lecture 5. labor is the physiologic process by which a fetus is expelled from the uterus to the...

Labor and delivery

Lecture 5

Labor is the physiologic process by which a fetus is expelled from the uterus to the outside world.

Changes in the uterine cervix tend to precede uterine contractions.

Definition

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What causes Labor?

• The process begins between 38 and 40th week.

• The exact cause of onset is not understood.• There are several hypothesis: Progesterone

withdrawal → relaxation of the myometrium, whereas estrogen stimulates myometrial contractions and production of prostaglandins.

• Oxytocin, a hormone produced by the pituitary, stimulates the uterus to contract.

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SIGNS OF IMPENDING LABOR

• Lightening• contractions• Cervical changes: Effacement• Bloody show: labor 24-48 hrs• Rupture of membranes (ROM)• GI disturbance: N/V, diarrhea, weight loss• Sudden burst of energy (nesting)

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Uterine contractions have two major goals:

To dilate cervixTo push the fetus through the birth canal

Success will depend on the four P’s: Powers Passenger PassagePsyche

Labor – Mechanics

Uterine contractions• Power refers to the force generated by the contraction of the uterine myometrium• Uterine contractions increase intrauterine pressure, causing tension on the cervix. This tension leads to cervical dilation and thinning, which in turn eventually forces the fetus through the

birth canal. •Uterine contractions during labor are monitored by palpation

and by electronic monitoring.

1. Power

Generally 3-5 contractions in a 10 minute period is considered adequate labor

Power

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Contractions

DURATION OF CONTRATION • 10:00 45 seconds • 10:10 45 seconds • 10:15 60 seconds • 10:20 55 seconds

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Passenger =fetus

Fetal variables that can affect labor:•Fetal size•Fetal Lie – longitudinal, transverse or oblique•Fetal presentation – vertex, breech, shoulder, compound (vertex and hand).

Position Station – degree of descent of the presenting part of the fetus, measured in centimeters from the ischial spines

Passenger

Passage = PelvisConsists of the bony pelvis and soft tissues of the birth canal (cervix, pelvic floor musculature)Small pelvic outlet can result in cephalopelvic disproportionX-ray pelvimetry to determine the smallest A-P diameter through which the fetal head must pass.

Passage

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Fetal presentation-the part of the fetus that enters the maternal pelvis first.

Descent

• Fetal head descends through the birth canal

• Defined relative to the ischial spines

• 0 station = top of head at the spines (fully engaged)

• +2 station = 2 cm past (below) the ischial spines

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Fetal Descent Stations.• Measured in neg. & pos. numbers.

(Centimeters)• The ischial spine is in (0) Station• If the presenting part is higher

than the ischial spine, the station has a (-) neg.

• Positive = presenting part has passed the ischial spine.

• Positive (+) 4 is at the outlet.

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Cervical Effacement and Dilatation

• Cervical Effacement: the progressive shortening and thinning of the cervix during labor. 0 – 100%

• Cervical Dilatation: the increase in diameter of the cervical opening measured in centimeters. 0 – 10 cm.

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True Labor

• Contractions produce progressive dilatation and enfacement of the cervix.

• Occur regularly and increase in frequency, duration, and intensity.

• The discomfort of true labor contractions usually starts in the back and radiates around to the abdomen

• Not relieved by walking.

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True and False Labor Contractions

True Labor False Labor

•Result in progressive cervical dilation •Do not result in progressive cervical dilation

• Occur at regular intervals • Occur at irregular intervals

•Interval between contractions decreases

•Interval between contractions remains the same or increases

•Frequency, duration, and intensity increase

•Intensity decreases or remains the same

•Located mainly in back and abdomen •Located mainly in lower abdomen and groin

•Generally intensified by walking •Generally unaffected by walking

•Not easily disrupted by medications •Generally relieved by mild sedation

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MATERNAL SYSTEMIC RESPONSES TO LABOR

• CV system–cardiac output increases.• Respiratory system–oxygen consumption during labor equals

moderate to strenuous exercise.• Renal system–with engagement, bladder pushed forward and

upward.• GI system–peristalsis and absorption decrease.• Fluid and Electrolyte balance–body temperature increases and

client perspires profusely.• Immune system–white blood count increases• Integumentary system–vagina and perineum have great ability to

stretch.• Musculoskeletal system–relaxation of pelvic joints, may result in

backache.• Neurological system–endorphins increase pain threshold,

sedative effect. 6/30/2012

Stage of labor : 1. First stage

2. Second stage 3. Third stage

4. fourth stage

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Stages of Labor

• First stage: early, active, transition– Dilatation

• Second stage– Pushing and birth

• Third stage– Delivery of placenta

• Fourth stage– Postpartum

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Stages of labor

The Labor Curve

First stage - A: latent phase; B + C + D: active phase; B: acceleration; C: maximum slope of dilation; D: deceleration; E: second stage.Adapted from: Friedman. Labor: Clinical evaluation and management, 2nd ed, Appleton, New York 1978.

Dilation from 0 to 10 cm.Begins with the first true labor contractions and ends with complete effacement and dilation of the cervix (10 cm dilation).The first stage of labor averages about 13½ hours for a nullipara and about 7½ hours for a multipara.It has three phases:

- Latent or Early- Active- Panting or transition

First stage

• Dilates from 0 to 3 cm.• Contractions are usually every 5 to 20 minutes, lasting 20 to 40 seconds, and of mild intensity.• The contractions progress to about every 5 minutes and establish a regular pattern.

First stage – latent (early)

First stage – latent (early) : role of the nurse

-- Nursing diagnosis -- Nursing intervention

•Deficient Fluid Volume related to decreased oral

intake

•Anxiety related to concern for self and the fetus

•Acute Pain related to uterine contractions or

position of the fetus

Nursing diagnosis

Maintaining Nutrition and Hydration• Provide clear liquids and ice chips as allowed.• Evaluate urine for ketones and glucose.• Administer I.V. fluids as indicated.

Relieving Anxiety• Establish a relationship with the

woman/support persons.• Provide information on the health care

facility's policies and procedures. • Inform the woman of maternal status and fetal

status and labor progress.• Explain all procedures and equipment used

during labor.• Answer any questions the woman has.• Review the birth plan and make appropriate

revisions.• Monitor maternal vital signs. • Remember the individual patient condition is

used to determine frequency of vital signs and FHR assessment.

Nursing intervention

Controlling PainEncourage ambulation as tolerated regardless of

membrane status as long as presenting part is engaged. (This may vary according to health care provider.)

Encourage diversional activities, such as reading, talking, watching TV, playing cards, listening to music.

Review, evaluate, and teach proper breathing techniques.

Encourage a warm shower. Laboring woman can sit on a chair in the shower

with the water running continuously over her lower back.

Encourage relaxation techniques.Provide comfort measures.Use of Jacuzzi or shower for relaxation if

available.Reposition external monitors as needed.

Nursing intervention

Dilates from 4 to 7 cm.Contractions are usually every 2 to 5 minutes; lasting 30 to 50 seconds and of mild to moderate intensity.After reaching the active phase, dilation averages 1.2 cm/hour in the nullipara and1.5 cm/hour in the multipara.

First stage – Active phase

Dilates from 8 to 10 cm.Contractions are every 2 to 3 minutes, lasting 50 to 60 seconds and of moderate to strong intensity. Some contractions may last up to (but not exceed) 90 seconds.

First stage – Transitional Phase

First stage – Active and Transitional phase : role of the nurse


Nursing Diagnosis

• Anxiety related to concern for self and fetus

• Acute Pain related to uterine contractions

• Impaired Urinary Elimination related to epidural anesthesia or from pressure of the fetus

• Ineffective Coping related to discomfort

• Risk for Infection related to rupture of the membranes

• Impaired Physical Mobility related to medical interventions and discomfort

• Ineffective Breathing Pattern related to pain and fatigue

Nursing interventions

Relieving AnxietyMonitor maternal vital signs and FHR, and keep the woman/couple informed of the maternal and fetus status.Maternal temperature every 2 to 4 hours unless elevated or membranes ruptured, then every 1 hour.Blood pressure, pulse, respirations usually every 30 to 60 minutes or as indicated by policy or maternal status.Evaluate FHR every 30 minutes if low-risk patient or every 15 minutes if high risk patient regardless if monitoring is continuous or intermittent. Provide encouragement and support. Involve the support person in the woman's care.

Nursing interventions

Minimizing PainEncourage position changes for comfort.Assist the woman with breathing and relaxation techniques as needed.Provide back, leg, and shoulder massage as needed.Assist with preparation for analgesia and anesthesia

Nursing interventions Monitor the woman following administration of analgesia/anaesthesia. Monitor the woman's blood pressure, pulse, and

respiratory rate after initiation or re-bolus of regional block every 5 minutes for the first 15 minutes.

Assess neonate for effects of maternal medication (neurobehavioral change, such as decreased motor tone and decreased respiratory rate).

Second stage: Expulsion Begins with complete dilation (10 cm cervix dilation) and ends with birth of the baby.The second stage may last from 1 to 4 hours in the nullipara and from 20 to 45 minutes in the multipara.Characterized by descent of the presenting part through the maternal pelvis and expulsion of the fetus.Indications of second stage:

Pelvic/rectal pressureMother has active role of pushing to aid in fetal descent.

Second stage: Expulsion

Examining the fetal head during the second stage may become difficult due to molding

Molding is the alteration of the fetal cranial bones to each other as a result of compressive forces of the maternal bony pelvis.Caput is the localized edematous area on the fetal scalp caused by pressure on the scalp by the cervix.

Second Stage – Expulsion -- Nursing diagnosis

Fear or Anxiety related to impending delivery

Acute Pain related to descent of the fetus

Risk for Infection related to episiotomy and tissue trauma

-- Nursing intervention

Minimizing Fear and Anxiety Monitor maternal vital signs as follows:

- Blood pressure every 5 to 15 minutes depending on the woman's status.- Pulse and respirations every 15 to 30 minutes.- Temperature every 1 hour when membranes have ruptured.

Monitor FHR and uterine contractions every 15 minutes in low-risk women and every 5 minutes in high-risk women.

Explain procedures and equipment during pushing and delivery.

Keep the woman or couple informed of their status.


Promoting Comfort Assist the woman to a comfortable position.Left or right lateral, or semi-sitting positions may be used.

Teach the woman to put her chin to her chest so her body forms and shape while pushing.

Evaluate bladder fullness, and encourage voiding or catheterize as needed.

Evaluate effectiveness of anaesthesia as indicated.


Preventing Infection and Promoting Safety• Prepare the delivery room using aseptic

technique• allowing ample time for setup before delivery.• Prepare the infant resuscitation area for delivery.• Prepare necessary items for neonatal care.• Notify necessary personnel to prepare for

delivery. If delivery room is to be used, transfer the

primigravida to the delivery room when the fetal head is crowning. The multigravida is taken earlier depending on fetal size and speed of fetal descent.

• Place all side rails up before moving. Instruct the woman to keep her hands off the rails, and move from the bed to the delivery table between contractions.


If delivering in LDR (Labor, Delivery,

Recovery) or LDRP (Labor, Delivery,

Recovery, Postpartum) room, prepare labor

bed for delivery in accordance with

manufacturer's instructions. Prepare infant

warmer and remainder of room for delivery.

Position the woman for delivery using a large

cushion for her head, back, and shoulders.

Elevate the head of the bed. Stirrups or

footrests may be used for foot support. Pad

the stirrups.


Clean the vulva and perineal areas when the woman is positioned for delivery.Guide the woman step by step during the delivery process.Practice standard precautions during labor and delivery.

Episiotomy

• Avoids lacerations• Provides more room for

obstetrical maneuvers• Shortens the 2nd Stage Labor• Midline associated with

greater risk of rectal lacerations, but heals faster

• Many women don’t need them.

Third Stage – Placental

Begins with delivery of the baby and ends with delivery of the placenta.The third stage may last from a few minutes to 30 minutes.Three signs of placental separation:

• Lengthening of umbilical cord• Gush of blood• Fundus becomes globular and more

anteverted against abdominalPlacenta is delivered using one hand on umbilical cord with gentle downward traction. Other hand on abdomen supporting the uterine fundus.Risk factor for aggressive traction is uterine inversion.

Clamp and Cut the Cord

• Clamp about an inch from the baby’s abdomen

• Use any available instruments or usable material

• Check the cord for 3-vessels, 2 small arteries and one larger vein

- Third stage – Placental : role of the nurse


Nursing diagnosis

Impaired Tissue Integrity related to placental separation

Risk for Injury related to potential hemorrhage

Nursing Interventions

Promoting Tissue Integrity Ask the woman to bear down gently. Observe for the signs of placental separation.

• The uterus rises upward in the abdomen.

• The umbilical cord lengthens.• Trickle or spurt of blood appears.• The uterus becomes globular in shape.

Evaluate the placenta for size, shape, and cord site implantation.


Preventing Hemorrhage

• Ensure accurate measurement of intake and output maintained throughout labor and delivery.Immediately after delivery of the placenta.

• Administer oxytocin (Pitocin 10 to 40 units/L at 100 mU/min) either I.V. or I.M. as directed by facility policy and provider.Infuse as bolus initially, then titrate to uterus (ie, if uterus is firm, decrease the infusion; if boggy, leave as bolus). Pitocin should never be administered I.V. push as it can cause cardiac dysrhythmia and death.


• Immediately after initiating Pitocin, massage uterine fundus until firm. Uterine massage is done with two hands, one at the lower uterine segment above the symphysis pubis and the other hand gently massages the fundus.

• Check to see that the placenta and membranes are complete.

• Evaluate and massage the uterine fundus until firm.

• If bleeding continues and uterus is firm, notify health care provider for evaluation of lacerations or retained placental fragments.

• Inspection and repair of lacerations of the vagina and cervix are made by the health care provider.


If still no relief, notify health care provider and prepare patient for possible surgery (dilation and curettage, blood Transfusion)

Immediate Care for Neonate Nursing Diagnosis

Nursing Intervention

Immediate Care for Neonate: Diagnosis

• Ineffective Airway Clearance related to nasal and oral secretions from delivery• Ineffective Thermoregulation related to environment and immature ability for adaptation• Risk for Injury related to immature defenses of the neonate

Immediate Care for Neonate: Interventions

Promoting Airway Clearance and Transitioning of the Neonate1. Transitioning/close observation of the

neonate is essential for at least 6 to 12 hours after birth.

2. Wipe mucus from the face and mouth and nose. Aspirate with a bulb syringe.

3. Clamp the umbilical cord approximately 1 inch (2.5 cm) from the abdominal wall with a cord clamp.

4. Evaluate the neonate's condition by the Apgar scoring system at 1 and 5 minutes after birth


Promoting Thermoregulation1. Dry the neonate immediately after delivery,

remove wet towels, and place infant on warm dry towels. A wet, small neonate loses up to 200 cal/kg/min in the delivery room through evaporation, convection, conduction, and radiation. Drying the infant cuts this heat loss in half.

2. Cover the neonate's head with a cotton stocking cap to prevent heat loss.

3. Wrap the neonate in warm blankets.4. Place the neonate under a radiant heat warmer,

or place the neonate on the mother's abdomen with skin-to-skin contact.

5. Provide a warm, draft-free environment for the neonate.

6. Take the neonate's axillary temperature a normal temperature is between (36.4 and 37.2 C).


Preventing Injury and Infection

1. Administer prophylactic treatment against ophthalmia neonatorum (gonorrheal or chlamydial).

2. Administer a single parental prophylactic injection of vitamin K within 1 hour of birth.This is done to prevent a vitamin K-dependent

hemorrhagic disease of the neonate.If the parents do not want the vitamin K administered,

inform the parents that circumcision may not be performed. However, inform parents that the Vitamin K levels will reach their peak (without neonatal injection) at 8 days after birth.


While in the delivery room (DR), place identical identification bracelets on the mother and the neonate.The nurse in the DR should be responsible for preparing and securely fastening the bands on the neonate.

Information includes the mother's name, hospital / admission number, neonate's sex, race, and date and time of birth.Foot printing and finger printing the neonate are not adequate methods of patient identification.Complete all identification procedures before the infant is taken from the delivery room.


Weigh and measure the infant shortly after birth.

Normal neonate weight is (2,700 to 4,000 g).Normal neonate length is (48 to 53 cm).

No later than 2 hours after birth, nursery/mother-baby personnel should evaluate the neonate's status and assess risks.Administer hepatitis B vaccine according to your facility's policy.


Vitamin K administration is not a requirement for home deliveries. Vitamin K levels naturally increase at 8 days of life. If infant is a boy, and parents desire circumcision, the procedure is withheld until after day 8.

Fourth Stage

Lasts from delivery of the placenta until the postpartum condition of the woman has become stabilized (usually 1 hour after delivery).

Blood pressure, uterine blood loss and pulse rate must be monitor closely ~ 15 minutesHigh risk for postpartum hemorrhage from:Uterine atony, retained placental fragments, unrepaired lacerations of vagina, cervix or perineum.Occult bleeding may occur – vaginal hematomaBe suspicious with increased heart rate, pelvic pain or decreased BP

Fourth Stage: role of the nurse

- - Nursing diagnosis - - Nursing intervention

Fourth Stage: Diagnosis 1. Risk for Injury related to uterine atony and

hemorrhage2. Deficient Fluid Volume related to

decreased oral intake, bleeding, and diaphoresis

3. Acute Pain related to tissue trauma and birth process, intensified by fatigue

4. Impaired Urinary Elimination related to epidural or spinal anaesthesia and tissue trauma

5. Disturbed Sensory Perception (tactile) related to effects of regional anaesthesia

6. Risk for Impaired Parenting related to inexperience

Fourth Stage: Interventions

Promoting Uterine Contraction and Controlling Bleeding

• Monitor blood pressure, pulse, and respirations every 15 minutes for 1 hour, then every½ hour to 1 hour until stable or transferred to the postpartum unit.

• Vital signs are taken more frequently if complications encountered.

• Take temperature every 4 hours unless elevated, then every 1 to 2 hours.

Fourth Stage: Interventions Maintaining Fluid Volume

• Maintain I.V. fluids as indicated.• Provide oral fluids and a snack or meal

as tolerated.• Encourage drink and food before

assisting the woman out of bed.Relieving Discomfort and Fatigue

• Apply a covered ice pack to the perineum during the first 24 hours for an episiotomy, perineal laceration, or edema.

• Administer analgesics as indicated.

Fourth Stage: Interventions • Assure that epidural catheter has been

removed.

• Assist the woman in finding comfortable

positions.

• Assist the woman with a partial bath and

perineal

care, and change linens and pads as

necessary.

• Allow for privacy and rest periods between

postpartum checks.

• Provide warm blankets.


Encouraging Bladder Emptying• Evaluate the bladder for distension.• Encourage the woman to void.

- Provide adequate time and privacy.- The sound from a running faucet may stimulate voiding.- Gently squirting tapid water against the perineum in a perineal bottle may help.

• Catheterize the woman (in and out) if the bladder is full and she is unable to void.

Birth trauma, anesthesia, and pain from lacerations and episiotomy may reduce or alter the voiding reflex.


Assessing return of sensation• Evaluate mobility and sensation of the lower extremities.

• Evaluate vital signs.• Remain with the woman, and assist her out of bed for the first time.

• Evaluate her ability to support her weight and ambulate.

Promoting Parenting

• Show the neonate to the mother and father or support person immediately after birth when possible.• Encourage the mother and father to hold the infant as soon as possible.• Teach the mother or parents to hold the neonate close to their faces when talking to the baby.• Have the mother or parents look at and inspect the infant's body to familiarize themselves with their child.

Promoting Parenting… … … cont • Assist the mother with breast-

feeding during the first 30 minutes, then 2 hours, after birth. This is typically a period of quiet alert time for the neonate, and he or she will usually take to the breast.

• Provide quiet alone time in a low-lighted room for the family to become acquainted.

• Observe and record the reaction of the mother or parents to the neonate.

lecture 5. labor is the physiologic process by which a fetus is expelled from the uterus to the...

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