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 Four Ps

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.

Labor: coordinated sequence of involuntary uterine contractions 2. Delivery: actual even of birth
1.

 Powers Passageway Passenger Psyche

The forces acting to expel the fetus 2. Effacement: shortening and thinning of the cervix during the first stage of labor 3. Dilation: enlargement of cervical os and cervical canal during first stage. 4. Pushing efforts of mother during second stage.
1.

 the

mothers rigid bony pelvis and the soft tissues of the cervix, pelvic floor and vagina.

 False

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, midpelvis and pelvic outlet
True

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

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.

Wedge-shaped or angulated Seen in males Not favorable for labor Narrow pelvic planes can cause slow descent and midpelvis arrest

Flat with an oval inlet Wide transverse diameter but short antero-posterior diameter, making outlet inadequate.

: the Fetus

This is the relationship between the presenting part of the baby -- the head, shoulder, buttocks, or feet -- and two parts of the mother's pelvis called the ischial spines. Normally the ischial spines are the narrowest part of the pelvis. They are a natural measuring point for the delivery progress. If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5 (each number is a centimeter). If the presenting part lies below the ischial spines, the station is reported as a positive number from +1 to +5. 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 head to tailbone axis of the fetus and the head to tailbone axis of the mother. If the two are parallel, then the fetus is said to be in a longitudinal lie. If the two are at 90degree angles to each other, the fetus is said to be in a transverse lie. Nearly all (99.5%) fetuses are in a longitudinal lie.

The fetal attitude describes the relationship of the fetus' body parts to one another. The normal fetal attitude is commonly referred to as the fetal position. The head is tucked down to the chest, with arms and legs drawn in towards the center of the chest. Abnormal fetal attitudes may include a head that is extended back or other body parts extended or positioned behind the back. Abnormal fetal attitudes can increase the diameter of the presenting part as it passes through the pelvis, increasing the difficulty of birth.

Cephalic (head-first) presentation: Cephalic presentation is considered normal and occurs in about 97% of deliveries. There are different types of cephalic presentation, which depend on the fetal attitude. Rarely, the fetus' head is extended back, and the chin, face, or forehead will present first depending on the degree of extension. This is a more difficult delivery, because this is not the smallest part of the fetus' head. It may result in a need for cesarean delivery. A cesarean delivery may be recommended for any of the fetal positions other than cephalic. Breech presentation: Breech presentation is considered abnormal and occurs about 3% of the time. A complete breech presentation occurs when the buttocks present first, and both the hips and knees are flexed. A frank breech occurs when the hips are flexed so the legs are straight and completely drawn up toward the chest. Other breech positions occur when either the feet or knees come out first. Shoulder presentation: The shoulder, arm, or trunk may present first if the fetus is in a transverse lie. This type of presentation occurs less than 1% of the time. Transverse lie is more common with premature delivery or multiple pregnancies.

The mother may experience anxiety or fear. It is the mental preparation of the mother for labor and deliver.

 True Labor Contraction increase in duration and intensity. Discomfort that begins in the back and radiates to the front of the abdomen. Walking intensifies contraction. Cervical dilatation and effacement are progressive. Resting or relaxing in warm water does not decrease the intensity of contractions.

False Labor

Irregular contractions that do not increase in duration and intensity. Discomfort that is felt primarilu in the abdomen Contractions that are not affected or lessened by walking, rest or warm water. No change (contraction) Contractions that produce no effect on cervix

Leopolds Maneuver is preferably performed after 24 weeks gestation when fetal outline can be already palpated.

 Instruct

woman to empty her bladder first. Place woman in dorsal recumbent position, supine with knees flexed to relax abdominal muscles. Place a small pillow under the head for comfort. Drape properly to maintain privacy. Explain procedure to the patient. Warms hands by rubbing together. (Cold hands can stimulate uterine contractions). Use the palm for palpation not the fingers.

Purpose

Procedure

Findings

First Maneuver: Fundal Grip

To determine fetal part lying in the fundus. To determine presentation.

Using both hands, feel for the fetal part lying in the fundus.

Head is more firm, hard and round that moves independently of the body. Breech is less well defined that moves only in conjunction with the body.

Second Maneuver: Umbilical Grip

To identify location of fetal back. To determine position.

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.

Fetal back is smooth, hard, 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, grasp the lower portion of the abdomen above symphisis pubis, press in slightly and make gentle movements from side to side.

The presenting part is not engaged if it is not movable. It is not yet engaged if it is still movable.

Fourth Maneuver: Pelvic Grip

To determine the degree of flexion of Facing foot part of the woman, fetal head. palpate fetal head pressing To determine attitude or habitus. downward about 2 inches above the inguinal ligament. Use both hands.

Good attitude if brow correspond to the side (2nd maneuver) that contained the elbows and knees. Poor atitude if examining fingers will meet an obstruction on the same side as fetal back (hyperextended head) Also palpates infant s anteroposterior position. If brow is very easily palpated, fetus is at posterior position (occiput pointing towards woman s back)

Provides a focus during contractions, interfering with pain sensory transmission. 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

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), ambulation. Keep mother and partner informed of progress Offer fluids and ice chips Encourage voiding every 1 to 2 hours.

Active Phase  Cervical dilatation is 4 to 7cm  Uterine contractions occur every 2 to 5 mins. And are 30 to 50 seconds in duration and moderate intensity.  Mother may experience feelings of helplessness  Mother becomes restless and anxious as contractions become stronger

Interventions: Encourage maintenance of effective breathing patterns. Provide a quiet environment Keep mother and partner informed of progress. Promote comfort with backrubs, sacral pressure, pillow support and position changes. Instruct partner in effleurage/back rub

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. Mother becomes tired, 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.

Monitor maternal V/S Monitor FHR via:

Doppler Fetoscope Electronic fetal monitor

Assess FHR before, during, and after contraction, noting that the normal FHR is 120 to 160 bpm Monitor uterine contractions by palapation or monitor, determining frequency, duration, and intensity. Assess status of cervical dilataion and effacement. Assess fetal station, presentation, and position by Leopolds Maneuvers. Assist with pelvic examination and prepare for Nitrazine test and a fern test Nitrazine test - used to test vaginal pH during late pregnancy to determine the breakage of the amniotic sac.While vaginal pH is normally acidic, a pH above 7.0 can indicate that the amniotic sac has ruptured Fern Test - test for estrogenic activity in which cervical mucus smears form a fernlike pattern at times when estrogen secretion is elevated, as at the time of ovulation. Assess the color of the amniotic fluid if the membranes have ruptured because meconium-stained fluid can indicate fetal distress.

> complete dilation to expulsion

1. Assessment

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, lasting 60 to 70 75 seconds, and the intensity is strong. Increase in bloody show occurs Mother feels urge to bear down, assist mother in pushing efforts.

Interventions: Perform assessments every 5minutes Monitor maternal v/s Monitor FHR Assess FHR before, during and after contractions Monitor uterine contractions by palpation or monitor, determining frequency, duration, and intensity. 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, such as lithotomy, semi-sitting,kneeling, side-lying, or squatiting. Monitor for sighs of approaching, birth, such as perineal bulging or visualization of the fetal head. Prepare for birth.

- delivery of newborn to delivery of placenta

contractions occur until the placenta is born placental separation and expulsion occur. Birth of placental occurs to 5 to 15 minutes after birth of the baby Schultz mechanism: margin of placenta separates, and the dull, red, rough maternal surface emerges from the vaginal first. Duncan mechanism: margin of placenta separates, ans the dull red, rough maternal surface emerges from the vagina first

Interventions:

Assess maternal v/s Assess uterine status Provide parents with an explanation regarding birth of the placenta Following birth of the placenta, uterine fundus remains firm and is located two fingerbreaths below the umbilicus Examine placenta for cotyledons and membranes to verify that is intact. Asses mother for shivering and provide warmth Promote a parentalneonatal attachement.

sign - the change of shape of the uterus from discoid to ovoid, indicating placental separation from the uterine wall. Lengthening of the cord Sudden gush of blood
Calkins

> placenta to hemostasis

Assessment
blood pressure returns to pre-labor level pulse is slightly lower than during labor fundus remains contracted, in the mindline,1 to 2 fingerbreadths below the umbilicus Lochia (. Discharges from the vagina of mucus, blood, and tissue debris, following childbirth.) is moderate or scant is red; vagina discharge with mucus

Lochia rubra bloody red in color, 1-3 days after birth Lochia serosa brownish 4-6 after birth Lochia alba whitish in colo, 7-10 days after birth

Interventions: Perform maternal assessments every 15 minutes for 1 hour, every 3o mins for 1 hour, 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