care of a pregnant woman from the onset of labor to the completion of the fourth stage of labor with the
expulsion of the placenta.
The Process of Labor ² Four P·s
Labor: coordinated sequence of involuntary uterine contractions 2. Delivery: actual even of birth
Powers Passageway Passenger Psyche
Dilation: enlargement of cervical os and cervical canal during first stage. 4.The forces acting to expel the fetus 2.
. Pushing efforts of mother during second stage. Effacement: shortening and thinning of the cervix during the first stage of labor 3.
mother·s rigid bony pelvis and the soft tissues of the cervix.
. pelvic floor and vagina.
midpelvis and pelvic outlet
Pelvis The false pelvis is the shallow portion above the pelvic brim The false pelcis supports the abdominal viscera
Pelvis The true pelvis lies below the pelvic brim The true pelvis consists of the pelvic inlet.
Normal female pelvis Transversely rounded or blunt Most favorable for successful labor and birth
Oval shaped Adequate outlet with a normal or moderately narrow pubic arch
Wedge-shaped or angulated Seen in males Not favorable for labor Narrow pelvic planes can cause slow descent and midpelvis arrest
making outlet inadequate.
Flat with an oval inlet Wide transverse diameter but short antero-posterior diameter.
: the Fetus
They are a natural measuring point for the delivery progress. buttocks. shoulder. If the presenting part lies below the ischial spines. The baby is said to be "engaged" in the pelvis when it is even with the ischial spines at 0
.This is the relationship between the presenting part of the baby -.the head. or feet -. the station is reported as a positive number from +1 to +5. the station is reported as a negative number from -1 to -5 (each number is a centimeter). Normally the ischial spines are the narrowest part of the pelvis. If the presenting part lies above the ischial spines.and two parts of the mother's pelvis called the ischial spines.
Nearly all (99. the fetus is said to be in a transverse lie. If the two are parallel. then the fetus is said to be in a longitudinal lie.This is the relationship between the head to tailbone axis of the fetus and the head to tailbone axis of the mother. If the two are at 90degree angles to each other.
.5%) fetuses are in a longitudinal lie.
The fetal attitude describes the relationship of the fetus' body parts to one another.
. Abnormal fetal attitudes may include a head that is extended back or other body parts extended or positioned behind the back. The normal fetal attitude is commonly referred to as the fetal position. The head is tucked down to the chest. increasing the difficulty of birth. Abnormal fetal attitudes can increase the diameter of the presenting part as it passes through the pelvis. with arms and legs drawn in towards the center of the chest.
or trunk may present first if the fetus is in a transverse lie. face. Transverse lie is more common with premature delivery or multiple pregnancies. or forehead will present first depending on the degree of extension. Rarely. because this is not the smallest part of the fetus' head. This is a more difficult delivery. This type of presentation occurs less than 1% of the time. A frank breech occurs when the hips are flexed so the legs are straight and completely drawn up toward the chest. which depend on the fetal attitude. Shoulder presentation: The shoulder.Cephalic (head-first) presentation: Cephalic presentation is considered normal and occurs in about 97% of deliveries. There are different types of cephalic presentation. It may result in a need for cesarean delivery. and the chin. the fetus' head is extended back. A cesarean delivery may be recommended for any of the fetal positions other than cephalic. A complete breech presentation occurs when the buttocks present first. Breech presentation: Breech presentation is considered abnormal and occurs about 3% of the time.
. Other breech positions occur when either the feet or knees come out first. and both the hips and knees are flexed. arm.
. It is the mental preparation of the mother for labor and deliver.The mother may experience anxiety or fear.
Cervical dilatation and effacement are progressive. Discomfort that begins in the back and radiates to the front of the abdomen. Walking intensifies contraction. rest or warm water. No change (contraction) Contractions that produce no effect on cervix
Irregular contractions that do not increase in duration and intensity. True Labor Contraction increase in duration and intensity. Resting or relaxing in warm water does not decrease the intensity of contractions. Discomfort that is felt primarilu in the abdomen Contractions that are not affected or lessened by walking.
.Leopold·s Maneuver is preferably performed after 24 weeks gestation when fetal outline can be already palpated.
(Cold hands can stimulate uterine contractions). Use the palm for palpation not the fingers. Explain procedure to the patient.
. supine with knees flexed to relax abdominal muscles. Instruct
woman to empty her bladder first. Place woman in dorsal recumbent position. Place a small pillow under the head for comfort. Drape properly to maintain privacy. Warms hands by rubbing together.
feel for the fetal part lying in the fundus. grasp the lower portion of the abdomen above symphisis pubis. downward about 2 inches above the inguinal ligament.
Second Maneuver: Umbilical Grip
To identify location of fetal back. If brow is very easily palpated.
Using both hands. To determine position.
Fourth Maneuver: Pelvic Grip
To determine the degree of flexion of Facing foot part of the woman. Use both hands. Poor atitude if examining fingers will meet an obstruction on the same side as fetal back (hyperextended head) Also palpates infant s anteroposterior position. fetus is at posterior position (occiput pointing towards woman s back)
Good attitude if brow correspond to the side (2nd maneuver) that contained the elbows and knees. Breech is less well defined that moves only in conjunction with the body. press in slightly and make gentle movements from side to side.Purpose
First Maneuver: Fundal Grip
To determine fetal part lying in the fundus.
The presenting part is not engaged if it is not movable. hard. palpate fetal head pressing To determine attitude or habitus. It is not yet engaged if it is still movable. fetal head. hard and round that moves independently of the body.
Fetal back is smooth.
One hand is used to steady the uterus on one side of the abdomen while the other hand moves slightly on a circular motion from top to the lower segment of the uterus to feel for the fetal back and small fetal parts. Use gentle but deep pressure.
Head is more firm. To determine presentation. and resistant surface Knees and elbows of fetus feel with a number of angular nodulation
Third Maneuver: Pawlik s Grip
To determine engagement of presenting part.
Using thumb and finger.
. interfering with pain sensory transmission.Provides a focus during contractions. Begin with simple breathing patterns and progress to more complex ones as needed. Promote relaxation and oxygenation.
First stage (stage of dilatation)
2 to full dilation
ambulation. Keep mother and partner informed of progress Offer fluids and ice chips Encourage voiding every 1 to 2 hours.y
Latent Phase Cervical dilatation is 0 to 4cm Uterine contractions occur every 15 to 3om minutes and are 20 to 40 second in duration and of mild intensity Mothe is talkative and eager to be in labor
Interventions Encourage mother and partner to participate in care Assist with comfort measures changes of position (left side lying).
sacral pressure. pillow support and position changes. Provide a quiet environment Keep mother and partner informed of progress.Active Phase Cervical dilatation is 4 to 7cm Uterine contractions occur every 2 to 5 mins. Instruct partner in effleurage/back rub
. Promote comfort with backrubs. Mother may experience feelings of helplessness Mother becomes restless and anxious as contractions become stronger
Interventions: Encourage maintenance of effective breathing patterns. And are 30 to 50 seconds in duration and moderate intensity.
. is restless and irritable and feels out of control
Interventions: Envoucare rest between contractions Wake mother at beginning of contraction so she can begin breathing pattern Keep mother and partner informed of progress Provide privacy Offer fluids and ice chips and ointment dry lips Encourage voiding every 1 to 2 hours. Mother becomes tired.Transition Phase
Cervical dilation is 7 to 10cm The uterine contractions occur every 2 to 3 minutes and are 45 to 90 seconds in duration and of strong intensity.
test for estrogenic activity in which cervical mucus smears form a fernlike pattern at times when estrogen secretion is elevated. and position by Leopold·s Maneuvers. during. determining frequency. Assist with pelvic examination and prepare for Nitrazine test and a fern test Nitrazine test . Assess fetal station.While vaginal pH is normally acidic. noting that the normal FHR is 120 to 160 bpm Monitor uterine contractions by palapation or monitor.0 can indicate that the amniotic sac has ruptured Fern Test .
Monitor maternal V/S Monitor FHR via:
Doppler Fetoscope Electronic fetal monitor
Assess FHR before. and intensity. presentation. duration. as at the time of ovulation. and after contraction. Assess the color of the amniotic fluid if the membranes have ruptured because meconium-stained fluid can indicate fetal distress. a pH above 7.
. Assess status of cervical dilataion and effacement.used to test vaginal pH during late pregnancy to determine the breakage of the amniotic sac.
> complete dilation to expulsion
1. lasting 60 to 70 75 seconds. duration. such as lithotomy. semi-sitting. Provide mother with encouragement and praise and provide rest between contractions Keep mother and partner informed Maintain privacy Provide ice chips and ointment for dry lips Assist mother into a position that promotes comfort and assists pushing efforts. Increase in bloody show occurs Mother feels urge to bear down. Prepare for birth. or squatiting. during and after contractions Monitor uterine contractions by palpation or monitor. determining frequency.
cervical dilation is complete progress of labor is measured by descent of fetal head through the birth canal (changes in fetal station) uterine contractions occur every 2 to 3 minutes. and the intensity is strong. and intensity. assist mother in pushing efforts. such as perineal bulging or visualization of the fetal head.kneeling.
Interventions: Perform assessments every 5minutes Monitor maternal v/s Monitor FHR Assess FHR before. Monitor for sighs of approaching. birth. side-lying.
delivery of newborn to delivery of placenta
uterine fundus remains firm and is located two fingerbreaths below the umbilicus Examine placenta for cotyledons and membranes to verify that is intact.
contractions occur until the placenta is born placental separation and expulsion occur. ans the dull red. rough maternal surface emerges from the vagina first
Assess maternal v/s Assess uterine status Provide parents with an explanation regarding birth of the placenta Following birth of the placenta. and the dull. Birth of placental occurs to 5 to 15 minutes after birth of the baby Schultz mechanism: margin of placenta separates.
. rough maternal surface emerges from the vaginal first. Asses mother for shivering and provide warmth Promote a parentalneonatal attachement. red. Duncan mechanism: margin of placenta separates.
indicating placental separation from the uterine wall. Lengthening of the cord Sudden gush of blood
.the change of shape of the uterus from discoid to ovoid.sign .
> placenta to hemostasis
in the mindline.) is moderate or scant is red. Discharges from the vagina of mucus.1 to 2 fingerbreadths below the umbilicus Lochia (.
blood pressure returns to pre-labor level pulse is slightly lower than during labor fundus remains contracted. blood. and hourly for 2 hours Provide warm blankets Apply ice packs to perineum Massage the uterus if needed and teach the mother to massage the uterus Provide breast-feeding support as needed
. following childbirth. 1-3 days after birth Lochia serosa ² brownish 4-6 after birth Lochia alba ² whitish in colo. and tissue debris. every 3o mins for 1 hour. 7-10 days after birth
Interventions: Perform maternal assessments every 15 minutes for 1 hour. vagina discharge with mucus
Lochia rubra ² bloody red in color.