Chapter 13/14: Labor and Birth Process

Factors Influencing the Onset of Labor

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Uterine stretch
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Progesterone withdrawal
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Increased oxytocin sensitivity
•
Increased release of prostaglandins

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Critical Factors Affecting Labor and Birth (“Five Ps”)

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Passageway (birth canal: pelvis and soft
tissues)
•
Passenger (fetus and placenta)
•
Powers (contractions)
•
Position (maternal)
•
Psychological response

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Five Additional Factors Affecting the Labor Process

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Philosophy (low tech, high touch)
•
Partners (support caregivers)
•
Patience (natural timing)
•
Patient preparation (childbirth knowledge
base)
•
Pain control (comfort measures)

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Passageway: Bony Pelvis #1

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Linea terminalis: division of false and true pelvis
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True pelvis (below linea terminalis)
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Inlet
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Midpelvis
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Outlet (pelvic measurements)
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False pelvis (above linea terminalis)
•

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Upper flared parts of two iliac bones and concavities
•
Wings of base of sacrum
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Question #1

Is the following statement True or False?

The true pelvis lies below the linea
terminalis.
a. True
b. False

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Answer to Question #1

a. True
The true pelvis lies below the linea
terminalis. The false pelvis lies above the
linea terminalis.

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Passageway: Soft Tissues

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Cervix
•

•
Thins through effacement to allow
presenting part to descend into vagina
•
Pelvic floor muscles
•
Vagina

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Passenger: Fetal Skull

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Largest and least compressible structure
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Sutures: allow for overlapping and changes in shape
(molding); help identify position of fetal head
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Fontanels: intersections of sutures; help in
identifying position of fetal head and in molding
•
Diameters: occipitofrontal, occipitomental,
suboccipitobregmatic, and biparietal

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Passenger: Fetal Attitude

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Passenger: Fetal Lie

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Passenger: Fetal Presentation

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Cephalic (vertex)
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Military
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Brow
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Face
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Breech
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Frank
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Full or complete
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Footling or incomplete
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Question #2

Is the following statement True or False?

Cephalic presentation refers to a fetus whose
head enters the pelvic inlet first.
a. True
b. False

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Answer to Question #2

a. True
When the head of the fetus is the first part of the
fetus to enter the pelvic inlet, the fetus is said to be
in the cephalic presentation.

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Passenger: Fetal Position

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Landmarks
•

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Occipital bone (O): vertex presentation
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Chin (mentum [M]): face presentation
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Buttocks (sacrum [S]): breech presentation
•
Scapula (acromion process [A]): shoulder
presentation
•
Three-letter abbreviation for identification

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Passenger: Fetal Station

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Passenger: Fetal Engagement

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Presenting part reaching 0 station
•
Floating: no engagement; presenting part
freely movable about pelvic inlet

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Cardinal Movements of Labor

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Powers

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Uterine contractions (primary stimulus)
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Intra-abdominal pressure from mother pushing and
bearing down
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Contractions: involuntary: thin and dilate cervix
•
Three parameters
•

•
Frequency
•
Duration
•
Intensity

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Psychological Response

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Factors influencing a positive birth experience
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Clear information on procedures
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Support, not being alone
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Sense of mastery, self-confidence
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Trust in staff caring for her
•
Positive reaction to the pregnancy
•
Personal control over breathing
•
Preparation for the childbirth experience

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Physiologic Responses to Labor: Maternal #1

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Increased heart rate, cardiac output, blood
pressure (during contractions)
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Increased white blood cell count
•
Increased respiratory rate and oxygen
consumption
•
Decreased gastric motility and food absorption
•
Decreased gastric emptying and gastric pH

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Physiologic Responses to Labor: Maternal #2

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Slight temperature elevation
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Muscle aches/cramps
•
Increased BMR
•
Decreased blood glucose levels

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Physiologic Responses to Labor: Fetal

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Periodic FHR accelerations and slight decelerations
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Decrease in circulation and perfusion
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Increase in arterial carbon dioxide pressure
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Decrease in fetal breathing movements
•
Decrease in fetal oxygen pressure; decrease in
partial pressure of oxygen

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Stages of Labor #1

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First stage true labor to complete cervical dilation (10
cm)
•

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Longest of all stages
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Three phases
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Latent phase
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Active phase
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Transition phase
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Nulliparous versus multiparous
•
Maternal behaviors
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Second stage: cervix
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Stages of Labor #2

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Third stage: birth of infant to placental separation
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Placental separation
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Placental expulsion
•
Fourth stage: 1 to 4 hours following delivery

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Question #3

Is the following statement True or False?

The second stage of labor is the longest
stage.
a. True
b. False

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Answer to Question #3

b. False
The first stage of labor is the longest stage.

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Signs of Placental Separation

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The uterus rises upward
•
The umbilical cord lengthens
•
A sudden trickle of blood is released from the
vaginal opening
•
The uterus changes its shape to globular

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Factors Influencing Pain During Labor and Birth

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Physiologic
•
Spiritual
•
Psychosocial
•
Cultural
•
Environmental

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Nursing Management of Laboring Women

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Assessment
•
Comfort measures
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Emotional support
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Information and instruction
•
Advocacy
•
Support for the partner

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Maternal Assessment During Labor and Birth

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Maternal status (vital signs, pain, prenatal record
review)
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Vaginal examination (cervical dilation,
effacement, membrane status, fetal descent
and presentation)
•
Rupture of membranes
•
Uterine contractions
•
Leopold maneuvers

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Fetal Assessment During Labor and Birth

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Amniotic fluid analysis
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Fetal heart rate monitoring
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Handheld versus electronic; intermittent versus
continuous; external versus internal
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Fetal heart rate patterns
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Baseline, baseline variability, periodic changes
(see Table 14.1)
•
Other assessment methods
•

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Guidelines for Assessing Fetal Heart Rate

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Initial 10- to 20-minute continuous FHR assessment on
entry into labor/birth area
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Completion of a prenatal and labor risk assessment on all
clients
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Intermittent auscultation every 30 minutes during active
labor for low-risk women and every 15 minutes for high-
risk women
•
During second stage of labor intermittent auscultation
every 15 minutes for low-risk women and every 5
minutes for high-risk women

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Continuous Electronic Fetal Monitoring

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Uses a machine to produce a continuous tracing of the
FHR
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Produce a graphic record of the FHR pattern
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Primary objective
•

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To provide information about fetal oxygenation and
prevent fetal injury from impaired oxygenation
•
To detect fetal heart rate changes early before they
are prolonged and profound

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Four Categories of Baseline Variability

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Absent: fluctuation range undetectable
•
Minimal: fluctuation range observed at <5 beats per
minute
•
Moderate: (normal) fluctuation range from 6 to 25 beats
per minute
•
Marked: fluctuation range >25 beats per minute

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Nursing Interventions

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Average FHR 110 to 160 beats per minute
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Fetal bradycardia
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Fetal tachycardia
•
FHR variability an indicator of fetal status

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Typical Periodic Baseline Changes

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Accelerations
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Decelerations
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•
Early
•
Late
•
Variable
•
Prolonged

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Nonpharmacologic Measures for Pain Management

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Continuous labor support
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Hydrotherapy
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Ambulation and position changes
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Acupuncture and acupressure
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Attention focusing and imagery
•
Therapeutic touch and massage; effleurage
•
Breathing techniques (e.g., patterned-paced
breathing)

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Pharmacologic Measures

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Systemic analgesia
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Regional or local anesthesia
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Neuraxial analgesia/anesthesia techniques: use of
analgesic or anesthetic, continuously or
intermittently into epidural or intrathecal space
•
Shift in pain management: woman as an active
participant during labor

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Systemic Analgesia

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Route: typically administered parenterally through
existing IV line
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Drugs
•

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Opioids (butorphanol, nalbuphine, meperidine,
fentanyl)
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Ataractics (hydroxyzine, promethazine)
•
Benzodiazepines (diazepam, midazolam)

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Regional Analgesia/Anesthesia

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Epidural block: continuous infusion or intermittent
injection; usually started when dilation >5 cm
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Combined spinal–epidural block (“walking epidural”)
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Patient-controlled epidural
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Local infiltration (usually for episiotomy or laceration
repair)
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Pudendal block (usually for second stage, episiotomy, or
operative vaginal birth)
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Intrathecal (spinal) analgesia/anesthesia (during labor
and cesarean birth)
•
Images adapted from: Elliott, L. (2020).

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