Normal Labor and Birth

The Five Ps of Labor

o Passageway: maternal bony pelvis and tissues o Passenger: the fetus o Powers: primary and secondary forces of labor o Position: maternal position o Psyche: psychological component of mother

The Passage
o Pelvis type o Pelvis size o Cervical effacement o Cervical dilation

Cervical Effacement and Dilation

o Uterus divides into upper (contractile) and lower (passive) segments. o Effacement: taking up of internal os and cervical canal into uterine side walls o Dilatation: Widening of cervical os from opening < 1 cm to approximately 10 cm.

Formation of Lower Uterine Segment

Primigravida: Effacement usually occurs before dilation

Multipara: dilation & effacement usually occur together

The Passenger
o o o o o Fetal head Fetal attitude Fetal Lie Fetal presentation Fetal position

The Passenger: Fetal Head

o Skull vault bones 2 - Frontal 2 - Parietal 1 - Occipital o Sutures Sagittal Frontal Coronal Lambdoidal

The Passenger: Fetal Head

Molding of the fetal head in cephalic positions

The Passenger: Fetal Head

o Landmarks Mentum (Chin) Sinciput (Brow) Anterior Fontanelle (Bregma) Vertex Posterior Fontanelle Occiput

The passenger: The Fetal Head

Anteroposterior diameters of the fetal skull Transverse diameters of the fetal skull

Passenger: Fetal Attitude

o Relation of fetal parts to one another o Normal attitude is flexion of neck, arms and legs o Hyperextension is abnormal attitude o Fetal attitude changes can cause larger diameter of fetal head to present to pelvis

Passenger: Fetal Lie

o Relationship of longitudinal axis of fetus to longitudinal axis of mother
Longitudinal lie: fetal spine is parallel to mothers spine l Transverse lie: fetal spine is at right angles to mothers spine
l

Vertex (head first) is most common, but breech (buttocks or feet first), transverse (laterally across uterus) and oblique (diagonally across uterus) also possible

Passenger: Fetal Presentation

o Presentation refers to fetal part entering pelvis first o Most common is cephalic but breech and shoulder also occur. o Cephalic presentations: vertex, military, brow or face o Breech presentations: complete, frank or footling o Shoulder presentation: occurs rarely; presenting part is shoulder, arm, back, abdomen or side

Passenger: Cephalic Presentations

o Vertex o Face Most common Hyperextended Head completely flexed Small diameter Smallest diameter presents presents Face is presenting part Occiput is the o Military presenting part Neither flexed or o Brow extended Partially extended Larger diameter Largest diameter presents presents Sinciput is presenting Top of head is part presenting part

Passenger: Malpresentations
o Complete Breech Fetus sitting with legs crossed in pelvis Knees and hips are flexed Buttocks and feet are presenting part o Frank Breech Hips are flexed with knees extended Buttocks are the presenting part o Footling Breech Hips and legs are extended Feet are the presenting part Can be a double or single footling o Shoulder Presentation AKA transverse lie Presenting part is shoulder, arm, back, abdomen or side

Passenger: Fetal Position

o Fetal landmarks of presenting fetal part to are used to describe position of fetus in relation to the front (anterior), back (posterior), or sides (right or left) of maternal pelvis. Fetal Landmarks O = Occiput (vertex) M = Mentum (face) S = Sacrum (breech) A = Acromion process (shoulder) Maternal Pelvis R = Right side L = Left side A = Anterior P = Posterior T = Transverse

l l l l

l l l l l

Categories of Presentations
ROA= Right Occipital Anterior LOA= Left Occipital Anterior

LOT = Right Occipital Transverse

Categories of Presentations
ROP= Right Occipital Posterior LMA= Left Mentum Anterior

LSP = Left Sacrum Posterior

The Passenger: Fetal Station

o Relationship of presenting part to imaginary line drawn between ischial spines of maternal pelvis o Ischial spines mark narrowest diameter through which fetus must pass o The station at the level of ischial spines is 0 o If presenting part is higher than spines, it is a negative number. o If presenting part is lower than spines, it is a positive number.

Passenger: Engagement
Engagement occurs when largest diameter of presenting part reaches pelvic inlet and can be felt on vaginal exam Floating: If presenting part directed towards pelvis but can easily be moved out of inlet Ballotable: When presenting part dips into inlet but can be displaced with upward pressure from examiner s fingers Engaged: If presenting part fixed in pelvic inlet and cannot be dislodged

The Power: Uterine Contractions

Power: Forces of Labor

o Primary forces are involuntary contractions of uterine muscle fibers, stimulated by pacemaker in upper uterine segment o Secondary forces consist of the voluntary use of abdominal muscles during the second stage of labor to facilitate the descent and delivery of the fetus

Power: Primary Forces of Labor

o Effacement: With each UC, muscles of upper uterine segment shorten, exerting longitudinal traction on cervix causing thinning and drawing up of internal os and cervical canal into uterine side walls Measured from 0 to 100% o Dilation (aka dilatation) As uterus elongates with UCs, fetal body straightens out and exerts pressure against lower uterine segment and cervix. Cervix opens as a result, allowing for birth of fetus Measured from 0 to 10 cm

Power: Primary Forces of Labor

Position of Laboring Woman

o Affects: circulation, fatigue, comfort o Upright position (walking, sitting. kneeling, squatting) Promotes descent of fetus Improves blood flow Relieves backache Straightens axis of birth canal Increases pelvic outlet

Psyche
o Preparation for childbirth o Sociocultural heritage o Previous childbirth experience o Support from significant others o Emotional status o Environmental influence

Premonitory Signs of Labor

o o o o o o Lightening Bloody show Painful Braxton Hicks Cervical ripening Diarrhea Energy burst

False vs True Labor

False Labor o Regular contractions o Decrease in frequency and intensity o Discomfort in lower abdomen and groin o Activitychange alters Ucs o UCs stop when sleeping o No appreciable cervical change o Sedation decreases UCs o Show usually not present True Labor o Regular contractions o Progressive frequency and intensity o Discomfort begins in back, radiating to abdomen o Activity increases UCs; continue when sleeping o Progressive effacement and dilation of cervix o Sedation does not stop UCs o Show usually present

Leopolds First Maneuver

Leopolds Second Maneuver

Leopolds Third Maneuver

Leopolds Fourth Maneuver

Stages of Labor and Birth

o First stage:begins with onset of true labor and ends with complete dilation o Second stage: begins with complete dilation and ends with birth of infant o Third stage: begins with expulsion of infant and ends with expulsion of placenta o Fourth stage: begins with expulsion of placenta, lasting 1 to 4 hours

First Stage of Labor

Latent Phase Cervical dilation: 0 - 3 cm Duration: 8.6 hrs in nullipara - 5.3 hrs in multipara Contraction frequency: 3 - 30 minutes; may be irregular Contraction duration: 30 - 40 seconds Contraction intensity: Mild by palpation, 25 - 40 mm Hg by IUPC Physical sensations: Menstrual-like cramps, low backache, light bloody show, diarrhea, possible SROM Maternal behavior: Able to ambulate and talk through contractions; pain controlled fairly well

First Stage of Labor

Active Phase Cervical dilation: 4 - 7 cm Duration: 4.6 hrs in nullipara - 2.4 hrs in multipara Contraction frequency: 2 - 5 minutes Contraction duration: 40 - 60 seconds Contraction intensity: Moderate to strong by palpation, 50 - 70 mm Hg by IUPC Physical sensations: Increasing discomfort, trembling of thighs/legs; pressure on bladder and rectum; backache with occipitoposterior fetal position. Maternal behavior: Working to keep control; quieter

First Stage of Labor

Transition Cervical dilation: 8 - 10 cm Duration: 3.6 hrs in nullipara - variable in multipara Contraction frequency: 1.5 - 2 minutes Contraction duration: 60 - 90 seconds Contraction intensity: Strong by palpation, 70 - 90 mm Hg by IUPC Physical sensations: Increased bloody show; urge to push; increased rectal pressure, ROM may occur. Maternal behavior: Ambulation difficult; may be irritable, agitated; self-absorbed; needs more support; may feel discouraged and unable to cope

Cardinal Movements of Labor

o o o o o o o Descent Flexion Internal Rotation Extension Restitution External Rotation Expulsion

Cardinal Movements of Labor

o Adaptations made by fetus to maneuver through pelvis during labor and birth. o In occiput (most common presentation), movements occur in following order: 1. Engagement of presenting part occurs 2. Descent of fetus into pelvis 3. Flexion of fetal head (often occurs with descent) 4. Internal rotation of fetal head to accommodate widest diameter of maternal pelvis

Cardinal Movements of Labor

5. Extension of fetal head as it comes under symphysis 6. Restitution as head turns 45 to untwist neck 7. External rotation viewed as head turns 45 to align shoulders with widest diameter of maternal pelvis 8. Expulsion as anterior shoulder slips under pubis

Second Stage of Labor

o o

o o o

10 cm to birth Duration: up to 3 hrs in nullipara and 0 - 30 min in multipara Contraction frequency: 2 - 3 minutes Contraction duration: 40 - 60 seconds Contraction intensity: Strong by palpation, 70 - 100 mm Hg by IUPC Physical sensations: As presenting part descends, urge to push increases; increased rectal and perineal pressure; sensation of burning, tearing and stretching of vagina and perineum Maternal behavior: Excited and eager to push; reluctant, ineffective pushing

Lacerations
o Lacerations to perineum or surrounding tissue may occur during childbirth; 3rd and 4th lacerations most commonly occur after midline episiotomy performed 1st involves only epidermal layers; if no bleeding may not need repair 2nd involves epidermal and muscle/fascia involvement requires suturing 3rd extends into rectal sphincter 4th extends through rectal mucosa

Third Stage of Labor

o Birth of infant to birth of placenta o Duration: 5 - 30 minutes o Physical sensations: Mild uterine contractions; feeling of fullness in vagina as placenta expelled o Maternal behavior: Attention focused on newborn; feelings of relief; euphoria

Apgar Score
o Quick method to assess fetal adaptation to extrauterine life o Five criteria scored at 1 and 5 minutes after birth with 0,1 or 2 pts given for each criteria Appearance: Pulse: Grimace: Activity: Respirations: Color Heart rate Reflex irritabilty Muscle tone Respiratory effort

o 8: minimal intervention o 4-7: suction, tactile stimulation, oxygen o 0-3: resuscitation

Placental Separation
o Uterine contraction after birth of infant diminishes surface area of placental attachment, causing placenta to begin to separate. o Bleeding occurs causing hematoma to form between placenta and uterine wall o Signs of separation: 1. Globular-shaped uterus 2. Gush of blood 3. Rise of fundus 4. Protrusion of umbilical cord

Placental Separation

Placental Delivery
o When signs of separation appear: Ask woman to bear down If undelivered, firm, gentle traction applied to cord with pressure on fundus Shiny Schultz: Separation occurs from inner to outer margins of placenta allowing fetal side to deliver first Dirty Duncan: Separation occurs from outer margins first, causing placenta to roll up with maternal surface first. Considered retained when 30 minutes have elapsed without delivery of placenta

Fourth Stage of Labor

o One to four hours following birth o Tremendous hemodynamic changes occur o Blood not lost at birth (250 - 500 ml) is redistributed into venous beds o B P drops, pulse increases o Uterus is contracted and is midline o Fundus is usually midway between umbilicus and symphysis pubis o Shaking chill is common o Hypotonic bladder may lead to urinary retention