Labor and Delivery

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LABOR & DELIVERY  Also known as Parturition, childbirth, birthing  Is the process by which the fetus & placenta are expelled from the uterus and the vagina into the external environment.  A parturient is a woman in labor.  Toco- and toko- (Gr.) are combining forms meaning childbirth.  Eutocia – normal labor  Dystocia – difficult labor The trigger that converts the random,painless Braxton – Hicks contractions 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 Several Theories have been proposed to explain why labor begins. These include: 1.) uterine stretch theory ( any hallow organ stretched, will always contract & expel its content) – contraction action (when the organ is full, it will empty.) 2.) oxytocin theory – post pit gland releases oxytocin that initiates labor. Hypothalamus produces oxytocin 3.) prostaglandin theory – stimulation of arachidonic acid – prostaglandin- contraction (from early pregnancy, a precursor from the fetal adrenal glands is conjugated in the placenta into estrogen. As estrogen reaches a high level, glycerophospholipid (A1 prostaglandin )precursors are laid down. At the point when estrogen becomes dominant, phospholipase A2 converts prostaglandin precursors into prostaglandin.Prostaglandin stimulate the myometrium) 4.) progesterone theory – before labor, decrease progesterone will stimulate contractions & labor

(when the level of progesterone (which has a relaxing effect on the uterus) decreases, the myometrium becomes sensitive to oxytocin, possibly by blocking calcium sequestration in the muscle fiber) 5.) theory of aging placenta – (By 260 days, the placenta began to age.)life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor).

Other factors that stimulate the release of phospholipase A2 are: • Damage to fetal membranes • Stretching of the uterus • Decreased uterine blood flow • Heavy smoking • Abruptio placenta • Stressed fetus  Prostaglandin inhibitors,(such as Aspirin) may delay labor Factors affecting Labor & Delivery: (5 P’s) Passanger,Passageway,Power,Placenta,Psych Passenger: The passage of the fetus through the birth canal is influenced by: -Size of the fetal head & shoulder -Dimensions of the pelvic girdle -Fetal presentation -Fetal position Fetal head – is the largest presenting part – common presenting part – ¼ of its length. Bones – 6 bones S – sphenoid E – ethmoid

F – frontal - sinciput

O – occuputal - occiput

2 T – temporal P – parietal 2 x

Measurement fetal head: 1. transverse diameter – 9.25cm - biparietal – largest transverse - bitemporal 8 cm 2. bimastoid 7cm smallest transverse Sutures – intermembranous spaces that allow molding. 1.) sagittal suture – connects 2 parietal bones ( sagitna) 2.) coronal suture – connect parietal & frontal bone (crown) 3.) lambdoidal suture – connects occipital & parietal bone Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis Fontanels: Anterior fontanel – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18 months after birth- close Posterior fontanel or lambda(vertex) – triangular shape, 1 x 1 cm. Closes – 2 – 3 months Anteroposterior diameter suboccipitobregmatic 9.5 cm, complete flexion, smallest AP occipitofrontal 12cm partial flexion occipitomental – 13.5 cm hyper extension submentobragmatic-face presentation Fetal LIE 

This is the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother.

 If the two are parallel, then the fetus is said to be in a longitudinal lie.

3  If the two are at 90-degree angles to each other, the fetus is said to be in a transverse lie. 

Nearly all (99.5%) fetuses are in a longitudinal lie.

Fetal presentation Two types: b.1. Longitudinal Lie ( Parallel) cephalic -

Vertex – complete flexion Face Brow

Poor Flexion

Chin Breech -

Complete Breech – thigh breast on abdomen, breast lie on thigh Incomplete Breech – thigh rest on abdominal Frank – legs extend to head Footling – single, double Kneeling

b.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation.

 Is the portion of the fetus that enters the pelvis first and covers the internal os of the cervix, such as: 

Cephalic (head)  Vertex  Brow  Face



Breech  Sacrum (frank) – legs are extended  Foot (footling or incomplete) – may be single or double

4  Sacrum and feet (full or complete) – the baby is in squatting position 

Shoulder or acromion, iliac crest, hand or elbow in transverse lie

If your baby is breech, his bottom is the part of his body closest to the birth canal. No one is sure what causes a breech presentation, but it happens in 3% to 5% of single-baby deliveries.

Fetal Attitude 

Is the relationship of the fetal parts to one another.



universal flexion or general flexion

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The back is markedly flexed, head is flexed on the chin, thighs are flexed on the abdomen, legs are flexed at the knee joints.

Fetal Position  Position is the relationship of the fetal reference point (occiput,mentum,sacrum or acromion process) to one of the four quadrants of the mother’s pelvis. The quadrants are formed by drawing an imaginary line from the mother’s sacral promontory to the upper edge of the

5 symphysis pubis and bisecting it transversely by a line from one side to the other, forming the right anterior and posterior quadrants and the left anterior and posterior quadrants.  Six positions are usually defined for each presentation except the shoulder presentation. Vertex

Face -

Breech

Occiput -mentum -sacrum

Shoulder -acromion

LOA

LMA

LSA

LAA

LOP

LMT

LST

LAP

LOT

LMP

LSP

RAA

ROA

RMA

RSA

RAP

ROP

RMT

RST

ROT

RMP

RSP

Station 

Refers to the relationship of the presenting part to the level of the ischial spines.



When the presenting part is at the level of the ischial spines, it is at station 0 (synonymous with engagement).



If the presenting part is above the spines, the distance measured and described as station -1 or so if it is 1 cm or so above the ischial spines;



Station +1 or so if it is 1 cm below the ischial spines.



At -4 station, head is “floating”

 At +4 station, head is “at outlet”. (crowning)

Passageway o

 Mom

The soft tissues of the passage include: 

Lower uterine segment



Cervix



Vaginal canal

Pelvis 1.) < 4’9” tall 2.) < 18 years old

6 3.) Underwent pelvic dislocation Pelvis 4 main pelvic types 1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy 2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow 3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow 4. Platypelloid – flat AP diameter – narrow, transverse – wider b. Pelvis 2 hip bones – 2 innominate bones 3 Parts of 2 Innominate Bones Ileum – lateral side of hips - iliac crest – flaring superior border forming prominence of hips Ischium – inferior portion - ischial tuberosity where we sit – landmark to get external measurement of

pelvis

Pubes – ant portion – symphisis pubis junction between 2 pubis 1 sacrum – post portion – sacral prominence – landmark to get internal measurement of pelvis 1 coccyx – 5 small bones compresses during vaginal delivery

Important Measurements 1. Diagonal Conjugate – measure between sacral promontory

and inferior margin of the symphysis pubis. Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC – 11.5 cm=true conjugate 2. True conjugate/conjugate vera – measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm 3. Obstetrical conjugate – smallest AP diameter. Pelvis at 10 cm or more. 4. Tuberoischi Diameter – transverse diameter of the pelvic outlet. Ischial tuberosity – approximated with use of fist – 8 cm & above.

Power – the force acting to expel the fetus and placenta – myometrium – powers of labor a. Involuntary Contractions (Primary forces: is the uterine contraction → complete effacement and dilation of the cervix. ) b. Voluntary bearing down efforts (Secondary forces: use of abdominal muscles to push during the 2nd stage of labor. Pushing force adds to the primary force after the cervix is fully dilated.) c. Characteristics: wave like d. Timing: frequency, duration, intensity

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Parts of contractions: Increment or crescendo – beginning of contractions until it increases Acme or apex – height of contraction Decrement or decrescendo – from height of contractions until it decreases Duration – beginning of contractions to end of same contraction Interval – end of 1 contraction to beginning of next contraction Frequency – beginning of 1 contraction to beginning of next contraction Intensity - strength of contraction

Best time to get BP & FHT just after a contraction or midway of contractions Placental reserve – 60 sec o2 for fetus during contractions Duration of contractions shouldn’t >60 sec Notify MD Mom has headache – check BP, if same BP, let mom rest. If BP increase , notify MD -preeclampsia

Difference Between True Labor and False Labor False Labor

True Labor

Irregular contractions

Contractions are regular

No increase in intensity

Increased intensity

Pain – confined to abdomen

Pain – begins lower back radiates to abdomen

Pain – relived by walking No cervical changes

Pain – intensified by walking Cervical effacement & dilatation * major sx of true labor.

TRUE SIGNS OF LABOR •

UTERINE CONTRACTION -

•

SHOW

the surest sign that the labor has begun

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•

the mucus plug that filled the cervical canal during pregnancy is expelled. The exposed cervical capillaries seep blood as s result of pressure exerted by the fetus. The blood, mixed with mucus

RUPTURE OF MEMBRANE -

sudden gush of fluid from the vagina.

-

actually there is no dry labor because even the amniotic membrane has ruptured.

Duration of Labor Primipara – 14 hrs & not more than 20 hrs Multipara – 8 hrs & not > 14 hrs Effacement – softening & thinning of cervix. Use % in unit of measurement Dilation – widening of cervix. Unit used is cm.

Assessing Uterine Contractions •

Uterine contractions exhibit a wavelike pattern: it begins with a slow increment, gradually reaches an acme, and then diminishes rather rapidly (decrement). Next there is an interval of rest until the next contraction begins.

3 methods of assessing uterine contractions: • Subjective description given by the woman • Palpation and timing by the nurse or physician – the fingertips are used; more accurate than the first method since the tensing of the uterus may be felt by palpation about 5 seconds before the woman is able to feel the contraction • Use of electronic monitoring devices that measure the frequency and duration of contractions. Placenta

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The placenta may impede labor when implantation took place in the lower uterine segment.

The placenta may cover part or all of the internal cervical os. This is known as placenta previa Signs of placental separation 1.Fundus rises – becomes firm & globular “ Calkins sign” 2.Lengthening of the cord 3.Sudden gush of blood Types of placental delivery 1.Shultz e “shiny” – begins to separate from center to edges presenting the fetal side shiny 2.Duncan “dirty” – begin to separate form edges to center presenting natural side – beefy red or dirty Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER Hurrying of placental delivery will lead to inversion of uterus. Psyche - Women who are relaxed, knowledgeable, and capable of actively participating in the control of the birth process usually experience shorter, less intense labors. Cultural Assessment o Address and honor values and beliefs of laboring woman o Nurses more effective when aware of  Cultural beliefs of specific group  Recognition that individual difference may have impact on laboring mother o Challenging for nurses to achieve balance between cultural awareness and risk of stereotyping Psychosocial Assessment

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 Laboring client has previous ideas, knowledge, and fears about childbearing - using assessment techniques, nurse can meet laboring client's needs for information and support  Support system o Father or support person - what are their caretaking activities, such as soothing conversation and touching? o Does relationship involve interactions? Is support person in close proximity?  Need to consider possibility that woman has experienced domestic violence - use ACOG(1998) guidelines when interviewing and interview alone o Has anyone close to you ever threatened to harm you? o Have you ever been hit, kicked, slapped, or choked. If yes, by whom? What is the total number of times? o Has anyone, including your partner, ever forced you to have sex? o Are you afraid of your partner or anyone else?  Anxiety o Observe for rapid breathing, nervous tremors, frowning, grimacing, clenching of teeth, thrashing, crying, and increase pulse and respiration o Provide support, information, and encourage client o Teach relaxation and breathing techniques o May need to provide a paper bag if client's lips are tingling (hyperventilating) STAGES OF LABOR & DELIVERY: I. First Stage of Labor (onset of true contractions to full dilation and effacement of cervix) - Begins from the onset of regular contractions to full dilatation of the cervix. The first stage is much longer than the 2nd & 3rd stages combined, averaging about 12 hours for primis and about 6 hours for multis. Phases of Labor: Latent Phase: Assessment:  Dilations: 0 – 3 cm  Mom – excited, apprehensive, can communicate  Frequency: every 5 – 10 min  Intensity mild Nursing Care:  Encourage walking - shorten 1st stage of labor  Encourage to void q 2 – 3 hrs – full bladder inhibit contractions  Breathing – chest breathing Active Phase: Assessment:  Dilations 4 -8 cm  Mom- fears losing control of self  Frequency: q 3-5 min lasting for 30 – 60 seconds  Intensity: moderate Nursing Care:  M – edications – have meds read  A – ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc  D – dry lips – oral care (ointment)

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o dry linens  B – abdominal breathing Transitional Phase: Assessment:  Dilations: 8 – 10 cm  Frequency: q 2-3 min contractions  Durations: 45 – 90 seconds  Intensity: strong  Mom – mood changes with hyperesthesia Hyperesthesia – increase sensitivity to touch, pain all over  Health Teaching : teach: sacral pressure on lower back to inhibit transmission of pain o keep informed of progress o controlled chest breathing Nursing Care:  T – ires  I – nform of progress  R – estless support her breathing technique  E – ncourage and praise  D – iscomfort Effacement – softening & thinning of cervix. Use % in unit of measurement Dilation – widening of cervix. Unit used is cm.

II. Second Stage of Labor (fetal stage, complete dilation and effacement to birth) – from full dilatation and effacement to delivery. The average duration for primi is 1 hour and for multis, about 20 minutes.  7 – 8 multi – bring to delivery room  10cm primi – bring to delivery room  Lithotomy pos – put legs same time up  Bulging of perineum – sure to come out  Breathing – panting ( teach mom)  PANTING- rapid and shallow Episiotomy – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum ( urethroanal fistula) Mediolateral – more bleeding & pain, hard to repair, slow to heal -use local or pudendal anesthesia. Ironing the perineum – to prevent laceration Modified Ritgens maneuver – place towel at perineum 1.)To prevent laceration 2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled. Pull shoulder down & up. Check time, identification of baby.

Mechanisms of Labor:

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Engagement – Biparietal Diameter of the baby reaches the ischial spines Descent – Presenting part progresses through pelvis; level os station Flexion – Descending head meets pelvic floor; chin is brought down Internal Rotation – Fetal head rotates from transverse to facilitate movement through pelvis. Extension – Once fetal head reaches perineum, it extends to be born. Restitution – After the delivery of head, it rotates back to position prior to engagement. External Rotation – shoulder engage and move similarly to head. Expulsion – entire infant emerges from mother II. Third Stage of Labor or Placental stage (Birth to expulsion of placenta) - Lasts from the delivery of the fetus to the delivery of the placenta.  Placenta has 15 – 28 cotyledons  Placenta delivered from 3-10 minutes a. Placental Seperation- because the uterus contracts and the placenta cannot so it buckles &

seperates  Signs of Placental Seperation  Globular and firmer uterus  Lengthening of umbilical cord by about 3 inches out of the vagina  Sudden gush of blood * Normal blood loss because of placental seperation is 300-500 ml b. Placental Expulsion Actual expulsion of the placenta happens either because of the mother’s bearing-down efforts or through gentle pressure on the fundus of a contracted uterus (Crede’s maneuver). Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER Hurrying of placental delivery will lead to inversion of uterus. CREDE’S MANEUVER – putting pressure to the uterus to fasten the expulsion of placenta.  PRESSURE MUST NEVER BE APPLIED ON A NON-CONTRACTED UTERUS as the

uterus may evert and hemorrhage.  If the placenta does not deliver spontaneously, it can be removed manually Fourth Stage: the first 1-2 hours after delivery of placenta – The 1-2 hours after delivery of placenta (recovery stage)  Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.  Check placement of fundus at level of umbilicus.  If fundus above umbilicus, deviation of fundus  Empty bladder to prevent uterine atony  Check lochia STAGES OF RECOVERY  Maternal Observations – body system stabilizes  Placement of the Fundus  Lochia  Perineum R - redness E- edema E-cchemosis D–discharges A – approximation of blood loss. Count pad & saturation Fully soaked pad : 30 – 40 cc weigh pad. 1gram=1cc  Bonding – interaction between mother and newborn – rooming in types  Straight rooming in baby: 24hrs with mom.  Partial rooming in: baby in morning , at night nursery

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NURSING CARE DURING LABOR ASSESSMENT: First Stage of Labor Premonitory Signs of Labor 1. Lightening – primis – 10-14 days before labor; multis: with onset of labor 2. Braxton-Hick’s contractions increase and may become annoying --à sleeplessness 3. 2 to 3 lb weight loss may occur 3 to 4 days before labor 4. Increased vaginal mucus discharge 5. Spurt of energy may occur 1-2 days before labor – allows the woman to make final preparations for delivery Initial Assessment should answer the following questions  Is she in labor?  How far has she progressed?  Have the membranes ruptured?  Are there complications that may require treatment?  What is her psychologic response to the beginning of labor? Check vital signs.  If BP is elevated, repeat procedure 30 minutes later to obtain a true reading when the woman is relaxed.  BP should be checked at least every hour btwn contractions. BP may rise 5 to 10 mmHg during a contraction.  Cardiac output is increased due to:  Uterine contraction causes the shift of about 300-500 ml of blood to the central blood volume ---» inc. BP  Anxiety and pain ---» stress response ---» inc. BP  TPR monitoring is done q 4 hours, or more frequently if indicated  Temperature & respiration should be normal. Closer observation is needed when the membranes have ruptured and in the presence of fetal tachycardia.  Pulse rarely exceeds 100 /minute. A persistent pulse of over 100 is suggestive of exhaustion or dehydration.  Check for edema of the legs, face, hands or sacrum  Obtain a specimen of urine for routine urinalysis to check for presence of protein, glucose or acetone  Inquire regarding symptoms of infection (diarrhea, cold, cough, sore throat)  Recheck for allergies  Check the woman’s dietary intake for the last 4 hours.  Perform Leopold’s to determine the fetal presentation,lie, position and engagement  Assess FHT for rate & regularity: note the area of maximal intensity. Methods of determining the degree of fetal distress throughout labor  Assessment of the rate & rhythm of the fetal heart. • Fetoscope monitoring • Electronic FHR monitoring o External monitoring o Internal monitoring o Telemetry  Fetal Blood Sampling  NonStress test  Contraction Stress Test ABNORMAL FHR PATTERNS

13  Tachycardia – fetal distress  Bradycardia – fetal hypoxia

 Late Deceleration • Decelerations that are delayed until 30-40 seconds after the onset of contraction and continues beyond the end of contraction; • Suggests uteroplacental insufficiency or decreased blood flow through the intervillous spaces of the uterus during contractions, as in marked hypotonia or abnormal uterine tonus caused by oxytocin administration. Management: o slow rate of administration of oxytocin or stop it o Change woman’s position from supine to lateral o Administer IV fluids or oxygen to woman  Variable pattern • Indicates compression of the cord Mgt: o Change position from supine to lateral or Trendelenburg o Administer O2 to woman o CS delivery  Sinusoidal pattern • FHR pattern resembles a frequently undulating wave; fetus is severely anemic or hypoxic Symptoms of the 2nd stage of Labor o The woman begins to bear down of her own accord o The woman’s increasing apprehension,irritability & unwillingness to be touched o Sudden increase in show o Woman thinks she needs to defecate o Membranes may rupture o Woman may say she wants to be “put to sleep” or have a CS o Perineum begins to bulge SPECIAL CONSIDERATIONS : ASEPSIS & ANTISEPSIS o Personnel should wear caps, masks; those who will participate in the delivery should be in sterile attire. o People with communicable disease (upper respiratory infection, open skin lesions, diarrhea) should not be allowed into the delivery room o Only sterile instruments should be used. AMNIOTOMY o Artificial rupturing of the membranes. It allows the fetal head to contact the cervix ---»more efficient contractions. o This may be done with a hemostat. Take FHR after (danger: escape of loop cord with fluid). OTHER NURSING MEASURES Coach the woman on bearing down efforts. o Short pushes of no longer than 6-7 seconds o Physiological pushing: pushing only with the urge to push (3-5 times with each contraction) and resting in between o Pushing with an open glottis and slight exhalation o (Valsalva maneuver impedes return flow of blood to the heart because of increased intrathoracic pressure) o Positioning – lithotomy, lateral sims, dorsal recumbent

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o Psychosocial support o Preparation of the DR and instruments (forceps, scissors, needle, needle holder, bowl/kidney basins, sutures, sponges) Planning and Intervention: 4th Stage of Labor  After the delivery of the placenta, oxytocin (Methergin) is given IM and/or Pitocin (Syntocinon) maybe given as a drip up to 8 hours after delivery.  Suturing of the episiotomy usually requires local anesthesia, unless the woman had a pudendal block or epidural anesthesia  Assessment: o Vital signs: BP, pulse o Uterus: degree of contraction; fundal height o Lochia: amount,presence of clots o Perineum/episiotomy o Bladder/distention o Family interaction Potential Complications: Hypothermic reactions o Chilling accompanied by uncontrollable shaking; o Exact etiology: unknown; possible explanations: sudden release of intraabdominal pressure, exhaustion, disequilibrium in the internal & external body temperatures o Management:  Clean, dry warm gowns, blankets  Avoid drafts  Warm fluids po