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Labor

IMS Murah-Manoe

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Terminology

LieThe relationship of the long axis ofthe fetus to the long axis of the uterus.

Longitudinal or transverse PresentationThat part of the baby

lowest in the pelvis

Vertex or cephalic 9697% of the time Breech 3-3.5 % of the time

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Cont .

Attitude refers to the degree of flexionof the fetus.

Complete flexion is the best attitude Position refers to the relationship of

the presenting part of the fetus to the

pelvic quadrants of mother.

The occiput is the point of reference for

the cephalic presentation

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Cont

Station refers to the location of thepresenting part of the fetus as it makes it

descent into the true pelvis. Point of reference is the ischial spines.

Floating is above the spines.

Engaged is the level of the spines. Lightening is another term for

engagement

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Cont

Effacement refers to the thinning outof the cervical canal.

It is expressed in percentages. Primigravidas usually efface more

quickly than they dilate.

Multiparas typically will experienceeffacement and dilatation at the same

time.

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Cont

Dilatation refers to the stretching of thecervix to accommodate delivery.

Complete dilatation is 10 Centimeters

Uterine contractions provide the force

Show refers to the blood tingedmucosy vaginal discharge.

The mucous plug is dislodged

Becomes more bloody as labor

progresses

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Labor :

Labor consists of regular, frequent,

uterine contractions which lead to

progressive dilatation of the cervix.

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The diagnosis of labor may not be

obvious for several reasons: Braxton-Hicks contractions are uterine

contractions occurring prior to the onsetof labor.

They are normal and can bedemonstrated with fetal monitoringtechniques early in the middle trimesterof pregnancy.

These innocent contractions can bepainful, regular, and frequent, althoughthey usually are not.

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Cont ....

While the uterine contractions of laborare usually painful, they are sometimesonly mildly painful, particularly in theearly stages of labor. Occasionally, theyare painless.

Cervical dilatation alone does notconfirm labor, since many women willdemonstrate some dilatation (1-3 cm) forweeks or months prior to the onset oftrue labor.

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Normal Labor Curve

http://localhost/var/www/apps/conversion/tmp/scratch_3/Labor_files/Normal640.jpg

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Latent Phase of Labor

http://localhost/var/www/apps/conversion/tmp/scratch_3/Labor_files/Latent640Phase.jpg

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Active Phase of Labor

http://localhost/var/www/apps/conversion/tmp/scratch_3/Labor_files/ActivePhase640.jpg

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True Labor

True labor will usually be determined by

observing the patient over time and

demonstrating progressive cervicalchanges, in the presence of regular,

frequent, painful uterine contractions.

False labor is everything else.

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Impending labor

Lighteningthe settling down into the

true pelvis

Burst of energy and increase in activity

level.

Braxton-Hicks contractions may be

confused as false labor.

Ripening of the cervix.Rupture of the membranes.

Showvaginal discharge.

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Cause of labor

is not known but may include both

maternal and fetal factors.

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Stage of labor

Stage One is the Dilating stage.

Latent phase

Active phase Transitional phase

Stage Two is the Birthing stage.

Stage Three is the Placental stage. Stage Four is the Recovery stage.

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First stage of labor :

The first stage of labor can be divided

functionally into two phases:

the latent phase the active phase.

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Latent phase or prodromal labor :

precedes the active phase of labor.

Are less than 4 cm dilated.

Have regular, frequent contractions that may or

may not be painful.

May find their contractions wax and wane

Dilate only very slowly

Can usually talk or laugh during their

contractions May find this phase of labor lasting hours to

days or longer.

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Active phase of labor :

Active phase labor is a time of rapid change incervical dilatation, effacement, and station.

Active phase labor lasts until the cervix is

completely dilated. Women in active phaselabor:

Are at least 4 cm dilated.

Have regular, frequent contractions that areusually moderately painful.

Demonstrate progressive cervical dilatation ofat least 1.2-1.5 cm per hour.

Usually are not comfortable with talking orlaughing during their contractions.

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Progress of Labor

For a woman experiencing her first baby,

labor usually lasts about 12-14 hours.

If she has delivered a baby in the past,labor is generally quicker, lasting about

6-8 hours.

These averages are only approximate,

and there is considerable variation from

one woman to the next, and from one

labor to the next.

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Cont

During labor, the cervix dilates (opens)and effaces (thins). This process hasbeen likened to the process of pulling aturtleneck sweater over your head.

The collar opens (dilates) to allow yourhead to pass through, and also thins(effaces) as your head passes through.

The process of dilatation and effacementoccurs for both mechanical reasons andbiochemical reasons.

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Cont..

The force of the contracting uterusnaturally seeks to dilate and thin thecervix.

However, for the cervix to be able torespond to these forces requires it to be"ready."

The process of readying the cervix on acellular level usually takes place overdays to weeks preceding the onset oflabor.

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Cont

Labor should be progressive. Serialvaginal examinations are used to plot thecourse of labor, detect abnormalities andallow for intervention.

While there are no set time intervals forperforming pelvic examinations, thecervix should progressively dilate duringactive phase labor at a rate of no lessthan 1.2 cm/hour (for first babies) to 1.5cm/hour (for subsequent babies).

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Progress of labor

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Descent

Descent means that the fetal head

descends through the birth canal. The

"station" of the fetal head describes howfar it has descended through the birth

canal.

This station is determined relative to the

maternal ischial spines, bonyprominences on each side of the

maternal pelvic sidewalls.

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Cont

"0 Station" ("Zero Station") means that

the top of the fetal head has descended

through the birth canal just to the level ofthe maternal ischial spines.

This usually means that the fetal head is

"fully" engaged (or "completely

engaged"), because the widest portion ofthe fetal head has entered the opening

of the birth canal (the pelvic inlet).

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Cont

If the fetal head has not reached theischial spines, this is indicated bynegative numbers, such as -2 (meaning

the top of the fetal head is still 2 cmabove the ischial spines).

If the fetal head has descended furtherthan the ischial spines, this is indicated

by positive numbers, such as +2(meaning the top of the head is now 2cm below the ischial spines).

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Cont

Negative numbers above -3 indicate the

fetal head is unengaged (floating).

Positive numbers beyond +3 (such as +4

or +5) indicate that the fetal head is

crowning and about to deliver.

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Cont

Women having their first baby often

demonstrate deep engagement (0 or +1)

for days to weeks prior to the onset oflabor.

Women having their second or third

baby may not engage below -2 or -3 untilthey are in labor, and nearly completely

dilated.

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Ischial spine

http://localhost/var/www/apps/conversion/tmp/scratch_3/Labor_files/IschialSpine1.jpg

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Fetal head at -1 station, 1 cm

above the level of the ischial

spines

http://localhost/var/www/apps/conversion/tmp/scratch_3/Labor_files/Station.jpg

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Fetal Aspects of Labor

The fetal skull is not ossified.

There are fontanels and interspaces to

allow formolding of the fetal head. The anterior fontanel is diamond shaped

at the junction of the two frontal bones

and the two parietal bones.

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Fetal skull

The fetal skull is not ossified.

There are fontanels and interspaces toallow formolding of the fetal head.

The anterior fontanel is diamond shapedat the junction of the two frontal bones

and the two parietal bones.

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Mechanism of normal labor

There are six classical steps in the

normal mechanism of labor

They are: Descent, Flexion, Internal

Rotation, Extension, External

Rotation and Expulsion or birth

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Cont

Usually, labor progresses in this fashion,if the fetus is of average size, with anormally positioned head, in a normal

labor pattern in a woman whose pelvis isof average size and gynecoid in shape

There is overlap of these mechanisms.

The fetal head, for example, maycontinue to flex or increase its flexionwhile it is also internally rotating anddescending

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Pelvic examination : There are

four basic pelvic shapes:

android

Anthropoid

Platypoidgynecoid

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Cont

A gynecoid pelvis is oval at the inlet, has

a generous capacity and wide subpubic

arch. This is the classical female pelvis.

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Cont

A platypoid pelvis is flattened at the inlet

and has a prominent sacrum.

The subpubic arch is generally wide butthe ischial spines are prominent.

This pelvis favors transverse

presentations

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Cont

An anthropoid pelvis is, like the gynecoid

pelvis, basically oval at the inlet, but the

long axis is oriented vertically rather thanside to side.

Subpubic arch may be slightly narrowed.

This pelvis favors occiput posterior

presentations.

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Cont

An android pelvis is more triangular inshape at the inlet, with a narrowedsubpubic arch.

Larger babies have difficulty traversingthis pelvis as the normal areas for fetalrotation and extension are blocked byboney prominences.

Smaller babies still

squeeze through.

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Nursing Care in Labor/delivery

On Admission need to be calm andreassuring.

Mother may be stressed and tired.

Collecting data:

Need to know EDC, previous OB history,pre-natal care.

Onset of laborcontractions, bloodyshow, condition of membranes.

Vital signsmother and baby.

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Lab Work on Admission

Urinalysisvoidedor catheterized inDelivery.

Protein

Glucose

Bacteria

Blood work :- CBC

- VDRL or RPR- Type- GBS

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Nursing Care During Labor

During Latent phase:

Vital signs and interview on admission

Encourage activity and ambulation (ifROM intact).

Provide information regarding what to

expect.

Diet may be only clear liquids or NPO.

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Cont

During Active phase:

Mother will be concentrating more on herlabor.

Assess her ability to cope andeffectiveness of her support system.

Never leave mother in active labor alone.

Offer opportunity to void every 2 hours.

Usually will be NPO with IV fluids toprovide for hydration and medications asneeded

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Cont

Transitional phase:

This is the last bit of stretching that must

be done before birth.Most difficult part of the labor process.

Prepare for delivery

At complete dilatation for primigravidaAt 7-8 cm for multipara

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Cont

Continue to offer opportunity to void as

needed.

Vital signs for mother and baby more

often. Signs you might observe are:

Nausea/vomiting

Involuntary shaking/tremors of the legsMood change

Desire to push

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Cont

With rupture of membranes:

May be SROM or AROM

Assess fetal condition by noting FHTs

Note amount and color of fluid:Meconium staining

With PROM these additional problems

may occur. Infection

Prolapsed cord

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Preparation for delivery

Provide for cleanliness throughout labor.

Perineal cleansing

Prepare sterile table and equipment. Provide emotional supportive care to

patient and family.

Notify physician .

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Evaluating the Fetal Condition

The fetal heart tones are the best

indicator of fetal condition.

Can be assessed with fetoscope,doppler, or monitor.

Best to listen during or immediately

following a contraction to determine fetal

distress

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The Fetal Heart Tones

The location they are best heard can be

an indicator of fetal position.

Above the umbilicus may be a breech

position.

Below the umbilicus probably indicates a

vertex presentation

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Cont

The location can also indicate fetal

descent.

May be heard in the side at the level of

umbilicus at first.

As progress is made in descent will be

closer to midline and lower.

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Cont

Just prior to birth may be in midline justover the pubic bone

Generally will need to establish abaseline for each baby.

Average range for normal FHTs is 120to 160 beats per minute

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Nursing Care During Stage II

Continue to assess vital signs of motherand baby more often as labor progresses.

Watch for signs of impending birth:

Bulging perineum

Crowning

Dilated anus

Uncontrollable urge to push

Perineal cleansing prep.

Notify physician

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Danger Signals to Note

Abnormal vaginal bleeding

Cessation of contractions after labor

established

Elevated B/P, sever headaches, blurred

vision

Elevated temperature, pulse,

respirationsRigid uterus after contraction

Exhaustion

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Cont

Irregular fetal heart rate:

Persistent tachycardia

Persistent bradycardiaDecelerations

Meconium-stained amniotic fluid

Hyperactivity of the fetus Prolapsed of the cord

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Care of the infant

Airway clearance and establishment of

independent respirations are the first

priority.

Warmth is of immediate concern as well.

Cord is clamped and cut.

Bondinggive baby to parents as soon

as possible.

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Assessment of Neonate

Apgar Assessment Results

Rating of 7 10 is a vigorous newborn.

Rating of 4 6 is a moderately

depressed newborn who may requiresome intervention.

Rating of less than 3 is s severely

depressed baby who will require

intervention.

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Cont

Vitamin K is given as one time dose of0.5-1 mg.

Other Needs of the Newborn

Identification is very important.

Triple band bracelets are commonlyused.

Babys footprints and mothers thumbprints are used, as well as a photo.

Security is also an important concern.

The OB area is a locked, secured unit.

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Stage III :Mechanism of

placental delivery are

- Schultze Mechanism--80% of the timethe shiny fetal surface is seen first.

- Duncan Mechanism20% of the timethe dull maternal surface escapes first.

The placenta will be carefully inspectedafter delivery

For abnormalities For completness

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Nursing care stage III

Placenta is delivered following birth of

the baby.

Pitocin hastens delivery of the placentaand is usually given at this point.

Signs of placental separation are:

Globular shape and firm uterus

Lengthening of the cord

Gush of blood or increase in bloody flow

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Mechanism of placental

delivery are

- Schultze Mechanism--80% of the timethe shiny fetal surface is seen first.

- Duncan Mechanism20% of the timethe dull maternal surface escapes first.

The placenta will be carefully inspectedafter delivery

For abnormalities For completness

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Nursing Care During Stage IV

Early Post-partum recoverythe first 1-2hours after delivery.

Careful observation and assessment isof utmost importance and may be doneevery 15 minutes during the first hour.

Check B/P, Pulse

Fundal tone and location Lochial flow

Perineal assessment

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Cont

Hemorrhage is the number 1 priority of

concern at this time.

Pitocin may be use to control P-Pbleeding.

Warmth is also a need during this period.

May be hungry and thirsty.

Allow for privacy with family for bonding.

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Special situations

Precipitate delivery

Cerebral trauma for baby

Risks for lacerations for Mom

Breech presentations

Cerebral trauma for baby

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Cont

Longer, more difficult labor for Mom

Twin (Multiple) Births

Premature births

Maternal risks PIH, P-P bleeding

Delivery of 2nd twin often more

problems

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Thank you