Power Labor % ~ Whe force suppliod by & fundus of & wberus 9 implemented “by uterie contrackios Ch causes — Cervical dilatation tnd then CKpulcion of t fetus fom & uterus - full ervical dilatation, 1° paver comes frm b 2° powed suite: abdominal usc | Tregular equ ddan Abdomen; remain at @ lowe bak; afount i _ abdemen ? grain Abdomen (wave) Disappears é ambulation | cleep Cont nueus oes wot 4 in duration, 4 in duration, Arquency , inten sity frequency . itencity No cervical dilatertion Adie, eevical dilatation hoor INCREMENT - ictencity 4s ACME - strongest DEGREMENT - istencity veNan of Contow, Changes © Upper por wien: thickens 2 distinc @ ine ion - ae walled. wuppe. functioning passive (enabling @ fetuc Orear of “¢ yushed owt easily) atoms und, Oveid ie clagated (vertical diameter va “gretee nh; vont diameter) u sl art a of & fetus fw beter Cervical > pelvic alignment (owitnl Chaaney 0 FFFAGEMENT « ‘owt 1 Udaning tf = ipa ean & dilatotion begiac - multiparac: oilatotion may proved & ceo & vomplte ‘ALNEwsTOL Cervical Effacement _ ¥¥ gas9 Cervical Effacement ZY l ] c I mont or widtai @ marin al men on ete a to permib & pocsage of ¢ - 4 amt ot vaginal secretions (chow) G]s fuphure OF Cervical captilaries 2 releare of mud plugPiyche +> qth "0" - o woman's frycholog cal out |00% ; prychglegi cal state of wings & woman Ainge iby labor 4 Envowrog, & menan otk quechon during prenatal vite or attend “pmpavation far child birth cL as &F vith, encowinge 0 share / alk abot 4 labor txpericde (debiching) Sager » LABOR = 12? $8 complete ~ Ones OF regular Contracting 1 beginning “x rapid cervical dilataben - mild, chert umbeactons (20-4or) ~ Crvical ovemedr, minimal dilatabin ~ mulpayr: Qui Ce progresyion ~ prolonged phowe, fe woman i ets wus | - no Gnalgesia ( @ phase) - MGT: omtrviled “vething ie imbnyent wallung (achve) emourdge lait minute preps artncrther dittrachin auuprescure other nmph arma a therapeutic meacures - fopiol cereal dilotatien © = snger unt ractions ,YO-U0s, 6 3-C aring C taneous ruptwe sion (spon membri ay a/ / — MCT continue being adtive Afrumé comfortable poribions (exeegy (06) = contract at ae oF intencity 2-3 ming , 0- - £10 om cenical ilataben - Show Cif wt yer occured) = ROM ok (cm Cif wot ruptured) — bth ful dilatabo (10un) ond PARTOORAM (wae) —»Compleke (ervical effacement - alert line (4) - peace wp Win WIV, anxiety, e 10, nin y - WOKOL Mm bisthia - fel t uge ty yah Wy = action line (24°) — fom full ermal dilatation ond Cervical Coemeat birth of & infomt - wolontfollavle wrge push / beay down © Cath tantrachon te = perineum inst Wilge and op r tne, ; oe may ohne tet tur and (Hel moy be expelled ~ CROWNING = appenrone of fete! walp lovental stage; bith ot & infant tp 7 ee dl hy 2 placenta “bith 4 8 uterus iC firm 2 rwnd below 7 wanbilitas - ombractions beyie ain +p po few mins 3 it now diccaid in shape until placental separation ts mins f Wirth of & intan ' gt +z - sudden guth o& leo € - vitible plaventp i, 3 vaginal Vv + uterine unten ing; firm_utens CHULTE.; shiny UNCAN, dirty center 49 edges tage + centerTABLE 154 PHYSIOLOGICAL EFFECTS OF LABOR System Response Cardiovascular + Cardiac output From prelabor levels + Blood lossat birth 300-500 ml on average + Blood pressure may rise with pain response and, du to work of the system uring contrat by anaverage systlic rise of 5 mmHg per contraction, Epidural anesthesia may cause hypotension. Hematopoietic + During labor, WHCS + increase toa level of 25,000-30.000 cellsmm’ compared 10 $,000-10,000 infection Respintory + Increased respiratory * rate to respond to increased cardiovascular parameters : + Total oxygen needs lengthened ‘Some women experience a loose bovel movement as contractions prow ~ delivery natural Cooter) Gedo mantuver - presun on é geatle contracked fundus Wy @ J” Hee ~ pressure tw noncentracted fads may auee uterine evércion (turning incide out), & hemorrha alered Spontonegutly, ~ 16 ade oleli manual removal Recommended Nursing Action + Monitor closely for hemortage. Increases 40%6-50% + Monitor for signs of pathology with Inypertensive patents are we epidural administration, This wsually involves an IV fluid bolus (see Chapter 16) Continue to monitor for any signs of Monitor for any signs of hyperventilation I hyperventilation ‘occurs, rebrething into paper bag can be help Ifmeeded, use appropriately patterned breathing to regulate respiratory rate, strong Neurologic and + Increased pain + Where pain registers is important in sensory + Increased respiratory appreciating why epidural anesthesia response rate is effective. Fr erly Ibor, the needs to suppres the + Diseuss nonpharmacologe pain techniques ithe patient does not ese medication, Psychological + Laborcan lead to + Offer expeditious care to the patient, responses emotional distress + because it isnot only infil and fatiguing = but it also represents the beginning ofa + labor. majo lie change for ‘woman and her pares Continue to encourage her process of Prior to birt, a woman ean investigate the services of doula ‘A douta isan individual with spevialized waining who provides physical, emotional, and psychological supporto laboring parents, A doula doesnot perform the simple shown to e need for analgesia and mesthesia requests, shorten labor time, and inerease satisfaction with the bh experience hor oer cot wash othe pate's Fash fr comfot i eed lini excesive laborthe same a thy woul they erecting to hep Byard + sa woman mse nor, cxcurage sp i ep ot Taran apy sane ex i + Ask he biting para to oid labor avoldoverttina becuse iret dicing labor ovtedaphorss Frese ofthe theater bade the ability the ‘ideo sense eds ered from sh ovaries ftepetie he ale 10 penas muchas? ‘bind of fl ik, Blo shots oi + Akthough many hospi poocls ‘nt that women hopes in ration there itl eveslotenal, DANGER SiGNs w > BP: feport if 7 N0/90.mmiig or GHPN 14 2 $0 malig systole 2 enteria | |" 5 yc nmllg diastole + feport falling OP (may indicate intrauterine hemorrhage o lemio shock iF G apprehension, 4PR, pallor) i So (> — @ Abnormal Pulse > > jo bpm during labor shenld be eect tony indi ate hemevehage ) © Inadequate | Prolonged Conbractions: — Teper if Umtfackions become lec Sequent, les imlence, shter in durabon (indseabve & uterine exhouttion w inertia) - obteru fw periods of relocation between umbfactios 7 veport cenWach on: longer than 30s (fetal well-being cpremice) © Abnormal lever cee tortour: Waddles moy pe yur t prcun of & fetal hea full bladder) ng nat allow decent of fetal head - void 4 2 during labor © Snore atin ehemion ~ mutt ye imechgated- nf ts sign oF 02 deprivation . internal hemorrhagePetjoul, DANGER Steals otw dF : htal tnd (> Whobpm) > 48 once : fal brad it (< N10 wpm) in a v vorb it duclyabion att : a: monitoring yy fctescage, Doppler © Meconinm Staining : Hated byponia v Mp nt ant vagal reflex a ™ Oly ia 4 Dowel. motility mutt We reported immedi ately @ fhyperach vity + hypoxia © ¥ 0s saturation: n°- 49-20% - 4yor~ neede father accecsment (catheter incerted a) pl < 4.2. Cacidasis) ; i sign & compromiced ane well: being + scalp puncture ASSESSMENTS MATERNAL 2 FETAL svn: taco © interview ? Phy teal Exam ~infd about nan - AMescmentt : vis, ankravhas , fain cole, labo preparation « urine Speumen es 3 pend: fetal posihor 2 pricentah (D Rittery - pact pregnancies; (D; toil(9 fhycical Exam " podominal 3 lover leg atseccment® fundal hy, vladder, shin twrgoy (hydration), edema, Wari ue Veins 4 large Uavivositicn = more prone for Ynvembophievihi x Severe edema = cuggete GEN, umbicmeg & PP Tot > 140/90 mmity ~ Wop: Maneuvers - Vaginal Exam :# determine extent oF On cofleming . tftavement, bad dilatation ; t ootinn fetal tat, poihon , dene ot devent X beck _dme yetween contractions ¥ much be kept 1 mimmum to revent infections | # mute not be done in & prucace J Viteding (frech bleeding indsuatve of plaventa previo) [i eeccorremtnreten |- Sonography : dtkermines ¢ diam ters of 7 fetal “chull, priceatation, pacition, Hexion, degne & descent © Atseccing Rupture of Membranes -SROM (cpontaneous rupture. oF Membranes): Sudden gun clow trickle of amaistic fluid ~ vaginal sections ove obtained ising a om: Tipped applicator (sterile) 2° tected t Nitvanne paper . % Vaginal Seorehons are audic; AF is alkaline # if AF WAC poised % vaginn, pl oF vaginal fluid is alkaline (ol 7 65), paper appears bme-artin w green ty deep blue # falle Wading: heavy, blondy chow 4 taleatie) 3 % Fern tak be wed = calor: yellbw- ctauned (100d incom pati ity) reen (megmium taining) - 5 home - ok fw color, odor, maT = pom Aale Pine ve ROMO labor - aKesc PURucts Y “ mF ut or atom 8-10 um T Ga" (tomy ———_ v 4 3°-bom FHR - 6 Ir-gom Gmirachont i 90 iG poricm itt 4 2» ———__» Ambulation 3 Change of Position: asiecc; ambulation should be conbnugd throughet ¢ stages (408) of labor wicking fw ROM during L.A © Mseysment of uterine Cont sack ons - monitored fw 20m in carly labor - Doppler i ued thereatter # length - from kt tension & uterus bo reloxahon - palpaole wanan's side (LoP/ pop) @ Electronic Monitoring - © Glaym Wiggering : 2110 bym ow 7 bpm ~ Sntiol Fledymic Monitoring > teidynamomette (cvapped @ abstoned) 7 vinuow fort Oble ¢ may limt woman's abilily Weathe deny > repacitio if Woman changes her plsiin CFH signal May ctop) > ret m their ade, sitting , bending forworh ovty foot st bed / birthing ball 7 vail® FUR Poromets - Dateline FHQR = 2 mint, betveen contrachns {10- 160 ypm - VARIABILITY : different between 2 4ect nnd pest tts mo ship, “yitters* a movement - 4 Baas 10-1 bpm, . slows if RAMs cleeps > Finding ¢ eMbseat - 10 tmplitude ranye detected « Minimal - omplinde fonge detuted bt SE eo Moderate (normal) - b-25 vpn ¢ Marked - 7 2Cbpn > Other fading s e tttal brady cardio ~ < [ID bpm 1 jom © fetal tachycardia - 7 ld bpm — PEMODIG CHANGES = shirt- tem, changes in fate other than @ pareline- Coenen ae rie > AateMbms - impr ange in F ‘ dle foal mort chante 0 “Dateral poukion, admimcvahm oF analgesic : Viena apparrt wbrugt * in FHA lomel to peak 30¢) - $2.wls Ado: peak of 2 bpm above baleling . dwahen ISS pk 2am from otet to return - B32 wh AQG: peak of 210 bpm wibeve Valeling, duvatim of > 10¢ bat Lam fom sek W retum = prolonged ayeleration: 22m fom Pomel y raen - HF aucteration lake rion = baceline change [new baseline > Detelerahons - vitually Gppareab, ucuall ymmthical , bs in FAR af pect”/ / on © Ectal head dunng contractions - carly delerahms wea late in Idber (low descent oF fetal head), viewed Gc inne - i€ late ih layer, & tal! dleccent of head, wld be CPD (céphalopelvic ditpreporbim) Accelerations * Abrupt increase in baseline (baseline to peak <30 s) —> +232 wks: 215 bpm for >15s * <32 wks: 210 bpm for 210s * Prolonged acl: 2-10 2-10 min *>10 min — Ain baseline Early Decelerations o ly - N rennet A ianocent” NN oie mitt @linege ti Bei gue => uh placental Late Decelerations inet dency ~ Wye a ee Change mom 'f position ; 03, WF Lineage Moises Dominguez: may we prcunibe wd pare fw (6 *; pattern persists/ / e Variable Decelerations > V . 180 ---- ane” —¥ not uniformed 400» . INNO. conte es Suey i Inored coal 7 wey waally p ¢ y ol chang je men's 1 a , Iehydfamaies give i, fw Deal cor , Knee -b- check position = smooth , wadulabng Sinusoidal Tracing wave t ‘ freque eee see ss ett of 3-C/min; 4 100 onenecerrnereretntnteeeneneetcee a pear, 220m SECC LP Contractions © Lineage soe Donngues BACKGROUND »® TEMPORARY but DISTINCT DECREASES of the FETAL ees SYMPTOMS ~ IDENTIFIED during ELECTRONIC FETAL HEART MONITORING * 44 FETAL MOVEMENTS » CLASSIFIED ACCORDING to their SHAPE & TIMING »* CRAMPING in MOTHER'S RELATIVE to UTERINE CONTRACTIONS LOWER ABDOMEN CLASSIFICATION EARLY LaTe VARIABLE (COMMON) ~ UNIFORM SHAPE. ~ UNIFORM SHAPE, but. ~ VARY in SHAPE, a ~ LOWEST POINT ot SAME GRADUAL CHANGE DURATION, & INTENSITY TIME as PEAK of ~ LOWEST POINT AFTER ~ NO CONSTANT with PEAK CONTRACTION PEAK of CONTRACTION of CONTRACTION 120. FETAL HEART RATE. (beats/min) PEAK of CONTRACTIONS == UTERINE CONTRACTIONS -e---2)-4-- TIME/ / ARIABLE CRO OVE detelerabons om pression OmMeER RLY Hi | NTERVENTION decwlemtiong ("UComprecsion | not mecescary teeverérions (K & Cee ee FEOE D L ATE LACENTAL VMUME why deceleration, | insuttidency Worreinng. Corre FIRST ‘Tason’ LABOR - labor} birth should pe Completed 5 Acsistance fon medical interventions me ‘tans © should begin m itt own, not induced © be able ‘fh move About itely, not _cmtined * bed o receive comhnueus Support during labo o no interenhions Cie WF) used routinely « Should be allowed te acume & i position Cupright 7 side lying) fw bir © mother } aby should be together 9 birt t unlimited Opportunity tw ceed — ; EMMbIL expreyion of Feelings, Cle tompower bth - ton it centre] lp & fetal alignment: Squatting . “oll tpurc* bithing cling (revow) i PEC Contraction time: Alcist, don't interrupt 1 promote @ support pecsm: adem Er an lel ora tke position: tctivity soaking ia tb fonts pit - ity * Soobing ia ab warm 130 Drin mgt. needs :” support; nonphanmdtelogic |. supportFigure 15.22 The effect of a full bladder on fetal descent, (A) The bladder is empty. (B) A full bladder impedes fetal progress.Mworeing. Cadre SECOND insor - encourage © women 4 push ¢ cntfachons 2 ret in’ vetween = enwthge wean +) Bisume Any potition Yaat is Gam table fo Wen ond Weatte ony way Yaar ic votweal fv Yren AND STAGE = FREBVEWLY F BIRTH 7 Placenta ae b ry de V im ev deem yy H rack Ise ]x Js Perineum cm Yt <— PROVIDE — supPoRT ———> ~. ~ lithotemy (may wot help fetal Posting dua von tod inte vic Congethon ble Poromeplet poss ~ Gims_pusition nee ehtective positions. ~ devcal recumbent | = rm oomprtss 49 - Gemi-aitving CIN de tension ~ Squotong aang to fewer perineal = is dene fim a lemi- fowler legs (aised against é ome, Squathny , 6 on th @ pitino t | fous ia between - = ‘encowtage, " tee w yreathe ent during pushing effort - Nuchal po no pacing fo j delivery of fetal/ / Crinenl CLEANING ® MASSACE = wacoging & perinevm os % fetal head enlarges“ vaginal opening helps tr keep ik Supple 2 prevent tearing - Cleon perineum % wormed anbseptic Cfodaphors ; cold selubon cates cramping. tine & derile Ho - clean from inward ty outward ; include o wide area ud Figure 15.25 The pattern for cleaning the perineum before birth. Cleaning from the birth canal outward moves bacteria away from, not into, the vagina. Numbers refer to the steps of the procedure.» = & a" © Ritgen maneuver: preveate onal sphincter $eor - technique + help achieve extention 2 Allow @ cmallect head diameter preceat > plove Sherine towel ows & vectum and pres forvord mm % fetal chin while ¢ ony hand preses downward & Oteiput o prune Swuld never be done on & fundus of % uterus t effect birth -» utering rupture Sequence of events in delivery for vertex presentations Controlled delivery of the head Ritgen’s maneuver Ritgen’s maneuver: For normal delivery/ / Sequence of events in delivery . immadiotely ? nth for vertex presentations of ¢ head, fp Check ntaown ack tw nuchal wd ((oojened 2 draw down ovtr % Fetal head). if tightly cited , oot i clamped 3 cut i delivery o shoulders - 6 Onilol iS cmsidered bon when € whole body i bora -_t newton_'s immediately plaved on é mothers naked blodemen 2 covered & ST QAI wGlm Vlanket & Cap ey Ss. to umceyve heat t : entourage, bonding Cutting * Clounyring * CORD -imbores fiat preath, marks © newbory's Wantihm iat? & owluele wovid ; . : aiavienet of independent respictin + physipjogic clamping: delaymg cutting yalil t macgke seat ; Abintaing iota @ tering level x ollows BC much O 100ml more ot bleed fron & plovento ty fetus av help endure adequate 2 p02 WBo comb # timing is individualized G1 late clumping could” ance _overinfusion of placentol_ Wood a possibly OF poly ythemia § hyperbi lirubine- mia/ / - comp t 2 heaastots @ 8-10 in fn 8 infant's wmbilicus - ood blood: fample tw typing » other meetin measures; baking fw stom celle titrectucing * INFANT - 7 cord i out, infont can remain on ¢ mother’s abdomen fe clin- t-Clun contact + Oty infant = 9 wormed Wwel , wiap in Merile plankee and (over head < 4 wrapped towel / tq ° prophyl oft iat sate (ag ainct chlamydia ~ begin brarlteediag [ breaticeding shaulates Oyun relodte for uberis totrathm 2 \avolution) 4 involution - retumn of % uteruc + pre-pregnonl state pee ~ UNANG YAYAP PROTOCOLWiring. Carve FRIRD, sacs - UE ploventa will deliver spmtoncoucly following mat births ; up sominc ic nomal - inspection: intack ¢ grocs abaormalites, no Ctyledonc leFb in utero (I¢-30 cotyledon) ~ if mother’ uterus hat not cotvacted, Pcp will tnasage @ fundus - Oxytocin (Pitvtie) io IM & per Lo al Iv fo htly t centrachon-» obtain baseline BP ® admin - fw pleeding Gt poor uterine tenbracho : carbepract temethaming (Hemabate) o methyl Cegonsving maleate (Wetherging) + Ord Against hemorrhage - tv emtraion ~ Wh stage of lobe: fick fev hour 9 birth Perinat INSPECTION qrediag oF perineal tears: Cradés 4- 4; ade 1; minimal , grade 4: extending a incuding ¢ veckum ~ Opisiotomy = Ala kagun ac Prfincotomy. . surgical indsion of & perineum ond poster Voginal wall during ¢ Jad stage of laow W quickly enlarge % opening fu 2 baby 4 pas Wrovgh . © Widline « verhcal; tacy W rt pair » medigloteral- ot wn dngle ~ Cpisiorchaphy = surgical repair oF injwy ty & wlva Wy cut wring . - local anesthe, Gan be gien