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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 F – frontal - sinciput E – ethmoid O – occuputal - occiput 1 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.

Fetal presentation Two types: b. breast lie on thigh Incomplete Breech – thigh rest on abdominal Frank – legs extend to head Footling – single. 2  If the two are at 90-degree angles to each other.  If the two are parallel. the fetus is said to be in a transverse lie. Fetal Position  Position is the relationship of the fetal reference point (occiput.1. iliac crest.) 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.2. hand or elbow in transverse lie If your baby is breech. double Kneeling b. thighs are flexed on the abdomen.5 cm. 3 x 4 cm. his bottom is the part of his body closest to the birth canal.  Nearly all (99. smallest AP occipitofrontal 12cm partial flexion occipitomental – 13.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 . Transverse Lie (Perpendicular) or Perpendicular lie. then the fetus is said to be in a longitudinal lie. 12 – 18 months after birth.  universal flexion or general flexion o The back is markedly flexed. Shoulder presentation. Longitudinal Lie ( Parallel) cephalic . complete flexion.5%) fetuses are in a longitudinal lie. but it happens in 3% to 5% of single-baby deliveries. 1 x 1 cm.mentum.Vertex – complete flexion Face Brow Poor Flexion Chin Breech .( > 5 cm – hydrocephalus).1. Closes – 2 – 3 months Anteroposterior diameter suboccipitobregmatic 9. No one is sure what causes a breech presentation. Fetal Attitude  Is the relationship of the fetal parts to one another.Complete Breech – thigh breast on abdomen. diamond shape.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.close Posterior fontanel or lambda(vertex) – triangular shape.  Is the portion of the fetus that enters the pelvis first and covers the internal os of the cervix. legs are flexed at the knee joints. head is flexed on the chin. such as:  Cephalic (head)  Vertex  Brow  Face  Breech  Sacrum (frank) – legs are extended  Foot (footling or incomplete) – may be single or double 3  Sacrum and feet (full or complete) – the baby is in squatting position  Shoulder or acromion.

) < 4’9” tall 2. the distance measured and described as station -1 or so if it is 1 cm or so above the ischial spines. wide.5 cm basis in getting true conjugate.  If the presenting part is above the spines.iliac crest – flaring superior border forming prominence of hips Ischium – inferior portion .  Six positions are usually defined for each presentation except the shoulder presentation. Anthropoid – oval. transverse – wider b. head is “at outlet”. posterior part shallow 3. (DC – 11. Pelvis 2 hip bones – 2 innominate bones 3 Parts of 2 Innominate Bones Ileum – lateral side of hips .) Underwent pelvic dislocation Pelvis 4 main pelvic types 1.  Station +1 or so if it is 1 cm below the ischial spines. (crowning) Passageway o The soft tissues of the passage include:  Lower uterine segment  Cervix  Vaginal canal  Pelvis Mom 1.) < 18 years old 5 3. Gynecoid – round. Android – heart shape “male pelvis”.5 cm . deeper most suitable (normal female pelvis) for pregnancy 2. oval shape. Measurement: 11.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. Platypelloid – flat AP diameter – narrow. it is at station 0 (synonymous with engagement). head is “floating”  At +4 station.Occiput -mentum -sacrum -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. True conjugate/conjugate vera – measure between . AP diameter wider transverse narrow 4.anterior part pointed. Vertex Face Breech Shoulder . forming the right anterior and posterior quadrants and the left anterior and posterior quadrants.12.5 cm=true conjugate 2.  At -4 station.  When the presenting part is at the level of the ischial spines.4 symphysis pubis and bisecting it transversely by a line from one side to the other. ape like pelvis.

TRUE SIGNS OF LABOR · UTERINE CONTRACTION . if same BP. Pushing force adds to the primary force after the cervix is fully dilated. Obstetrical conjugate – smallest AP diameter. The exposed cervical capillaries seep blood as s result of pressure exerted by the fetus. The blood.the surest sign that the labor has begun · SHOW 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. notify MD -preeclampsia 7 .the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Characteristics: wave like d. Power – the force acting to expel the fetus and placenta – myometrium – powers of labor a.the mucus plug that filled the cervical canal during pregnancy is expelled.0 cm 3. duration. Involuntary Contractions (Primary forces: is the uterine contraction → complete effacement and dilation of the cervix. let mom rest. If BP increase . ) b. . Voluntary bearing down efforts (Secondary forces: use of abdominal muscles to push during the 2nd stage of labor. intensity 6 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 Difference Between True Labor and False Labor False Labor True Labor Irregular contractions No increase in intensity Pain – confined to abdomen Pain – relived by walking No cervical changes Contractions are regular Increased intensity Pain – begins lower back radiates to abdomen Pain – intensified by walking Cervical effacement & dilatation * major sx of true labor. Timing: frequency. 4. Measurement: 11. Tuberoischi Diameter – transverse diameter of the pelvic outlet.) c. Pelvis at 10 cm or more. Ischial tuberosity – approximated with use of fist – 8 cm & above.

3 methods of assessing uterine contractions: · Subjective description given by the woman · Palpation and timing by the nurse or physician – the fingertips are used.Lengthening of the cord 3.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. Unit used is cm. .actually there is no dry labor because even the amniotic membrane has ruptured. including your partner. crying.sudden gush of fluid from the vagina.mixed with mucus · RUPTURE OF MEMBRANE . thrashing. slapped. grimacing.The placenta may impede labor when implantation took place in the lower uterine segment.what are their caretaking activities. less intense labors.using assessment techniques. or choked. frowning. The placenta may cover part or all of the internal cervical os.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. 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. Duration of Labor Primipara – 14 hrs & not more than 20 hrs Multipara – 8 hrs & not > 14 hrs Effacement – softening & thinning of cervix. and fears about childbearing . and then diminishes rather rapidly (decrement). nervous tremors. nurse can meet laboring client's needs for information and support  Support system o Father or support person . and increase pulse and respiration . Psyche . If yes.Sudden gush of blood Types of placental delivery 1. clenching of teeth. by whom? What is the total number of times? o Has anyone. and capable of actively participating in the control of the birth process usually experience shorter. Assessing Uterine Contractions · Uterine contractions exhibit a wavelike pattern: it begins with a slow increment. This is known as placenta previa Signs of placental separation 1.Shultz e “shiny” – begins to separate from center to edges presenting the fetal side shiny 2. 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 8  Laboring client has previous ideas. gradually reaches an acme. Use % in unit of measurement Dilation – widening of cervix. knowledgeable.Fundus rises – becomes firm & globular “ Calkins sign” 2. ever forced you to have sex? o Are you afraid of your partner or anyone else?  Anxiety o Observe for rapid breathing. Placenta . 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 . kicked. Next there is an interval of rest until the next contraction begins. knowledge.Women who are relaxed.

The first stage is much longer than the 2nd & 3rd stages combined. 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. Second Stage of Labor (fetal stage. can communicate  Frequency: every 5 – 10 min  Intensity mild Nursing Care:  Encourage walking . Use % in unit of measurement Dilation – widening of cervix.Begins from the onset of regular contractions to full dilatation of the cervix. Phases of Labor: Latent Phase: Assessment:  Dilations: 0 – 3 cm  Mom – excited.o Provide support. averaging about 12 hours for primis and about 6 hours for multis. fetal monitor. apprehensive. 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. information. about 20 minutes. etc  D – dry lips – oral care (ointment) 9 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. First Stage of Labor (onset of true contractions to full dilation and effacement of cervix) . complete dilation and effacement to birth) – from full dilatation and effacement to delivery.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. cervical dilation and effacement. II.  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 .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. The average duration for primi is 1 hour and for multis. Unit used is cm.

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 . Placental Seperation. level os station Flexion – Descending head meets pelvic floor. it extends to be born.redness E. Breathing – panting ( teach mom)  PANTING.  If the placenta does not deliver spontaneously. External Rotation – shoulder engage and move similarly to head. Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER Hurrying of placental delivery will lead to inversion of uterus. fast to heal.) Will facilitate complete flexion & extension. Check time. check cord if coiled.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.  Check placement of fundus at level of umbilicus. possible to reach rectum ( urethroanal fistula) Mediolateral – more bleeding & pain. identification of baby. Third Stage of Labor or Placental stage (Birth to expulsion of placenta) . Restitution – After the delivery of head. 2nd hr q 30 minutes.  PRESSURE MUST NEVER BE APPLIED ON A NON-CONTRACTED UTERUS as the uterus may evert and hemorrhage.)To prevent laceration 2. less pain easy to repair. CREDE’S MANEUVER – putting pressure to the uterus to fasten the expulsion of placenta. Pull shoulder down & up. 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. Expulsion – entire infant emerges from mother II. hard to repair. (Support head & remove secretion.  If fundus above umbilicus. Extension – Once fetal head reaches perineum. it rotates back to position prior to engagement.edema E-cchemosis D–discharges . Ironing the perineum – to prevent laceration Modified Ritgens maneuver – place towel at perineum 1. chin is brought down Internal Rotation – Fetal head rotates from transverse to facilitate movement through pelvis. Mechanisms of Labor: 10 Engagement – Biparietal Diameter of the baby reaches the ischial spines Descent – Presenting part progresses through pelvis. 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). slow to heal -use local or pudendal anesthesia.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.rapid and shallow Episiotomy – median – less bleeding.

face. hands or sacrum  Obtain a specimen of urine for routine urinalysis to check for presence of protein. BP  Anxiety and pain ---≫ stress response ---≫ inc. multis: with onset of labor 2. Lightening – primis – 10-14 days before labor. Increased vaginal mucus discharge 5.  BP should be checked at least every hour btwn contractions. Braxton-Hick’s contractions increase and may become annoying --a sleeplessness 3. cold.  Perform Leopold’s to determine the fetal presentation. sore throat)  Recheck for allergies  Check the woman’s dietary intake for the last 4 hours. glucose or acetone  Inquire regarding symptoms of infection (diarrhea.  Partial rooming in: baby in morning . position and engagement  Assess FHT for rate & regularity: note the area of maximal intensity. at night nursery 11 NURSING CARE DURING LABOR ASSESSMENT: First Stage of Labor Premonitory Signs of Labor 1. BP may rise 5 to 10 mmHg during a contraction. Methods of determining the degree of fetal distress throughout labor  Assessment of the rate & rhythm of the fetal heart.  If BP is elevated.  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  TPR monitoring is done q 4 hours. 2 to 3 lb weight loss may occur 3 to 4 days before labor 4. or more frequently if indicated  Temperature & respiration should be normal.  Check for edema of the legs. repeat procedure 30 minutes later to obtain a true reading when the woman is relaxed. Closer observation is needed when the membranes have ruptured and in the presence of fetal tachycardia. 1gram=1cc  Bonding – interaction between mother and newborn – rooming in types  Straight rooming in baby: 24hrs with mom. Count pad & saturation Fully soaked pad : 30 – 40 cc weigh pad.A – approximation of blood loss. · Fetoscope monitoring · Electronic FHR monitoring o External monitoring o Internal monitoring o Telemetry  Fetal Blood Sampling  NonStress test  Contraction Stress Test ABNORMAL FHR PATTERNS 12  Tachycardia – fetal distress  Bradycardia – fetal hypoxia .lie. A persistent pulse of over 100 is suggestive of exhaustion or dehydration.  Pulse rarely exceeds 100 /minute. 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. cough.

 Suturing of the episiotomy usually requires local anesthesia. Take FHR after (danger: escape of loop cord with fluid). unless the woman had a pudendal block or epidural anesthesia  Assessment: o Vital signs: BP. 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. masks. 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. sponges) Planning and Intervention: 4th Stage of Labor  After the delivery of the placenta. · Suggests uteroplacental insufficiency or decreased blood flow through the intervillous spaces of the uterus during contractions. pulse . Late Deceleration · Decelerations that are delayed until 30-40 seconds after the onset of contraction and continues beyond the end of contraction.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. bowl/kidney basins. AMNIOTOMY o Artificial rupturing of the membranes. It allows the fetal head to contact the cervix ---≫more efficient contractions. dorsal recumbent 13 o Psychosocial support o Preparation of the DR and instruments (forceps. open skin lesions. needle. o People with communicable disease (upper respiratory infection. those who will participate in the delivery should be in sterile attire. lateral sims. o This may be done with a hemostat. sutures. diarrhea) should not be allowed into the delivery room o Only sterile instruments should be used. as in marked hypotonia or abnormal uterine tonus caused by oxytocin administration. OTHER NURSING MEASURES Coach the woman on bearing down efforts. oxytocin (Methergin) is given IM and/or Pitocin (Syntocinon) maybe given as a drip up to 8 hours after delivery. 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. needle holder. scissors.

disequilibrium in the internal & external body temperatures o Management:  Clean. o Exact etiology: unknown.o Uterus: degree of contraction. exhaustion. dry warm gowns.presence of clots o Perineum/episiotomy o Bladder/distention o Family interaction Potential Complications: Hypothermic reactions o Chilling accompanied by uncontrollable shaking. possible explanations: sudden release of intraabdominal pressure. fundal height o Lochia: amount. blankets  Avoid drafts  Warm fluids po 14 .