nursing action is to change the mother’s position. o Signs of fetal distress:  Bradycardia (= FHR less than 100/minute) or tachycardia  (=FHR more than 180/minute) o Meconium-stained amniotic fluid in non-breech presentation  Fetal thrashing – hyperactivity of the fetus as it struggles for more oxygen d. Emotional support is provided for the woman in labor by keeping her constantly informed of the progress in labor. e. Healthy Teachings  Bath – is advisable if contractions are tolerable or not too close to one another. Will make the mother feel more comfortable  Ambulation – during the latent phase of labor helps shorten the first stage of labor. But definitely not allowed anymore if membranes have ruptured.  Solid or liquid foods are to be avoided because: o Digestion is delayed during labor o A full stomach interferes with proper bearing down o May vomit and cause aspiration  Enema – NOT a routine procedure o Purposes:  A full bowel hinders the progress of labor- effectiveness of enema in labor is shown by evaluating change in uterine tone and amount of show  Expulsion of feces during second stage of labor predisposes mother and baby to infection.  Full bowel predisposes to post-partum discomfort o Procedure of enema administration  Enema solution may either be soap suds or fleet enema  Optimal temperature of the enema solution – 105oF to 115oF ( 40.5oC – 46.1oC)  Patient on side-lying position  When there is resistance while inserting the rectal catheter, withdraw the tube slightly while letting a small amount of solution enter  Clamp rectal tube during s contraction  Important nursing action: Check FHR after enema administration to determine fetal distress o Contraindications to enema in labor :  Vaginal bleeding  Premature labor  Abnormal fetal presentation or position  Ruptured membranes   Crowning  Encourage the mother to void very 2-3 hours by offering the bedpan because:  A full bladder retards fetal descent  Urinary stasis can lead to urinary tract infection  A full bladder can be traumatized during delivery PERINEAL PREP  Perineal Prep – done aseptically Use “No.7” method, always from front to back.  Perineal shave – maybe done to provide a clean area for delivery. Muscles at the symphysis pubis should be kept taut and razor moved along the direction of hair growth  Encourage Sim’s position because :  It favors anterior rotation of the fetal head  It promotes relaxation between contractions  It prevents continual pressure of the gravid uterus on the inferior vena cava ( the blood vessel which brings unoxygenated blood back to the heart), pressure results in Supine Hypotensive Syndrome, also called Vena Cava Syndrome. Hypotension is due to the reduced venous return resulting in decreased cardiac output and therefore, a fall in arterial BP.  Woman in labor should not be allowed to push or bear down unnecessarily during contractions of the first stage because:  It leads to unnecessary exhaustion  Repeated strong pounding of the fetus against the pelvic floor will lead to cervical edema, thus interfering with dilatation  Abdominal breathing – is advised for contractions during the first stage in order to reduce tension and prevent hyperventilation. f. Administer analgesics as ordered. The dosage is based on the patient’s weight, status of labor and size and stage of gestation.  Narcotics are the most commonly used, specifically Demerol.  Pharmacologic effect: Depresses the sensory portion of the cerebral cortex. It is not only a potent analgesic, it is also a sedative and an antispasmodic.  It is not given early in labor because it can retard labor progress ( is an antispasmodic), but cannot also be given if delivery is only one hour away because it causes respiratory depression in the newborn ( that is why it can be given only if cervical dilatation is 6-8cm.)  Given 25-100mg.,depending on the body weight  Takes effect in 20 minutes – patient experiences a sense of well- being and euphoria   Narcotic antagonists (e.g. Narcan or Nalline) are given to counteract the toxic effects of Demerol g. Assist in administration of regional anesthesia – preferred over any other form of anesthesia because it does not enter maternal circulation and thus does not affect the fetus. Patient is completely awake and aware of what is happening. Does not depress uterine tone, thus optimal uterine contraction is achieved.  Xylocaine is anesthesia of choice  Patient on NPO with IV to prevent dehydration, exhaustion and aspiration and because glucose aids uterine muscles in proper functioning.  Types of Anesthesia:  Paracervical – transvaginal injection into either side of the cervix. Patient on lithotomy position. Coupled with a local anesthetic, results in “painless childbirth” ( uterine contractions are not felt by mother)  Pudendal – through the sacro- spinous ligament into the posterior areolar tissues to reduce perception of pain during second stage and make mother comfortable. Patient on lithotomy. Side effect : an ecchymotic (purplish discoloration of the skin due to blood in the subcutaneous tissues) area or hematoma in the right of the perineum may be an aftermath. No special treatment is needed: ice bag applied to the area on the first day may reduce the swelling   Low Spinal  Epidural – injection of local anesthetic at the lumbar level outside the dura mater  Saddle block – injection into the 5th lumbar space, causing anesthesia into the parts of the body that come in contact with a saddle (perineum, upper thighs and lower pelvis). Blocks nerves that transmit pain of first stage of labor. In sitting or side-lying position, with back flexed.  Forceps are generally needed in delivery of patient under anesthesia because of loss of coordination in second-stage pushing  Postspinal headaches maybe due to leakage of anesthetic into the CSF or injection of air at time of needle insertion. Management : Flat on bed for 12 hours and increase fluid intake  Common side-effects:  Hypotension – because Xylocaine is a vasodilator. Management : turn to side; prompt elevation of legs; administration of vasopressor and oxygen, as ordered  Fetal bradycardia  Decreased maternal respirations h. A sure sign that the baby is about to be born is the bulging of the perineum. In general, primigravidas are transported from LR to the DR when the cervix is fully dilated or when there is bulging of the perineum; multiparas are transported at 7-8cm cervical dilatation. B. Transition Period – when the mood of the woman suddenly changes and the nature of the contractions intensify. 1. Characteristics : a) If membranes are still intact, this period is marked by a sudden gush of amniotic fluid as fetus is pushed into the birth canal. If spontaneous rupture does not occur, amniotomy (snipping of BOW with a sterile pointed instrument e.g. Kelly or Allis forceps or amniohook to allow amniotic fluid to drain), is done to prevent fetus from aspirating the amniotic fluid as it makes its different fetal position changes. Amniotomy, however cannot be done if station is still “minus” as this (can lead to cord compression). b) Show becomes prominent. c) There is an uncontrollable urge to push with contractions, a sign of impending second stage of labor. Profuse perspiration and distention of neck veins are seen. d) Nausea and vomiting is a reflex reaction due to decreased gastric motility and absorption.  e) In primis, baby is delivered within 20 contractions (=40 minutes); in multis, in 10 contractions (=20 mintues) 2. Nursing actions are primarily comfort measures: a) Sacral pressure ( applying pressure with the heel of the hand on the sacrum) relieves discomfort from contractions b) Proper bearing down techniques: push with contractions c) Controlled chest ( costal) breathing during contractions d) Emotional support C. Second Stage (stage of Expulsion) – begins with complete dilatation of the cervix and ends with delivery of the baby. 1. Power/forces: In voluntary uterine contractions and contractions of the diaphragmatic and abdominal muscles 2. Mechanisms of Labor/ Fetal Position Changes : (D FIRE ERE) a. Descent (may be preceded by engagement) b. Flexion – as descant occurs, pressure from the pelvic floor causes the chin to bend forward onto the chest  c. Internal Rotation – from AP to transverse, then AP to AP d. Extension – as head comes out, the back of the neck stops beneath the pubic arch. The head extends and the forehead, nose, mouth and chin appear e. External Rotation (also called restitution) - anterior shoulder rotates externally to the AP position f. Expulsion – delivery of the rest of the body 3. Nursing Care a. When positioning legs or lithotomy, put them up at the same time to prevent injury to the uterine ligaments  b. As soon as the fetal head crowns, instruct mother not to push, but to pant instead ( rapid and shallow breathing) to prevent rapid expulsion of the baby. If panting is deep and rapid, called hyperventilation the patient will experience lightheadedness and tingling sensation of the fingers leading to carpopedal spasms, because of respiratory alkalosis. Management: let the patient breath into brown paper bag to recover lost carbon dioxide; a cupped hand will serve the same purpose. c. Assist in episiotomy – incision made in the perineum primarily to prevent lacerations.  Other purpose of episiotomy: o Prevent prolonged and severe stretching of muscles supporting bladder or rectum o Reduce duration of second stage when there is hypertension or fetal distress o Enlarge outlet, as in breech presentation or forceps delivery  Types of episiotomy: o Median – from middle portion of the lower vaginal border directed towards the anus o Mediolateral – begun in the midline but directed laterally away from the anus  Natural anesthesia is used in episiotomy, i.e., no anesthetic is injected because pressure of fetal presenting part against the perineum is so intense that nerve endings for pain are momentarily deadened. d. Apply the Modified Ritgen’s Maneuver:  Cover the anus with sterile towel and exert upward and forward pressure on the fetal chin, while exerting gentle pressure with two fingers on the head to control emerging head. This will not only support the perineum, thus preventing lacerations, but will also favor flexion so that the smallest sub-occipitobregmatic diameter of the fetal head is presented.  Ease the head out and immediately wipe the nose and mouth of secretions to establish and maintain a patent airway (REMEMBER: the first principle in the care of the newborn is establish and maintain a patent airway). (The head should be delivered in between contractions.)  Insert 2 fingers into the vagina so as to feel for the presence of a cord looped around the neck (nuchal cord). If so, but loose, slip it down the shoulders or up over the head; but if  tight; clamp cord twice, an inch apart, and then cut in between.  As the head rotates, deliver the anterior shoulder by exerting a gentle downward push and then slowly give an upward lift to deliver the posterior shoulder  While supporting the head and the neck, deliver the rest of the body. Take note of the exact time of delivery of the baby. a. Immediately after delivery, newborn should be held below the level of the mother’s vulva for a few minutes to encourage flow of blood from the placenta to the baby. b. The infant is held with his head in a dependent position (-head lower than the rest of the body) to allow for drainage of c. secretions. REMEMBER: Never stimulate a baby to cry unless you have drained him out of his secretions first. d. Wrap the bay in a sterile diaper to keep him warm. REMEMBER: Chilling increases the body’s need for oxygen. e. Put the bay on the mother’s abdomen. The weight of the baby will help contract the uterus. f. Cutting of the cord is postponed until the pulsations have stopped because it is believed that 50 – 100 ml of blood is flowing from the placenta to the baby at this time. After cord pulsations have stopped, clamp it twice, an inch apart, and then cut in between g. Show the baby to the mother, inform her of the sex and time of delivery then give the baby to the circulating nurse. D. Third Stage (Placental Stage) – begins with the delivery of the baby and ends with the delivery of the placenta. 1. Signs of placental separation: a. Uterus becoming round and firm again, rising high to the level of the umbilicus (Calkin’s sign) – the earliest sign of placental separation b. Sudden gush of blood from the vagina c. Lengthening of the cord from the vagina 2. Types of placental delivery: a. Schultz – if placenta separates first at its center and last at its edges, it tends to fold on itself like an umbrella and presents the fetal surface which is shiny. 80% of placentas separate in this manner (“Shiny” for Schultz) b. Duncan – if placenta separates first at its edges, it slides along the uterine surface and presents with the maternal surface which is raw, red, beefy, irregular and “dirty”. Only about 20% of placentas separate this way. (”Dirty” of Duncan) 3. Nursing Care a. Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous fundal push as this can cause uterine inversion. Just watch for the signs of placental separation. b. Tract the cord slowly, winding it around the clamp until placenta spontaneously comes out, rotating it slowly so that no membranes are left inside the uterus, a method called Brandt-Andrews maneuver. c. Take not of the time of placental delivery; it should be delivered within 20 minutes after the delivery of the baby. Otherwise, refer immediately to the doctor as this can cause severe bleeding in the mother. d. Inspect for completeness of cotyledons; any placental fragment retained can also cause severe bleeding and possible death e. Palpate the uterus to determine degree of contraction. If relaxed, boggy or non-contracted, first nursing action is to massage gently and properly. An ice cap over the abdomen will also help contract the uterus since cold causes vasoconstriction. f. Inject oxytocin (Methergin – 0.2. mg/ml or Syntocinon = 10 U/ml) – IM to maintain uterine contractions, thus prevent hemorrhage. Note: oxytocins are not given before placental delivery because placental entrapment can occur.   Categories of lacerations (tend to heal more slowly because of ragged edges): o First degree – involves the vaginal mucous membranes and skin o Second degree – involves not only the vaginal mucous membranes and skin, but also the muscles o Third degree – involves not only the muscles, vaginal mucous membranes and skin, but also the external sphincter of the rectum o Fourth degree – involves not only the external sphincter of the rectum, the muscles, vaginal mucous membranes and skin, but also the mucous membranes of the rectum  Assist the doctor in doing episiorrhaphy (- repair of episiotomy or lacerations). In vaginal episiorrhaphy, packing is done to maintain pressure on the suture line, thus prevent further bleeding. Note: Vaginal packs have to be removed after 24 – 48 hours g. Make mother comfortable by perineal care and applying clean sanitary napkin snugly to prevent its moving forward from the anus to the vagina. Soiled napkins should be removed from front to back. h. Position the newly-delivered mother flat on bed without pillows to prevent dizziness due to decrease in intra-abdominal pressure. i. The newly-delivered mother may suddenly complain of chills due to the rapid decrease of pressure, fatigue or cold temperature in the delivery room. Management: Provide additional blankets to keep her warm. j. May give initial nourishment, e.g., milk, coffee, or tea k. Allow patient to sleep in order to regain lost energy E. Fourth Stage – first 1 – 2 hours after delivery which is said to be the most critical stage for the mother because of unstable vital signs. 1. Assessment: a. Fundus – should be checked every 15 minutes for 1 hour then every 30 minutes for the next 4 hours. Fundus should be firm, in the midline and, during the first 12 hours postpartum, is a little above the umbilicus. First nursing action for a non-contracted uterus: massage. b. Lochia – should be moderate in amount. Immediately after delivery, a perineal pad can be completely saturated after 30 minutes. c. Bladder – a full bladder is evidenced by a fundus which is to the right of the midline, dark-red bleeding with some clots. d. Perineum – is normally tender, discolored and edematous. It should be clean, with intact sutures.  e. Blood pressure and pulse rate – may be slightly increased from excitement and effort of delivery, but normalize within one hour. 2. Lactation-suppressing agents – estrogen-androgen preparation given within the first hours postpartum to prevent breastmilk production in mothers who will not (or cannot) breastfeed. E.g., diethylstilbestrol, TACE or deladumone. These drugs tend to increase uterine bleeding and retard menstrual return. 3. Rooming-in concept – mother and baby are together while in the hospital. The concept of a family, therefore, is felt at the very beginning because parents have the baby with them, thus providing opportunities for developing a positive relationship between parents and newborn. Eye-to-eye contact is immediately established, releasing maternal caretaking responses.