Giving Birth (22) Debbie Amason, RN,MS Labor Labor-and involuntary physiologic process whereby the contents fo the

gravid uterus are expelled through the birth canal into the external environment Theories/factors that influence..Exact cause is unknown, but believed to be influenced by several factors: Uterine muscle stretchinguterus can no longer expand pressure on cervix---pressure drops onto cervix Stimulated by oxytocin Change in ratio of estrogen and progesterone---shift of these causes labor Decreasing function of placentaplacenta only develops to a certain point and then starts deteriorating, thus causing labor Increase in fetal cortisol *fetal membranes production of prostaglandin

Signs of labor Preliminary signs of labor: lightening, increased energy levels, Braxton Hicks contractions, cervical ripening, increased vaginal secretions,cervical softening, bloody show True-regular uterine contractions that increase in frequency, strength, and duration, and do not disappear when lying down or walking around; effacement (shortening or thinning of the cervix) and dialation of the cervix; SROM-spontaneous rupture of membranes Differentiate between true and false labor--True labor will cause the cervix to dilate & are regular, gradually increasing in intensity, false labor will not dialate cervix & may or may not be regular and do not increase Duration of labor: Primipara 14 hrs & not more than 20 hrs & Multipara 8 hrs & not > 14 hrs True Labor Contractions are regular Increased intensity Pain begins lower back radiates to abdomen Pain intensified by walking Cervical effacement & dilatation * major sx of true labor.

False Labor Irregular contractions No increase in intensity Pain confined to abdomen Pain relived by walking No cervical changes

Issues for new nurses Pain-- Most people want to relieve pain promptly, however pain is an expected part of the labor process Inexperience-- If never had a baby, basic skills, assess critical thinking, provide comfort, problems solving Unpredictability-- Own timetable Intimacy-- maintain professional behavior Physiological responses Maternal & Fetal Cardiovascular Hemapoetic Respiratory Temp. regulation Urinary Musculoskeletal GI Neuro Integumentary Components of Labor The 4 Ps passage passenger powers psyche

1. Passage
refers to pelvis & soft tissues which include: lower uterine segment, cervix, vaginal canal 2 pelvic measurements --Necessary to determine adequacy: diagonal conjugate- narrowest at inlet; transverse diameter- narrowest at outlet if disproportion occurs usually the pelvis ( If fetus presents in unusual position); could be R/t mother: being < 49 tall being < 18 years old Underwent pelvic dislocation 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

Passage of fetal head Fetal skull composed of: 8 bones--2 frontal bones fused; 2 parietal bones; 2 occipital bones; 2 temporal bones . && Where these bones meet become the Suture lines-- Sagittal- separates parietal bones; Coronalseparates frontal and parietal; lamboid- separates parietal and occipital. && These suture lines allow for overlapping of bones during delivery fontanels-- anterior (diamond shape); posterior- ( triangle) smallest diameter-- Smallest diameter is the SUBOCCIPITOBREGMATIC This area must present to pelvic inlet.---this is the part you want presenting to pelvis Engagement- presenting part that enters the pelvis reaches the level of the ischial spines Molding-- change shape of head produced by force of contractions against cervix- TEMPORARY Definitions Fetal attitude- degree of flexion the fetus assumes or relation of the fetal parts to one another: (relationship of fetal parts to one another) complete flexion moderate flexion partial flexion station- relation of presenting part to the level of the ischial spines: -4 to +4; when the presenting part is level with the ischial spines, it is at station 0 (synonymous with engagement); if it is above the spines it is -1 to -4; if it is below the spines it is +1 to +4; at -4 station the head is floating; at + 4 station the head is at outlet aka- crowning. Crowning-- Presenting part reaches the perineum; +4 station Fetal lie-- Relation of fetal long axis to long axis of the mother: Longitudinal (breech, cephalic) Transverse (shoulder) Presentations Cephalic- 95%---4 types (longitudinal lie) Vertexcomplete flexion Browpoor flexion Facepoor flexion Mentum (chin) Breech- 3%--3 types (longitudinal lie) Complete- the baby is in squatting position Franklegs are extended, sacrum presents,

2. Passenger

Footlingsingle, double; foot presents Transverse- 2% (shoulder) (horizontal lie)

Positions relation of presenting part to a specific quadrant of the maternal pelvis; Position is the relationship of the fetal reference point (occiput,mentum,sacrum or acromion process) to one of the four quadrants of the mothers pelvis. The quadrants are formed by drawing an imaginary line from the mothers sacral promontory to the upper edge of the 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. 4 parts of fetus used as landmarks vertex- occiput (o) Face- mentum (m) Breech- sacrum (sa) Shouldar- scapula (A methods used to determine Abdominal inspection and palpation vaginal exam auscultation FHTs Ultrasound labor is longer if not vertex-- R/t ineffective descent, ineffective dilation, and irregular contraction> increased fatigue, increased risk of c/s, increased risk for lacerations and decreased bonding. also places fetus at risk--r/t increased risk of CPD; increased risk for PROM> increased infection; increased anoxia

the force acting to expel the fetus and placenta myometrium powers of labor uterine contractions abdominal muscles 3 phases of a contraction contour changes Uterine rupture--If labor becomes difficult a prominent and observable abdominal indention called Bandls ring appears on the abdomen; This is a danger sign indicative of impending uterine rupture Involuntary Contractions (Primary forces: is the uterine contraction complete effacement and dilation of the cervix. ) 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.) Characteristics: wave like

3.Powers

Timing: frequency, duration, intensity Best time to get BP & FHT just after a contraction or midway of contractions Cervical changes Effacement- the gradual thinning, shortening, and drawing up of the cervix measured in percentages of 0% -100% Dilation- the gradual opening up of the cervix measured in cm from 010 cm 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; shouldnt be greater than 60 sec, notify MD Interval end of 1 contraction to beginning of next contraction Frequency beginning of 1 contraction to beginning of next contraction Intensity - strength of contraction

4.Psyche

Psyche psychological state or feelings the woman brings into labor with them those who manage best are: strong self esteem good support Women who are relaxed, knowledgeable, and capable of actively participating in the control of the birth process usually experience shorter, less intense labors. Need to assess if they have: Anxiety Domestic violence A support system Psychological Responses lead to emotional distress r/t: Pain- reduces ability to cope> quick tempered Fatigue- generally tired from carrying extra weight; dont sleep well > sleep deprivation Fear- if no classes labor looms as a big unknown. If progress rapid or slower than normal may lead to concerns for baby. Culture every woman in labor responds to cultural cues response to pain choice of nourishment position

proximity of support person customs r/t PP period differences must be addressed

Mechanisms of labor cardinal movements Descent- fetus moves into the pelvic inlet flexion- pressure from pelvic floor forces fetal head to bend forward onto chest. Internal rotation- head enters inlet in a transverse position. extension- as occiput is born, neck stops at symphysis and actsas a pivot. Head comes under pubic bone and extends up as delivered. External rotation- once head delivers, it rotates back to that transverse position for shouldars. expulsion Stages of Labor 4 stages: 1-dilation 2-delivery 3-placenta 4-recovery first 4 hours after delivery is called the 4th stage to emphasize the need for close observation.

Stage 1_________________________________________________________________ _______

divided into 3 phases: latent active transition 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.

Contractions are mild, every 5-30 mins, may last 30-45 seconds Usually first time mothers are super excited during this time

Latent Phase:

Assessment: Dilations: 0 3 cm Mom excited, apprehensive, can communicate

Frequency: every 5 10 min Intensity mild With first time mothers it may take about 6 hours, in multis it may take about 4.5

Nursing Care: Encourage walking - shorten 1st stage of labor Encourage to void q 2 full bladder inhibit contractions Breathing chest breathing Analgesia given now will slow labor

Active Phase:
Assessment: Dilations 4 -7cm Mom- fears losing control of self Frequency: q 3-5 min lasting for 40 60 seconds Intensity: moderate If given pain med it usually wont slow it down, as a matter of fact, it will often quicken; or have no effect on labor Multi is about 2 hoursprimis are about 3 hours 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) dry linens B abdominal breathing Assessment: Dilations: 8 10 cm Frequency: q 2 min contractions Durations: 60 90 seconds Intensity: strong Mom mood changes with hyperesthesia--increase sensitivity to touch, pain all over Health Teaching : teach: sacral pressure on lower back to inhibit transmission of pain; keep informed of progress; controlled chest breathing DO NOT LEAVE Nursing Care: T ires I nform of progress R estless support her breathing technique

Transitional Phase:

E ncourage and praise D iscomfort Care during Stage 1 respect contraction time promote position changes promote voiding offer support respect and promote support persons activities support pain management efforts amniotomy Assessments- Stage 1 initial interview: EDC frequency, duration of contractions any show ROM? Vital signs last oral intake allergies History Review physical and psychological events of this pregnancy Current pregnancy Past pregnancy Past health Family history Physical Exam review of systems abdominal assessment assess for ROM vaginal exam sonogram vital signs lab

Second Stage____________________________________________________________ _____

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 PANTING- rapid and shallow

Care

during Stage 2 urge to push argumentative and angry need good support stay with client FHR assessed throughout pushing efforts Prepare setting 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

Positioning Various positions available if use lithotomy position make sure you raise legs at same times to decrease strain back do not put up in stirrups until the last minute Pushing push with contraction to be effective best position is semi fowlers not to hold breath but breathe out while pushing to prevent pushing have patient pant Birth fetal head is delivered and nose and mouth are suctioned check for nuchal cord delivery time is recorded when entire body is delivered cord clamped cord blood obtained Newborn Assessment Apgar Developed by Dr. Virginia Apgar Timing Assessments Score Cord Physical defects Identification attachment

Third Stage____________________________________________________________ _______________

Definition

from delivery of fetus to delivery of placenta Placenta usually delivers spontaneously & must be inspected for intactness Oxytocin added to IVFs perineal repair signs of placental separation Globular and firmer uterus Lengthening of umbilical cord by about 3 inches out of the vagina Sudden gush of blood Placental expulsion--Actual expulsion of the placenta happens either because of the mothers bearing-down efforts or through gentle pressure on the fundus of a contracted uterus (Credes maneuver). Slowly pull cord and wind to clamp BRANDT ANDREWS MANEUVER Hurrying of placental delivery will lead to inversion of uterus. If the placenta does not deliver spontaneously, it can be removed manually

Stage 4_________________________________________________________________ ________________

immediate postpartum time 1-4 hours after delivery Assessments q 15 minutes for first hour clean perineum & assess: R redness E edema E ecchymosis D discharge A approximation (of blood loss) offer clean gown shaking- normal response Bonding

Danger signs- Fetal tachycardia bradycardia decelerations meconium staining hyperactivity acidosis Danger signs- maternal change in BP abnormal HR abnormal contractions pathological retraction ring abnormal lower abdominal contour

increased apprehension

Report immediately decrease in BP tachycardia uterine atony excessive bleeding temperature above 100.4 ASSESSMENT: First Stage of Labor Premonitory Signs of Labor Lightening primis 10-14 days before labor; multis: with onset of labor Braxton-Hicks contractions increase and may become annoying -- sleeplessness 2 to 3 lb weight loss may occur 3 to 4 days before labor Increased vaginal mucus discharge 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 womans dietary intake for the last 4 hours. Perform Leopolds 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 External monitoring Internal monitoring Telemetry Fetal Blood Sampling NonStress test Contraction Stress Test ABNORMAL FHR PATTERNS 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: slow rate of administration of oxytocin or stop it Change womans position from supine to lateral Administer IV fluids or oxygen to woman

Variable pattern Indicates compression of the cord Mgt:

Change position from supine to lateral or Trendelenburg Administer O2 to woman

Sinusoidal pattern FHR pattern resembles a frequently undulating wave; fetus is severely anemic or hypoxic Symptoms of the 2nd stage of Labor The woman begins to bear down of her own accord The womans increasing apprehension,irritability & unwillingness to be touched Sudden increase in show Woman thinks she needs to defecate Membranes may rupture Woman may say she wants to be put to sleep or have a CS Perineum begins to bulge SPECIAL CONSIDERATIONS : ASEPSIS & ANTISEPSIS Personnel should wear caps, masks; those who will participate in the delivery should be in sterile attire. People with communicable disease (upper respiratory infection, open skin lesions, diarrhea) should not be allowed into the delivery room Only sterile instruments should be used. AMNIOTOMY Artificial rupturing of the membranes. It allows the fetal head to contact the cervix ---more efficient contractions. 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. Short pushes of no longer than 6-7 seconds Physiological pushing: pushing only with the urge to push (3-5 times with each contraction) and resting in between Pushing with an open glottis and slight exhalation (Valsalva maneuver impedes return flow of blood to the heart because of increased intrathoracic pressure) Positioning lithotomy, lateral sims, dorsal recumbent Psychosocial support Preparation of the DR and instruments (forceps, scissors, needle, needle holder, bowl/kidney basins, sutures, sponges)

CS delivery

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: Vital signs: BP, pulse Uterus: degree of contraction; fundal height Lochia: amount,presence of clots Perineum/episiotomy Bladder/distention Family interaction Potential Complications: Hypothermic reactions Chilling accompanied by uncontrollable shaking; Exact etiology: unknown; possible explanations: sudden release of intraabdominal pressure, exhaustion, disequilibrium in the internal & external body temperatures Management: Clean, dry warm gowns, blankets Avoid drafts Warm fluids po