labor and delivery.pptx

Chapter 7 Body Systems

Labor and Delivery

Prepared By/ Dr. Nagwa Ibrahim

Labor and Delivery Labor is a physiologic process during which the products of conception (ie, the fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterusLabor is a clinical diagnosis. The onset of labor is defined as regular, painful uterine contractions resulting in progressive cervical effacement and dilatation.

2Cervical dilatation in the absence of uterine contraction suggests cervical insufficiency, whereas uterine contraction without cervical change does not meet the definition of labor.3The delivery process is described in some terms :1- Fetal position Refers to the orientation of the fetus within the birth canal , It can be :

4Occiput Anterior(OA)Occiput anterior is usually the easiest position for the fetal head to traverse the maternal pelvis.

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Left Occiput Anterior(LOA)The fetal occiput is directed towards the mother's left, anterior side.

Right Occiput Anterior (ROA)The fetal occiput is directed towards the mother's right, anterior side

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Occiput Posterior (OP)

Right Occiput Posterior (ROP)

Left Occiput Posterior (LOP)7

Left Occiput Transverse (LOT)

Right Occiput Transverse (ROT)

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Fetal lie : Relationship of long axis of fetus [spine] to long axis of motherIf the two are parallel, then the fetus is said to be in a longitudinal lie. If the two are at 90-degree angles to each other, the fetus is said to be in a transverse lie. Nearly all (99.5%) fetuses are in a longitudinal lie.

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Longitudinal lie. Transverse lie. Fetal attitude:This is the degree of flexion of the fetus body parts (body, head, and extremities) to each otherTypes of Fetal attitude(a) Complete flexion. This is normal attitude in cephalic presentation. there is complete flexion at the head when the fetus "chin is on his chest." This allows the smallest cephalic diameter to enter the pelvis, which gives the fewest mechanical problems with delivery.11b) Moderate flexion. In cephalic presentation, the fetus head is only partially flexed or not flexed. A larger diameter of the head would be coming through the passageway(c) Poor flexion. the fetus head is extended or bent backwards.. It is difficult to deliver because the widest diameter of the head enters the pelvis first. This type of cephalic presentation may require a C/Section if the attitude cannot be changed.12(d) Hyperextended. the fetus head is extended all the way back. This allows a face or chin to present first in the pelvis. 1314

Complete flexionModerate flexionPoor flexionHyperextendedFetal station: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.

15If 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 station.

16Copyright 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.17

Fetal presentationThe part of the fetus that is "presenting" at the cervixA ) Cephalic (head) presentation:Cephalic presentation is considered normal and occurs in about 97% of deliveries. There are different types of cephalic presentation1819

1- Face presentation2- vertex presentation3- Brow presentationB ) Breech presentation:Breech presentation is considered abnormal. 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. Other breech positions occur when either the feet or knees come out first.

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Frank Breech c) 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 pregnancies22

First Stage of Labor The first stage begins with regular uterine contractions and ends with complete cervical dilatation at 10 cmDivided into :Early laborActive laborTransition laborStages of Labor The labor divided into four stages :1- Early labor :Defined by cervical dilation of 0 to 3 cm Contractions occurring every 5 to 20 minutes and lasting 30 to 45 seconds In this stage, mother typically notices backache and mild discomfort

Contractions progress over time, becoming longer, stronger, and closer togetherBetween contractions, mother feels relatively normal and pain freeFor first-time mothers, may last 8 to 20 hoursWith subsequent births, stage lasts 6 to 8 hours or less2- Active labor :Defined by cervical dilation of 4 to 8 cm, and contractions 4 to 5 minutes apart, lasting about 60 secondsMarks beginning of intense contractionsBetween contractions, mother may experience trembling, nausea, vomitingRelaxation and slowed breathing between contractions often is comforting to motherUsually lasts 1 to 2 hoursCopyright 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.28

3- Transition Labor :Defined by cervical dilation of 8 to 10 cmContractions are about 2 to 3 minutes apart and last for about 60 to 90 secondsContractions are intense and may occur with little rest for mother in betweenMay be accompanied by rectal pressure if baby's head is positioned lowIn many pregnancies, amniotic sac ruptures (rupture of membranes) toward end of first stage Period of transition lasts only 15 to 30 minutes on average Copyright 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.31

Management of First stage of laborAdmission assessment Obtain a verbal history and perform an assessment of the woman including: Relevant medical/obstetric history Frequency and duration of contractions Pain intensity of the contractions Assessing if the membranes are ruptured32The fetus' movementsThe presence or absence of vaginal bleeding.Baby lightening : the fetus' head is descent into the pelvis. The mother may feel that her baby has become light , Her breathing may be relieved because tension on the diaphragm is reduced, whereas urination may become more frequent due to the added pressure on the urinary bladder.

33Maternal observationsMonitor the maternal vital signsAssess the fetus' presentationAssess the frequency, duration, and intensity of uterine contractions Women with ruptured membranes should have the amniotic fluid loss checked for colour, consistency and odor34Monitor the progress of labor by: Assessing the contractions Abdominal palpation Vaginal examination Fetal well-being assessment :Auscultate the fetal heart rate (FHR)Notify any deviations from normal labor as soon as possible35Allow the mother to: Ambulate as they desire Diet as desired( low fat, low roughage diet )and encourage oral hydration In the latent phase Select comfortable positions ( left side position). Advise the woman to avoid the supine position Empty her bladder prior to abdominal or vaginal assessment and void 2 hourly in the active phase of labor

36Second Stage of Labor The second stage begins with complete cervical dilatation and ends with the delivery of the fetus. Fetal head enters birth canalContractions become more intense and frequent (usually 2 to 3 minutes apart)Often mother becomes diaphoretic and tachycardiac during this stageCopyright 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.38

Experiences an urge to bear down with each contractionMay express need to have bowel movementNormal sensation caused by pressure of fetal head against mothers rectumMucous plug (sometimes mixed with blood, thus name bloody show) is expelled from dilating cervix and discharged from vaginaPresenting part of fetus (usually head) emerges from vaginal openingKnown as crowning, indicates delivery is imminentUsually lasts 1 to 2 hours in nullipara motherUsually lasts 30 minutes or less in multipara mother Signs and Symptoms of False LaborLighteningIrregular intermittent contractionsCervical changes: cervix dilates slightly Baby's head in pelvis pushes against cervix causing relaxation41Signs and Symptoms of Imminent Delivery Regular contractions lasting 45 to 60 seconds at 1- to 2-minute intervalsIntervals are measured from beginning of one contraction to beginning of nextMother has urge to bear down or has sensation of bowel movementLarge amount of bloody show and Rupture of MembranesCrowning occurs

Mechanism of LaborPassage of fetus through birth canal involves position changes called: Cardinal Movements of LaborThe cardinal movements are described as seven movements43Engagement: presenting part enters midpoint of pelvis at ischial spines, the presenting part is at 0 station Descent :The downward passage of the presenting part through the pelvis. This occurs intermittently with contractions. 443. Flexion : pressure from pelvic floor causes head to flex towards chest and chin touches chest.4. Internal rotation :As the head descends, the presenting part, usually in the transverse position, is rotated about 45 to anteroposterior (AP) position under the symphysis

455. Extension :Upward resistance from the pelvic floor and the downward forces from the uterine contractions cause the occiput to extend and rotate around the symphysis. This is followed by the delivery of the head466. Restitution and external rotation :When the fetus' head is free of resistance, it untwists about 45 left or right, returning to its original anatomic position in relation to the body.

477. Expulsion :After the fetus' head is delivered, further descent brings the anterior shoulder to the level of the pubic symphysis. The anterior shoulder is then rotated under the symphysis and delivered , followed by delivery the posterior shoulder and the rest of the fetus.


Preparation for Delivery :When preparing for delivery, try to provide area of privacyMother should be positioned on a bed, stretcher, or tableSurface should be long enough to project beyond mothers vaginaManagement of second stage of laborDelivery area should be as clean as possibleShould be covered with absorbent material to guard against staining and contamination by blood and fecal materialMother should be placed in dorsal lithotomy positionKnees should be flexed and widely separatedVaginal area should be draped appropriatelyPillow or blanket, if available, should be placed beneath mothers buttocksCopyright 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.52

Dorsal lithotomy positionEvaluate mothers vital signs for baseline measurementsMonitor fetal heart for signs of fetal distress at least every 5 minutes and after each contractions Advise mother should be bear down and push during contractions and to rest between contractions to conserve strength

If mother finds it difficult to refrain from pushing, should be encouraged to breathe deeply or through her mouth between contractionsDeep breathing help decrease force of bearing down and promote restAid in delivery of infant :Ritgen maneuver Modified Ritgen maneuver can be performed to deliver the head , By the time the head distends : * One hand: a towel-draped, gloved hand may be exert forward pressure on the chin of the fetus through the perineum just in front of the coccyx* The other hand: exerts pressure superiorly against occiput ,Thus, the head is delivered


Ritgen maneuverSuction infants mouth and nose with bulb syringe to clear airway but before next contraction

Check the fetus' neck for a wrapped umbilical cordIf the cord is wrapped too tightly to be removed, the cord can be double clamped and cutDeliver the anterior shoulder57

Copyright 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.58

Guide infants head downward to deliver anterior shoulder Next, the fetus' anterior shoulder is delivered with gentle downward traction on its head and chin. And upward pressure in the opposite direction facilitates delivery of the posterior shoulderThe rest of the fetus should now be easily delivered with gentle traction away from the mother59Copyright 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.60

Clamping and cutting the cordAfter delivery, the infant is placed at the levelof vagina for 3 min, the fetoplacental circulationis not occluded :80 ml of blood shift to the fetus -> then clamps the cord


Take following steps to manage umbilical cord :Clamp cord about 4 to 6 inches away from infant in two placesCut between two clamps with sterile scissorsExamine cut ends of cord to ensure there is no bleedingHandle cord carefully at all times because it can tear easilyCopyright 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.64

Evaluation of the Infant After delivery, infant should be positioned on side or with padding under back if neededClear airway and provide tactile stimulation to initiate respirationsIf no need for resuscitation, assign an Apgar score at 1 minute and 5 minutes to evaluate in infant cesarean sectionDefinition :Is a surgical procedure to deliver the baby through incisions in the abdominal and uterine wall.66Indications of cesarean sectionCephalopelvic disproportion: the head of the foetus is too large to come through the pelvis.Small pelvisUterine Inertia : Inefficient uterine contraction.Placenta pravia : Implantation of placenta in the lower uterine segment.Premature separation of placenta6768

Small pelvisMalposition and malpresentationPre-eclamsiaDiabetes ( causes over size of the fetus. )Cardiac diseases.Vaginal scaring.multiple births


Cervical dystoctia (failure of the cervix to dilate in spite of strong contraction of the uterus). Prolapse of the umbilical cord.Fetal distress.Previous Cesarean SectionsMaternal hypertension

71Types of cesarean sectionA midline longitudinal incision

The lower uterine segment section

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Complications of cesarean sectionRespiratory complications: due to effects of pain, immobilization in post operative period and anaesthesia.So Encourage deep breathing exercises.Teach the patient to cough (the abdomen must be supported by the patients hands and/or towel)

73Excessive abdominal pain due to:Wound infection.Haematoma.Excessive localized edema.Intestinal complications.Haemorrhage74Begins with delivery of infant and ends when placenta is expelled and uterus has contracted

Length of this stage varies from 5 to 30 minutesThird Stage of Labor Delivery of the Placenta During this period, uterine contraction decreases basal blood flow, whichresults in thickening and reduction in the surface area of the myometrium underlying the placenta with subsequent detachment of the placentaSigns of placental separation from the uterus: 1. uterus become globular and firmer 2. Sudden gush of blood 3. Uterus rises in the abdomen because the placenta passes down 4. The umbilical cord protruded out of the vagina. indicating that the placenta has descended

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Management of third stage of laborAllowing the placenta to deliver spontaneouslyExcessive traction should not be applied to the cord to avoid inverting the uterus, which can cause severe postpartum hemorrhageOxytocin can be administered throughout the third stage to facilitate placental separation by inducing uterine contractions and to decrease bleeding.

The placenta can also be manually separated by passing a hand between the placenta and uterine wall. After the placenta is delivered, inspect it for completeness and for the presence of 1 umbilical vein and 2 umbilical arteries When placenta is expelled, should be placed in plastic bag or other container 81Pieces of placenta retained in uterus can cause persistent hemorrhage and infectionAfter the placenta is delivered, Palpate the patient's abdomen to confirm reduction in the size of the uterus and its firmness. Ongoing blood loss and a boggy uterus suggest uterine atony

Initiate fundal massage to promote uterine contractionMonitor mother for signs of hemorrhage or shockExamination of the birth canal, including the cervix and the vagina, the perineum, and the distal rectum, is warranted, and repair of episiotomy or perineal /vaginal lacerations should be carried out.

83EPISIOTOMY AND REPAIR Episiotomy is an incision on perineum to enlarge vaginal outletPurposes of episiotomy - Easier to repair - Postoperative pain is less - Healing improved 84Timing of episiotomywhen the head is visible during a contraction to a diameter of 3 to 4 cmTiming of the repair of episiotomyAfter the placenta has been deliveredSuture material 3-0 chromic catgut

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Fourth Stage of Labor The fourth stage of labor is the period from the delivery of the placenta until the uterus remains firm on its own. In this stabilization phase, the uterus makes its initial readjustment to the non pregnant state. The primary goal is to prevent hemorrhage from the uterine atony and the cervical or vaginal lacerations.NOTE :Atony is the lack of normal muscle tone. Uterine atony is failure of the uterus to contract.

86NURSING CARE DURING THE FOURTH STAGE OF LABORTransfer the patient from the delivery table. Remove the drapes and soiled linen. Remove both legs from the stirrups at the same time and then lower both legs down at the same time to prevent cramping. Assist the patient to move from the table to the bed.

87Provide care of the perineum. An ice pack may be applied to the perineum to reduce swelling from episiotomy especially if a fourth degree tear has occurred and to reduce swelling from manual manipulation of the perineum during labor from all the exams. Apply a clean perineal pad between the legs.

88Transfer the patient to the recovery room. This will be done after you place a clean gown on the patient, obtained a complete set of vital signs, evaluated the fundal height and firmness, and evaluated the lochia.

89Ensure emergency equipment is available in the recovery room for possible complications.(1) Suction and oxygen in case patient becomes eclamptic.(2) Pitocinis available in the event of hemorrhage.(3) IV remains patent for possible use if complications develop.Check the fundus.(1) Ensure the fundus remains firm.(2) Massage the fundus until it is firm if the uterus should relax

90(3) Massage the fundus every 15 minutes during the first hour, every 30 minutes during the next hour, and then, every hour until the patient is ready for transfer.(4) Inform the physician if the fundus remains boggy after being massaged.


Massaging the fundusNOTE: A boggy uterus many indicate uterine atony or retained placental fragments. Boggy refers to being inadequately contracted and having a spongy rather than firm feeling..Monitor lochia flow. Lochia is the maternal discharge of blood, mucus, and tissue from the uterus. This may last for several weeks after birth.

93(1) Keep a pad count. Record the number of pads soaked with lochia during recovery.(2) Identify presence of bright red bleeding or blood clots.(3) Document thick, foul-smelling lochia.(4) Observe for constant trickle of bright red lochia. This may indicate lacerations.(5) Identify lochia amounts as small, moderate, or heavy (large)

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Observe the mother for chills. The cause of the mother being chilled following birth is unknown. However, it refers primarily to the result of circulatory changes after delivery. The best means of relief is to cover the mother with a warm blanket.

96Monitor the patient's vital signs and general condition.Observe patient's urinary bladder for distention. Be able to recognize the difference between a full bladder and a fundusCharacteristics of a full bladder.(a) Bulging of the lower abdomen(b) Spongy feeling mass between the fundus and the pubis.(c) Displaced uterus from the midline, usually to the right.(d) Increased lochia flow.

9798Bulging of the lower abdomen

Evaluate the perineal area for signs of edema and/or hematomaObserve for signs of hemorrhage.(1) Uterine atony.(2) Vaginal or cervical lacerations.(3) Retained placental fragments.(4) Bladder distention.(5) Severe hematoma in vagina or surrounding perineum.

99Delivery Complications1 ) Premature Rupture of the Membranes /PROMPremature rupture of membranes (PROM) is a rupture (breaking open) of the membranes (amniotic sac) before labor beginsIn most cases, the cause of PROM is unknown. Some causes or risk factors may be:Infections of the uterus, cervix, or vaginaPoor eating or drinking

100Too much stretching of the amniotic sac (this may happen if there is too much fluid, or more than one baby putting pressure on the membranes)SmokingPrevious history of PROMNatural weakening of the membranes or from the force of contractions101What are the symptoms of PROM?leaking or a gush of watery fluid from the vagina Constant wetness in panties Treatment and Nursing Care:Bed rest, no intercourseAssess time membranes ruptures and if labor startedCheck temperature frequently

102Describe character of amniotic fluidCheck WBCProvide psychological supportMonitoring for signs of infection such as fever, pain, increased fetal heart rate, and/or laboratory tests


2) Prolapsed Umbilical CordThe umbilical cord drops (prolapses) through the open cervix into the vagina ahead of the baby.Causes of umbilical cord prolapse :Premature rupture of the membranesPremature delivery of the babyDelivering more than one baby per pregnancy (twins, triplets, etc.)

105Excessive amniotic fluidBreech delivery (the baby comes through the birth canal feet first)An umbilical cord that is longer than usualUmbilical cord prolapse presents a great danger to the fetus , the fetus can put stress on the cord. This can result in a loss of oxygen to the fetus, and may even result in a stillbirth.

106How is an umbilical cord prolapse detected?Use a fetal heart monitor to measure the babys heart rate. If the umbilical cord has prolapsed, the baby may have bradycardia Conduct a pelvic examination and may see the prolapsed cord, or palpate the cord with the fingers.


Management of Prolapsed umbilical cords Immediate delivery is the best solutionPalpate FHTs, NEVER ATTEMPT TO REPLACE CORD!Give O2 per mask to the motherCover exposed cord with sterile wet gauze Will minimize temperature changes that may cause umbilical artery spasmInstruct mother to pant with each contraction to prevent bearing down


5.6.7.3 ) Abnormal Presentation Most infants are born head first (cephalic or vertex presentation)Sometimes presentation is abnormal :Breech presentationShoulder presentationBreech DeliveryMost babies will move into delivery position a few weeks prior to birth with the head moving closer to the birth canal. When this fails to happen, the babys buttocks and/or feet will be positioned to be delivered first. This is referred to as "breech presentation112Categories of breech presentation :Frank breechFetal hips are flexed and legs extend in front of fetusButtocks are presenting partComplete breechFetus has both knees and hips flexedButtocks are presenting partIncomplete breechFetus has one or both hips incompletely flexedResults in presentation of one or both lower extremities (often foot)

Figure 46-14. Types of breech presentation. (A) Front or back. (B) Complete. (C) Incomplete.114Causes A Breech Presentation: Most common causes are:Abnormal shape of the pelvis, uterusAnatomical malformation of the fetusExcessive amniotic fluid (polyhydramnios). In pregnancies of multiples

115ManagementInfant in breech presentation is best delivered in hospital where emergency cesarean section is alternative to vaginal delivery116Shoulder DystociaOccurs when fetal shoulders are wedged against maternal symphysis pubisIn this presentation, head delivers normally but then pulls back tightly against maternal perineum

Common condition in pregnancyComplications :Brachial plexus damageFractured clavicleFetal anoxia from cord compressionManagementPosition mother on her left side in dorsal-knee-chest positionThis increases diameter of pelvisTry to guide infants head downward to allow anterior shoulder to slip under symphysis pubisAvoid excessive force or manipulationCopyright 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.120

Dorsal-knee-chest positionGently rotate fetal shoulder girdle at angle to wider pelvic openingPosterior shoulder usually delivers without resistanceAnterior shoulder usually followsAfter delivery, continue with resuscitative measures as neededCopyright 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.122

Shoulder PresentationResults when long axis of fetus lies perpendicular to that of motherPosition usually results in fetal shoulder lying over pelvic openingFetal arm or hand may be presenting partCopyright 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.124

ManagementNormal delivery of a presentation is not possibleProvide mother with adequate oxygen, ventilatory and circulatory support, and rapid transport Cesarean delivery is required whether fetus is viable or notRuptured UterusSpontaneous or traumatic rupture of the uterusEtiology: Rupture of a previous C-birth scarProlonged laborInjudicious use of Pitocin -- overstimulationExcessive manual pressure applied to the fundus during delivery

126Signs and Symptoms:Sudden sharp abdominal pain, abdominal tendernessCessation of contractionsAbsence of fetal heart tonesShockTherapeutic Interventions:Deliver the baby ! / Cesarean Delivery


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labor and delivery.pptx

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