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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

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 . 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.Cervical Effacement and Dilation o Uterus divides into upper (contractile) and lower (passive) segments.

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 .Frontal § 2 .Parietal § 1 .The Passenger: Fetal Head o Skull vault bones § 2 .

but breech (buttocks or feet first).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. transverse (laterally across uterus) and oblique (diagonally across uterus) also possible . 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 mother’s spine l Transverse lie: fetal spine is at right angles to mother’s spine l Vertex (head first) is most common.

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

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 .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.

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 positive number. it is a negative 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 . o If presenting part is lower than spines.

muscles of upper uterine segment shorten. 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 . 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. 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.The Power: Uterine Contractions Power: Forces of Labor o Primary forces are involuntary contractions of uterine muscle fibers.

Power: Primary Forces of Labor Position of Laboring Woman o Affects: circulation. kneeling. sitting. fatigue. comfort o Upright position (walking. 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 .

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 Leopold’s First Maneuver .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.

Leopold’s Second Maneuver Leopold’s Third Maneuver Leopold’s Fourth Maneuver .

5.40 seconds § Contraction intensity: Mild by palpation. lasting 1 to 4 hours First Stage of Labor Latent Phase § Cervical dilation: 0 . pain controlled fairly well First Stage of Labor Active Phase § Cervical dilation: 4 . may be irregular § Contraction duration: 30 .3 hrs in multipara § Contraction frequency: 3 .4 hrs in multipara § Contraction frequency: 2 .30 minutes. pressure on bladder and rectum. 25 .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. trembling of thighs/legs. quieter .40 mm Hg by IUPC § Physical sensations: Menstrual-like cramps.3 cm § Duration: 8.60 seconds § Contraction intensity: Moderate to strong by palpation. possible SROM § Maternal behavior: Able to ambulate and talk through contractions.70 mm Hg by IUPC § Physical sensations: Increasing discomfort.7 cm § Duration: 4.6 hrs in nullipara .2. backache with occipitoposterior fetal position. § Maternal behavior: Working to keep control. 50 . diarrhea. low backache.5 minutes § Contraction duration: 40 .6 hrs in nullipara . light bloody show.

Descent of fetus into pelvis 3. Flexion of fetal head (often occurs with descent) 4. 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. self-absorbed. ROM may occur. Internal rotation of fetal head to accommodate widest diameter of maternal pelvis .6 hrs in nullipara . agitated. needs more support.90 mm Hg by IUPC § Physical sensations: Increased bloody show. urge to push.10 cm § Duration: 3. movements occur in following order: 1.variable in multipara § Contraction frequency: 1.First Stage of Labor Transition § Cervical dilation: 8 . o In occiput (most common presentation).5 . increased rectal pressure. 70 .2 minutes § Contraction duration: 60 . may be irritable. Engagement of presenting part occurs 2.90 seconds § Contraction intensity: Strong by palpation. § Maternal behavior: Ambulation difficult.

30 min in multipara Contraction frequency: 2 . External rotation viewed as head turns 45˚ to align shoulders with widest diameter of maternal pelvis 8. sensation of burning. tearing and stretching of vagina and perineum Maternal behavior: Excited and eager to push. 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. increased rectal and perineal pressure. Expulsion as anterior shoulder slips under pubis Second Stage of Labor o o o o o o o 10 cm to birth Duration: up to 3 hrs in nullipara and 0 . Extension of fetal head as it comes under symphysis 6. Restitution as head turns 45˚ to untwist neck 7.60 seconds Contraction intensity: Strong by palpation. 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 .100 mm Hg by IUPC Physical sensations: As presenting part descends. reluctant. 70 .Cardinal Movements of Labor 5.3 minutes Contraction duration: 40 . urge to push increases.

oxygen o 0-3: resuscitation Placental Separation o Uterine contraction after birth of infant diminishes surface area of placental attachment. Gush of blood 3. causing placenta to begin to separate. Rise of fundus 4. feelings of relief.30 minutes o Physical sensations: Mild uterine contractions. Globular-shaped uterus 2. 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. o Bleeding occurs causing hematoma to form between placenta and uterine wall o Signs of separation: 1. feeling of fullness in vagina as placenta expelled o Maternal behavior: Attention focused on newborn. tactile stimulation.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.Third Stage of Labor o Birth of infant to birth of placenta o Duration: 5 . Protrusion of umbilical cord .

firm. causing placenta to roll up with maternal surface first. 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.Placental Separation Placental Delivery o When signs of separation appear: § Ask woman to bear down § If undelivered. 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 . § 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.