Labor – Series of events by which uterine contractions& abdominal pressure expel a fetus & placenta from a woman’s body. body. Theories of Labor Labor begins before a fetus matures (preterm; 20 – 37 weeks) Labor is delayed until a fetus and placenta have passed beyond optimal point fo r birth (post term) 1. Uterine Muscle Stretching releases prostaglandins 2. Pressure on Cervix stimulates release of oxytocin from Posterior Pituitary 3. Oxytocin Stimulation works together with prostaglandins to i nitiate contractions 4. Increased Estrogen and decreased progesterone stimulates contractions 5. Placental Age stimulates contractions 6. Rising Fetal Cortisol Levels reduces progesterone and increases prostaglandins 7. Fetal Membrane production of p rostaglandins stimulates contractions Preliminary Signs of Labor (ONSET OF LABOR) 1.
Lightening or Dropping Fetal head settles and descends into the inlet of the true pelvis. Change in the abdominal contour of a woman because uterus becomes lower and gives a relief from diaphragmatic pressure and shortness of breath (“lightens her load”) Woman may experience Shooting leg pains from increased pressure on sciatic nerve and Increased vaginal discharge and urinary frequency from pressure on the bladder. In Primiparas: Occurs early about 2 weeks before labor In Multiparas: Occurs on the day of labor or even after labor has begun
2.
Increase in the level of activity Woman has sudden burst of energy d/t increase epinephrine initiated by decrease in progesterone produced by placenta. Additional epinephrine prepares the woman’s body for the work of labor ahead.; Often 24 – 48 hours before onset of labor
3.
Increased Braxton Hicks Contraction
4.
Ripening of the cervix Seen only on pelvic exam Sign”). At term, cervix Cervix feels softer than normal, similar to the consistency of earlobe (“Goodel’s Sign”). becomes still softer (“butter soft”) and it tips forward. Internal announcement that labor is very close at hand
DIFFERENCE BETWEEN TRUE LABOR AND FALSE LABOR CONTRACTIONS True Contractions False Contractions Begin irregularly but become regular and predictable predictable Begin and remain irregular Doesn’t increase in duration, frequency, or intensity Increase in duration, frequency, and intensity Pain: Felt first in lower back and radiates to Pain: Felt first abdominally and remained confined abdomen on abdomen and groin Often disappear with ambulation and sleep Continue no matter what the woman’s activity Pain: intensified by walking Pain: relieved by walking Achieve Cervical Dilatation and Effacement Doesn’t achieve cervical dilatation and effacement *Major Sign of True Labor* Bloody Show – mucus plug that filled the cervical canal during pregnancy (operculum) is expelled. Effacement – Effacement – softening and thinning of the cervix; use % in the unit of measurement. Dilatation – enlargement or widening of cervix (approximately 10 cm to permit passage of a fetus) Rupture of the Membranes – labor may begin with rupture of the membranes. Early rupture can be advantageous if it causes the fetal head to settle into pelvis which can shorten labor .
2 Risks Associated with Ruptured Membranes 1. Intrauterine Infection 2. Prolapse of the Umbilical Cord which can cut the oxygen supply to f etus
1. 2. 3. 4. 5. 6. 7. 8.
Emergency Signs Unconscious and Convulsion Looks very ill Fever Vaginal Bleeding Severe Abdominal Pain Severe headache with disturbed vision Severe DOB Severe Vomiting
Components of Labo r or 4 p’s 1.
Powers: Uterine Contractions The forces acting to expel the fetus a. Effacement and Dilatation b. Pushing effort of mother during the s econd stage of labor (Birth Stage)
2.
Passage Route a fetus must travel from uterus through cervix and vagina to the external perineum. For a fetus to pass through the pelvis, the pelvis must be in adequate size. Two pelvic measurements to determine adequacy of the pelvic size. a. Diagonal conjugate (the anterior – posterior diameter of the inlet) b. Transverse diameter of the outlet
3.
Passenger Refers to the fetus, membranes, and placenta. The body part of the fetus that has the widest diameter is the HEAD, so this is the part that is least likely to pass pelvic ring.
Structure of the Fetal Skull 4 Superior Bones important in childbirth 1 Frontal (actually 2 fused bones) 2 Parietal 1 Occipital Sutures Where bones of the skull meet; separating lines of the skull Allow cranial nerves to move and overlap, molding or diminishing the size of the skull so it can pass thru birth canal. a. Sagittal – joins 2 parietal bones b. Coronal – line of the juncture of frontal bon es and parietal bones c. Lambdoid – line of the juncture of occipital bone and parietal bones
FONTANELS – spaces or openings where skull bones join; found at the junction of main suture lines. a. Anterior Fontanel (BREGMA) Location: junction of 2 parietal bones and 2 fused frontal bones sagittal sutures Location: junction of coronal and sagittal
b.
Shape: Diamond 2 – 3 cm in width (transverse diameter) and 3 – 4 cm in length (anteroposterior diameter) Normally closes at 12 – 18 months of age.
Posterior Fontanel (LAMBDA) Location: junction of parietal bones and occipital bone Location: junction of lambdoid and sagittal sutures Shape: Triangular Anterior Fontanel Measurement: 1 – 2 cm in length; smaller than Anterior Cannot be palpated readily because it is so small Closes by 2 – 3 months
Diameters of the Fetal Skull The narrowest diameter (9.5cm) is from the inferior aspect of occiput to the center of Anterior Fontanel (SUBOCCIPITOBREGMATIC DIAMETER). The occipitobregmatic diameter is measured from the bridge of nose to occipital prominence (12 cm) the occipitomental diameter, which is the widest anteroposterior diameter (13.5cm) is measured from chin to posterior fontanelle. Molding Change in shape of the fetal skull produced by the force of uterine contractions pressing the vertex of the head against the non –yet dilated cervix. Commonly seen after birth. Attitude Posture of fetus or degree of flexion a fetus assumes during labor or the relation of fetal parts to each other. a. Vertex (Attitude: Good or Full flexion) Fetal back rounded, head is forward on the chest, arms and legs are folded in against the body. Most common presentation; allows suboccipitobregmatic diameter to present to cervix. b.
Sinciput (Attitude: Moderate flexion; Military) Fetal head is moderately flexed Brow or sinciput is the presenting part.
c.
Brow (Attitude: Partial Extension) Extension )
d.
Face (Attitude: Poor Flexion, Complete Extension) Face is the presenting part Extreme edema and distortion of face may occur. Presenting part (Occipitomental) is so wide that birth is IMPOSSIBLE.
e.
Memtum (Attitude: Very Poor Flexion) Fetus completely hyperextended the head to present the chin Occipitomental is the presenting part.
Station Relationship between the presenting part and the ischial spine Landmark used is ISCHIAL SPINE
High or Floating (-4) – presenting part is not engaged Station (-) – presenting part is above ischial spine (-1) – presenting part 1cm above ischial spine
(-2, - 3) – presenting part 2 – 3 cm above ischial spine Station 0 – presenting part is at the level of ischial spines; ENGAGED (settling of the presenting part into the pelvis at the level of ischial spines.) Station (+) – presenting part below ischial spine (+1 station) – 1cm below ischial spine (+3, +4) – presenting part @ perenium; crowning occurs @ second stage of labor. Lie
Relationship between the long axis of the fetal body and long axis of the mother’s body Relationship between the spine of the fetus to th e spine of the mother a. Longtitudinal or Vertical Fetal spine parallel to the mother’s spine Fetus is in cephalic presentation. (head first) b. Transverse c. Oblique
Presentation Portion of the fetus that enters the pelvic inlet first. a. Cephalic Presentation (CIL) Most frequent type of presentation. Head is the body part that will first contact the cervix. *Vertex, Sinciput, Brow, Face, Memtum
b.
Breech Presentation Either buttocks or feet are the first body parts that will contact the c ervix. Complete Breech – thighs slightly flexed on abdomen; both buttocks and tightly flexed feet present to cervix Frank – moderate attitude b/c hips are flexed but knees are extended to rest on the chest. Buttocks alone are present in cervix Footling – neither thigh nor lower legs are flexed; Single footling (1 foot) and Double Footling (both present)
c.
Transverse or Shoulder Presentation
Position Relationship of the presenting part to a specific quadrant of a woman’s pelvis. LOA (Left Occipitoanterior ) – most frequent fetal position ROA (Right Occipitoanterior) – the second most frequent fetal position 4.
Psyche A woman’s emotional system that can determine her total response to labor and influence both physiological and psychological functioning Mother may experience anxiety or fear
STAGES OF LABOR First Stage (Dilatation and Effacement Stage) 1.
Phase 1 - Latent Phase Onset of true uterine contractions and ends when rapid cervical dilatation begins Mother feels excited but anxious or worried and can communicate. Phase lasts approximately 6 hours for nullipara and 4.5 hours for multipara A woman who enters labor with a non ripe cervix will have a longer latent phase. Another reason is Cephalopelvic Disproportion (disproportion between fetal head and pelvis) Assessment Dilatation: 0 – 3 cm Duration / Interval: 20 – 40 secs, 5 – 30 min Intensity: Mild to Moderate Nursing Interventions (What to Do) 1. Check every hour for emergency signs, frequency and duration of contractions and fetal heart rate 2. Check every 4 hours for Blood Pressure, Pulse Rate, Cervical Dilatation, and Fever. 3. Encourage walking to shorten the 1 st stage of labor 4. Encourage to void every 2 – 3 hours because full bladder inhibit uterine contractions 5. Encourage to drink but not to eat heavy meal for it may interfere surgery (light meal is considered) 6. Breathing technique What not to do: Don’t do vaginal exam more frequently than every 4 hours.
2.
Phase 2 - Active Phase (In Labor Room) Spontaneous rupture of membranes may occur at this time Phase lasts approximately 3 hours in nullipara and 2 hours in multipara Difficult for a woman because contractions go stronger, last longer, and begin to cause true discomfort Assessment: Dilatation: occurs more rapidly from 4 – 7 cm Duration/Interval: 40 – 60 secs, 3 – 5 mins. Intensity: Moderate to Strong Nursing Interventions: 1. May position position woman left lateral (to facilitate breathing) 2. Check every 30 minutes for emergency signs 3. Checky every 4 hours for Blood Pressure, Pulse Rate, Cervical Dilatation, and Fever. 4. Record time of ruptured membranes and Note the color of amniotic fluid. 5. Record findings in Partograph or Patients Record 6. Teach abdominal breathing 7. Dampen lips to prevent dryness / O ral Care for Dry Lips (Ointment) 8. May sip water 9. Linens should be dry, if wet, change the linen What not to do: 1. Don’t allow woman to push unless delivery is coming up (imminent). It will just exhaust her. 2. Don’t give any medications that would speed up labor for it may cause trauma to mother and baby.
3.
Phase 3 - Transition Phase Mood suddenly change accompanied by Hyperesthesia (hypersensitivity to touch, pain all over) Woman feels a loss of control, panic, and irritability. Assessment: Dilatation: 8 – 10 cm Duration / Interval: 60 – 90 secs, 2 – 3 mins Intensity: Strong (contractions reach their peak of intensity) *If duration is more than 90 secs inform MD ASAP; Fetal Distress may be present.* *Stop oxytocin if Heart Rate of Baby is not good* Nursing Interventions 1. Check every 30 minutes for emergency signs 2. Checky every 4 hours for Blood Pressure, Pulse Rate, Cervical Dilatation, and Fever. 3. Record time of ruptured membranes 4. Note the color of amniotic fluid because meconium stained fluid indicates fetal distress 5. Assess fetal station, presentation, and position by Leopolds Maneuver 6. Record findings in Partograph or Patients Record 7. Inform of progress (best way to give emotional support to the mother) 8. Abdominal Breathing (chest breathing) SECOND STAGE OF LABOR (FETAL STAGE / BIRTH STAGE) Period from full dilatation & cervical effacement to birth of the infant Woman may experience nausea or vomiting b/c pressure is no longer exerted on her stomach a s the fetus descends in the pelvis. She pushes with force that she perspires and blood vessels in her neck become distended. As the fetal head touches the internal side of the perineum, perineum bulges (sure to come out) and appears tensed; CROWNING occurs 1.
2.
3.
Phase 1 Station: 0 to +2 Contraction: 2 – 3 minutes apart. Phase 2 Station: +2 to +4 Contraction: 2 to 2.5 minutes. Apart with urgency to be ar down Phase 3 Station: +4 to birth Contraction: to 2 minutes apart; fetal head visible increased (crowning)
Nursing Intervention: 1. Position Woman in Lithotomy (supine with legs flexed supported on stirrups) 2. Teach Panting Technique (2 short breaths followed by 1 long breath) 3. Assist in Episiotomy 4. Ritgens Maneuver (PS) - support perineum to prevent laceration 5. Once the head is out, support the head 6. Note the time of delivery and gender of the baby 7. Latching: Place baby on the abdomen in prone position (for bonding and the weight of the baby facilitates contraction of the uterus) 8. Check 2Arteries and 1Vein on the cord. 9. Wait for the pulsation to stop before clamping since 60 – 100 cc of blood will be going to the baby. Do not breastfeed the baby the cord is not y et clamped. 10. Clamp the cord
MECHANISMS OF LABOR OR CARDINAL MOVEMENTS * Engagement – Engagement – bi-parietal diameter of fetal head passes pelvic inlet 1. Descend – Downward movement of the bi- parietal diameter of fetal head within the pelvic inlet fetal presenting part through the true p elvis) 2. Flexion – fetal head reaches pelvic floor, head bends forward onto the chest. 3. Internal Rotation – fetus & skull rotates along axis from transverse to antero posterior & pelvic outlet. 4. Extension (Restitution) – internal rotation complete; fetal head passes under symphysis pubis & is delivered 5. External Rotation (Shoulder Rotation) – allow shoulders to rotate internally to fit the p elvis. 6. Expulsion – entire body of baby emerged from the mother; birth is complete
Episiotomy surgical incision of perineum in order to prevent laceration, widen vaginal canal and shorten second stage of labor a. Mediolateral Episiotomy Incision beginning to the midline but directed laterally away from the rectum. Advantage: less danger of complication from rectal mucosal tear b. Midline Episiotomy Incision on the midline of perineum Advantages: easy to repair, fast healing, less blood loss, less postpartum discomfort Disadvantages: incision may extend to anus that leads to urethroanal fistula. 1st degree – fourchette and perineal skin 2nd degree – muscle 3rd degree – external sphincter of rectum 4th degree – inner portion of rectum Nursing Interventions: Interventions: 1. Check episiotomy site 2. Institute measures to relieve pain 3. Provide ice packs during 1 st 24 hours 4. Instruct client to use sitz bath 5. Provide perineal care using clean technique 6. Instruct client in proper care of incision 7. Instruct client to dry perineal area from front to back and to blot area than to wipe it. 8. Instruct client to shower rather than bath in a tub 9. Apply perineal pad not touching the inside surface of pad 10. Report any bleeding and discharge to Physician. THIRD STAGE OF LABOR: PLACENTAL STAGE Begins with the birth of infant and ends with the delivery of the placenta
1.
Placental Separation Calkins Sign: Initial Sign; Fundus Rises – becomes firm and globular (if not, uterine atony) Lengthening of the cord Sudden gush of blood
2.
Placental Expulsion Placental Delivery: May take 5 – 10 minutes and a maximum of 20 minutes. (if hindi lumabas, placental extraction or manual removing of placenta) Crede’s Maneuver – gentle pressure on the contracted uterine fundus; Pressure must NEVER be applied to a non contracted uterus to avoid the uterus to ev ert and lead to hemorrhage.
Abnormalities: 1. Placenta Acreta – attached to uterine surface 2. Placenta Rucreta – goes inside uterus 3. Placenta Percura – goes into other organs Type of Placenta 1. Schultze (fetal membrane surface) shiny and glistening placenta separates at its center and lastly as its edges, tends to fold on itself like an u mbrella and presents at the vaginal opening with fetal surface evident Placenta complete with 30 cotyledons. 2.
Duncan (the irregular maternal surface) dirty presentation of the uterus; looks raw and red and irregular placenta separates first at its edges, It slides along the uterine surface and presents at the vagina with maternal surface evident Cotyledons can’t be counted
Brandt Andrews Maneuver Pushing uterus or fundus upwards while gently pulling the cord downward to deliver separated placenta.
Normal Blood Loss: Loss : 300 – 500 ml Nursing Interventions: 1. Check completeness of Placenta and its membranes (Cotyledons 30) 2. Check fundus (if relaxed, fundal massage) 3. Check Blood Pressure (Administer Methergine IM as ordered. Check BP before administration) a dministration) 4. Monitor Hypertension (or give Oxytocin IV) 5. Check perineum for lacerations 6. Assist in Episiorraphy (repair of an incision done), vaginal pack should be us ed for 48 hours to prevent puerperal sepsis 7. In Recovery Room, woman should be FLAT ON BED to prevent dizziness d/t abdominal pressure. 8. If chilling occurs due to dehydration, just give additional blanket 9. Diet (Chronological) a. Give clear liquid b. once regulated, can be given full liquid such as milk, ice cream, soup c. soft diet d. regular diet 10. Let mother sleep to regain energy Not to do: Don’t squeeze or massage abdomen to deliver the placenta. RECOVERY STAGE (STAGE 4) First one to two hours after delivery or until stable a. Maternal Observations – body system stabilizes; check V/S every 15 minutes for the 1 st hour and every 30 minutes for the 2 nd hour. b.
Placement of the Fundus – should be just above the umbilicus or level of umbilicus. If palpated on the right side it means full bladder (therefore empty the bladder) If fundus is above umbilicus (deviation of fundus) 1. Empty bladder to prevent uterine atony 2. Check lochia
c.
d.
e.
Lochia - “bleeding, vaginal discharge after delivery Lochia Rubra – 1-3 days / red Lochia Serosa – 4-10 days/ pinkish to brown / decrease in amount, with musty odor Lochia Alba – 11th day – 3 weeks / whitish onwards Check Perineum (REEDA) Redness Edema Ecchymosis Discharges Approximation of Blood Loss (Count the pad and saturation) Fully Soaked pad: 30 – 40 ml weigh pad 1 gram = 1 ml Bonding Strict Rooming In – 24 hours Baby stays with mother to promote b reastfeeding for adequate nutrition and bonding between mother and child. (R.A 7600 and MILK CODE EO 51)
Inform the ff: 1. Newborn Screening within 48 hours – 2 weeks after birth 2. Importance of Breast Feeding 3. Birth Registration 4. Schedule for Post Partum Visits a. 1st Visit – Visit – 3 – 5 days post partum b. 2nd Visit – Visit – 6 weeks post partum
