Labor and Delivery PDF

Labor and Delivery Labor is a process whereby with time regular uterine contractions bring about progressive effacement and dilatation of the cervix, resulting in the delivery of the fetus and expulsion of the placenta Also known as Parturition, childbirth, birt...

Labor and Delivery Labor is a process whereby with time regular uterine contractions bring about progressive effacement and dilatation of the cervix, resulting in the delivery of the fetus and expulsion of the placenta Also known as Parturition, childbirth, birthing Parturient is a woman in labor. Toco and Toko (Gr.) are combining forms meaning childbirth Eutocia – normal labor Dystocia – difficult labor B. True conjugate/conjugate vera THEORIES OF LABOR ONSET Measure between the anterior surface of the Uterine Stretch Theory sacral promontory and superior margin of the Any hollow body organ will contract and empty symphysis pubis. its content when stretched to its fullest capacity Measurement: 1 1.0 cm Oxytocin theory C. Obstetrical conjugate Increased production of oxytocin by the smallest AP diameter. Pelvis at 10 cm or more. anterior pituitary increases as pregnancy nears Tuberoischi Diameter – transverse diameter of term while production of oxytinase by the the pelvic outlet. Ischial tuberosity – placenta decreases approximated with use of fist – 8 cm & above. Progesterone Deprivation Theory 2. Passenger (Fetal) As pregnancy nears term, progesterone level The passage of the fetus through the birth canal drops, hence uterine contraction occurs is influenced by: Theory of Aging Placenta Size of the fetal head & shoulder Advance placental age decreases blood supply Dimensions of the pelvic girdle to the uterus. This event triggers uterine Fetal presentation contractions, thereby, starting the labor. Fetal position Size Primarily related to fetal skull. Cpd Factor Affecting Labor and Delivery Process cephalopelvic disproportion the 1. Passage (Maternal) baby's head or body is too large size and type of pelvis, ability of the to fit through the mother’s pelvis. cervix to efface and dilate, distensibility Fetal skull of the vagina and introitus, measurement. CPD Is the largest presenting part and least Mom compressible fetal structure, making it an < 4’9” tall important factor in relation to labor and birth. < 18 years old Bones Underwent pelvic dislocation 6 BONES Important Measurements S – sphenoid O –occuputal – occiput, A. Diagonal Conjugate T – temporal P – parietal 2 x Measure between sacral promontory and F – frontal – sinciput E – ethmoid inferior margin of the symphysis pubis. Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC – 11.5cm=true conjugate) Sutures intermembranous spaces that allow molding. Transverse Lie Moldings: the overlapping of the sutures of the Fetal spine is 90°to skull to permit passage of the head to the pelvis maternal spine Sagittal suture – connects 2 parietal bones Fetuses line horizontally Coronal suture – connect parietal & frontal bone Lambdoidal suture – connects occipital & parietal bone Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis Oblique Lie Fontanels Fetal spine is 45° to 1. Anterior fontanel –bregma, diamond shape, maternal spine midway 3 x 4 cm, (> 5 cm –hydrocephalus), closes12 – between longitudinal and 18 months after birth transverse rare and 2. Posterior fontanel or lambda – triangular considered abnormal shape, 1 x 1 cm, closes – 2 to 3 months after birth Anteroposterior diameter Suboccipitobregmatic Presentation 9.5 cm, complete flexion, smallest AP Part of fetus that presents to maternal pelvic Occipitofrontal inlet: Cephalic, vertex, transverse, breech 12cm partial flexion Occipitomental Cephalic Fetal Presentation: 13.5 cm hyper A. Vertex Extension Submentobragmatic Parietal bones of the presenting face presentation part of the fetus Lie Considered optimal for fetal Relationship of spine of fetus to spine of descent mother: longitudinal (parallel), transverse, Longitudinal lie with complete oblique flexion attitude B. Brow & Sinciput Brow or forehead is the presenting part of the fetus longitudinal lie with moderate flexion Longitudinal Lie attitude fetal spine is parallel to maternal spine fetuses line vertically can be both cephalic or breach most common, about 99%  FOUR STAGES OF LABOR C. Face First 1-2 h Nursing Considerations Face is the presenting Vital signs q15 mins Follow protocol until stable part of the fetus (BP, Longitudinal lie with pulse) partial extension attitude Fundus q15 mins Position – even to 1 Severe edema and cm/finger breadth above the facial distortion occur from umbilicus for the first 12 h, pressure of uterine then descends by one contractions finger breadth each succeeding day, pelvic usually by D. Mentum day 10 chin is the Lochia q15 mins Lochia (endometrial (color, sloughing) – day 1-3 rubra presenting part of the volume) (bloody fetus with fleshy odor; may be longitudinal lie clots); day 4-9 serosa with partial extension attitude (pink/brown with fleshy severe edema odor); day 10+ alba (yellow- and facial distortion white); at no time should occur from pressure of there be a foul odor uterine contractions (indicates infection) vaginal delivery Urinary Measure first May have urethral edema, is usually impossible void urine retention Bonding Encouraged Emphasize touch, eye interaction contact LABOR TRUE FALSE Contractions Regular, becomes Irregular & not More frequent, Intense Gradual increase Induration & Intensity Discomforts Begins at the Primarily on the Lower back & Abdomen only Radiates around Abdomen Effects of Contractions are Contractions walking Intensified when may Walking Decrease or Disappear when Walking Cervical Progressive No cervical changes Dilatation & Changes Effacement  orifice (discourage breath holding for more than 5sec), position squatting, side-lying, Fowler’s as appropriate Provide comfort measures; support coping measures; assist support person Fetus/neonate Monitor fetal heart rate and regularity –Provide immediate neonatal care Assist M.D./nurse/midwife in newborn care Please refer to ESSENTIALS OF NEWBORN CARE The ENC guidelines are categorized into the time bound, non-time bound and unnecessary Cervical changes procedures. Effacement – thinning and shortening of Time bound procedures the cervix during late pregnancy and/or Should be routinely performed first labor; measured in percentages (100% is Refer to the four core steps of enc which are fully effaced) immediate drying, skin to skin contact followed Dilation – opening and enlargement of the by clamping of the cord after 1-3 minutes, non- cervical canal; measured in centimeters 0- separation of the newborn from the mother 10 cm (10 cm is fully dilated) and breastfeeding initiation. Non-time bound or non-immediate interventions PROVIDING COMFORT DURING LABOR AND BIRTH include: (Intrapartal nursing management) Mmunizations Eye care Stage 1: Maternal Vitamin k administration Monitor vital signs, fluid and electrolyte Weighing and washing balance, frequency, duration, and intensity of Unnecessary Procedures include: uterine contractions and degree of discomfort routine suctioning routine separation of (hourly, at minimum); urine protein and glucose newborn for observation with every voiding; laboratory results; foot printing preparedness; ROM application of alcohol Provide comfort measures – e.g., positioning, medicine and other substances on the cord back massage/effleurage (light abdominal stump and bandaging the cord stump or stroking in rhythm with breathing during a abdomen contraction to ease mild/moderate discomfort), administration of prelacteals like glucose water warm/cold compresses, ice chips or formula. 1. Support coping measures – reassure, explain Four Core Steps of Essential Newborn Care procedures, reinforce/teach breathing Immediate and thorough drying techniques, relaxation, focal point Early skin-to-skin contact 2. Assist support person Properly timed cord clamping Fetal – monitor status Non-separation of the newborn and mother for Stage 2: Maternal early initiation of breastfeeding Monitor physical status; assess progress of labor, perineal and rectal bulging, increased vaginal show Assist in techniques to foster expulsion – encourage bearing down focus on vaginal STAGES OF LABOR 3. Transition Phase A. FIRST STAGE (STAGE OF DILATATION) Begins with the first true labor contractions and ends with complete effacement and dilation of the cervix (10 cm dilation). 3 PHASES 1. Latent Phase Hyperesthesia – increase sensitivity to touch, pain all over Health Teaching: – Encourage sacral pressure on lower back to inhibit transmission of pain »keep informed of progress »controlled chest breathing Mgt: Mgt: 1. encourage ambulation 1. check V/S, FHR, contractions 2. check V/S, FHR, contraction 2. be alert for bladder distention 3. clear fluids or ice chips 3. I.E. 4. left-side lying position 4. avoid pushing 5. breathing techniques: slow, deep chest or 5. provide short, concise information abdominal breathing 6. breathing technique: high – chest, pant-blow 6. encourage voiding Q2H 7. nausea & vomiting may occur 2. Active Phase B. SECOND STAGE (STAGE OF EXPULSION) From complete dilation of cervix to delivery of the baby AVE: 2 h for nulliparas 20 min for multiparas Contractions are now severe, lasting 60- 90sec 1. check V/S, FHR, contractions at 1.5 to 3 min intervals 2. calm environment Crowning occurs when the presenting 3. comfort measures part appears at the vaginal orifice, back rub or effleurage distending the vulva side lying position Timing of transfer to delivery room 4. breathing techniques: accelerated slow panting Nulliparas – during second stage when the 5. IVF presenting part begins to distend the 6. provide psychosocial support perineum– Multiparas – at the end of first stage when the cervix is dilated 8-9 cm Mgt: 1. check V/S, FHR, contractions 2. I.E. 3. positioning: lithotomy position 4. perineal preparation 5. breathing technique 2 short breaths, hold 3rd breath while pushing never open mouth 6. Catheterization C. FOURTH STAGE (RECOVERY STAGE) may be placed in your bladder to drain urine immediate recovery period from delivery of since you won't be able to get up and go to the placenta to stabilization of maternal systemic bathroom. The Foley catheter is placed after the responses and contraction of the uterus epidural and is usually not uncomfortable DURATION: from 1 to 4 h 7. Episiotomy Mother begins to readjust to non- pregnant state – a cut (incision) made in the tissue between the Areas of concern include vaginal opening and the anus during childbirth discomfort due to contraction of uterus (after Purposes: pain) and/or episiotomy to avoid laceration of the perineum fatigue or exhaustion to shorten the 2nd stage of labor hunger, thirst 8. Hand Maneuver excessive bleeding Modified Ritgen’s maneuver – is the forward bladder distention upward pressure applied in the perineum with parent-infant interaction the main purpose of preventing laceration as Mgt: well as promote flexion of the head in brow 1. Assess uterine contractility presentation. uterus must be firm & well contracted palpate for cord coil check for uterine involution Suction mouth and nose LOCATION OF FUNDUS: 9. Cord Clamping & Cutting Immediately after delivery - slightly above the level of cut the cord when it stops pulsating umbilicus 1st 24 hrs (12-24 hrs)- @ the level of umbilicus C. THIRD STAGE (PLACENTAL STAGE) PPD1 - 1 fingerbreadth below the umbilicus Begins with delivery of the baby and ends with The involution of the uterus subsides at 1 delivery of the placenta. fingerbreadth per day. may last from a few minutes to 30 minutes. PPD10 - (-) Palpation; its behind the symphysis (if more than 30 min, placenta is considered pubis retained) 2. Assess for lochia discharge normal blood loss: 300 – 500 ml COMPOSITION: 1. Placental Separation signs All but one is a normal composition of lochia: a. Calkin’s sign shreds of decidua 1st sign: uterus becomes globular in shape small clotted blood with mucus 2nd sign: gushing of blood WBC 3rd sign: lengthening of the cord bacteria 2. Placental Expulsion amniotic fluid a. Brandt – Andrews Maneuver Pattern PRESENTATION a. Lochia Rubra b. Shultz Mechanism - shiny (fetal side) bloody red c. Duncan Mechanism - dirty or rough side up to 3 days (maternal side) b. Lochia Serosa 3. Inspect the placenta 4 to 6 days Third Stage (Placental Stage) brownish Mgt: c. Lochia Alba Medication 7 to 10 days a. Oxytocin (Syntocinon) Whitish given IV after delivery of baby b. Methylergonovine Maleate (Methergine) given IM after delivery of the placenta 3. Assess Perineum challenging, while calmness and support can R - edness facilitate smoother labor. E - edema E - cchemosis Signs of true labor D - discharges Bloody show A - approximation of blood loss. Count pad & saturation the mucus plug of the cervical canal during – Fully soaked pad: 30 – 40 cc weigh pad. 1gram=1cc pregnancy is expelled as a result of cervical softening and increased pressure of the Three phases of uterine contraction presenting part. The exposed cervical capillaries Increment – steep crescent slope from release a small amount of blood that mix with beginning of a contraction until its peak the mucus, resulting in bloody show. Acme/peak – strongest intensity Spontaneous rupture of membrane Decrement – diminishing intensity one in four women experience SROM before onset of labor. This reduces the capacity of the The components of labor and delivery are often uterus, thickens the uterine wall, and increases summarized using the "4 Ps" framework, which helps uterine irritability. Labor usually follows. describe the essential factors influencing the progress Uterine Contractions and outcome of labor. These components are: The surest sign that labor has begun is 1. Power (Uterine Contractions and Maternal Effort): productive uterine contractions. Because Uterine Contractions: Regular and rhythmic contractions are involuntary and come without contractions of the uterus that help dilate the warning cervix and push the baby down through the birth canal. At term, 90% will be in labor within 24 h after Maternal Effort: In the second stage of labor, membrane rupture. If labor does not begin in the mother’s voluntary pushing efforts 24 h, the case must be considered complicated complement uterine contractions to expel the by prolonged rupture of the membranes baby. because of the increased risk of ascending 2. Passenger (Fetus): infection. Fetal Size and Position: The baby’s size, position Risk of cord prolapses is increased if (vertex, breech, etc.), and the degree of flexion engagement of the presenting part not occur. or extension can affect how easily the baby moves through the birth canal. Fetal Presentation: Refers to the part of the baby that enters the pelvis first (e.g., head, feet, or shoulders). 3. Passageway (Birth Canal): Pelvis and Soft Tissues: The shape and size of the mother's bony pelvis and the ability of the soft tissues (cervix, vagina, and perineum) to stretch and accommodate the baby. Cervical Effacement and Dilation: The cervix must thin out (efface) and open (dilate) to allow the baby to pass through. 4. Psyche (Maternal Emotional State): Mental and Emotional Well-being: The mother’s psychological state, including her stress levels, anxiety, and mental preparedness, can influence labor progression. Fear and stress may increase tension, making labor more