COMPONENTSCOMPONENTS OFOF LABORLABOR

Ps of LaborPs of Labor

PassagePassage

PassengerPassenger

PowerPower

PsychePsyche

PersonPerson

A. PASSAGEWAY- refers to the A. PASSAGEWAY- refers to the adequacy of the pelvis and birth adequacy of the pelvis and birth canal in allowing fetal descent canal in allowing fetal descent

PELVIC GIRDLE: PELVIC GIRDLE:

1)W/ APPROPRIATE PELVIC 1)W/ APPROPRIATE PELVIC SHAPESHAPE

2) W/ O STRUCTURAL 2) W/ O STRUCTURAL ABNORMALITIESABNORMALITIES

Too prominent ischial spines and short bi-Too prominent ischial spines and short bi-ischial diameterischial diameter

Sacrum too acutely curved anteriorlySacrum too acutely curved anteriorly

Narrow pubic arch angleNarrow pubic arch angle

3) W/ APPROPRIATE PELVIC 3) W/ APPROPRIATE PELVIC SIZE/DIAMETERSSIZE/DIAMETERS

-Measure the actual diameters of the pelvic inlet -Measure the actual diameters of the pelvic inlet and outlet through which the fetus must passand outlet through which the fetus must pass

1.1. Diagonal conjugateDiagonal conjugate

- from the anterior surface of sacral - from the anterior surface of sacral promontory to the anterior surface of the promontory to the anterior surface of the inferior margin of the symphysis pubisinferior margin of the symphysis pubis

- more than 12.5 cm- more than 12.5 cm

2. True conjugate or Conjugate vera2. True conjugate or Conjugate vera

- from anterior surface of the sacral - from anterior surface of the sacral promontory to the posterior surface of the promontory to the posterior surface of the inferior margin of the symphysis pubisinferior margin of the symphysis pubis

- Diagonal conjugate minus 1.5-2 cm- Diagonal conjugate minus 1.5-2 cm

-10.5 to 11 cm at inlet-10.5 to 11 cm at inlet

3. Ischial tuberosity diameter3. Ischial tuberosity diameter

- done at level of anus- done at level of anus

- from 1 ischial tuberosity to another- from 1 ischial tuberosity to another

- measures the transverse diameter of the outlet- measures the transverse diameter of the outlet

- 11 cm- 11 cm

B. PASSENGER – refers to the fetus B. PASSENGER – refers to the fetus and its ability to move through the and its ability to move through the

passagewaypassagewayFETAL SKULLFETAL SKULL 8 CRANIAL BONES8 CRANIAL BONES 1 FRONTAL1 FRONTAL 2 PARIETAL2 PARIETAL 1 OCCIPITAL1 OCCIPITAL 2 TEMPORAL2 TEMPORAL 1 SPHENOID1 SPHENOID 1 ETHMOID1 ETHMOID 14 FACIAL BONES14 FACIAL BONES

Shiny schultze – fetal surfaceShiny schultze – fetal surface Dirty duncan – maternal surfaceDirty duncan – maternal surface

No clinical significanceNo clinical significance

SUTURESSUTURES

CORONALCORONAL

SAGITTALSAGITTAL

LAMBDOIDLAMBDOID

FONTANELLESFONTANELLES ANTERIOR/BREGMATICANTERIOR/BREGMATIC

POSTERIOR/OCCIPITALPOSTERIOR/OCCIPITAL

SPHENOID/ANTERO-LATERALSPHENOID/ANTERO-LATERAL

MASTOID/POSTERO-LATERALMASTOID/POSTERO-LATERAL

FONTANELLESFONTANELLES ANTERIOR/BREGMATICANTERIOR/BREGMATIC

POSTERIOR/OCCIPITALPOSTERIOR/OCCIPITAL

SPHENOID/ANTERO-LATERALSPHENOID/ANTERO-LATERAL

MASTOID/POSTERO-LATERALMASTOID/POSTERO-LATERAL

PASSENGERPASSENGER1) W/ APPROPRIATE PRESENTATION1) W/ APPROPRIATE PRESENTATION

2) W/ APPROPRIATE LIE2) W/ APPROPRIATE LIE

3)W/ APPROPRIATE POSITION3)W/ APPROPRIATE POSITION eg L.O.A, L.S.P, L.A.A., R.M.T eg L.O.A, L.S.P, L.A.A., R.M.T

First letter determined by:First letter determined by:

the right or left side of the mother’s pelvis the right or left side of the mother’s pelvis

as you face the perineum during internal as you face the perineum during internal examinationexamination

Second letter determined by:Second letter determined by:

using a reference point or landmark after using a reference point or landmark after knowing the presentationknowing the presentation

-occiput -brow -mentum-occiput -brow -mentum

-sacrum -acromion-sacrum -acromion

Third letter determined by:Third letter determined by:

the direction of the reference point or landmarkthe direction of the reference point or landmark

-anterior -anterior

-transverse-transverse

-posterior-posterior

4) W/ APPROPRIATE ATTITUDE

5)5)W/W/ PROGRESSIVEPROGRESSIVE DESCENTDESCENT

STATIONSTATION

ischial spines: midway in the true pelvisischial spines: midway in the true pelvis

station 0station 0

above it: station – 1 to -5above it: station – 1 to -5

below it: station +1 to +5below it: station +1 to +5

STATIONSTATION

Negative numbers above -3 indicate the fetal Negative numbers above -3 indicate the fetal head is unengaged (floating)head is unengaged (floating)

Positive numbers beyond +3 (such as +4 or Positive numbers beyond +3 (such as +4 or +5) indicate that the fetal head is crowning and +5) indicate that the fetal head is crowning and about to deliver.about to deliver.

FLOATINGFLOATING

ENGAGEDENGAGED

7) BABY HAS NO CONGENITAL or 7) BABY HAS NO CONGENITAL or ACQUIRED STRUCTURAL ACQUIRED STRUCTURAL ABNORMALITIESABNORMALITIES

8) NOT IN CARDIO-RESPIRATORY 8) NOT IN CARDIO-RESPIRATORY DISTRESSDISTRESS

FETAL ASSESSMENT DURING FETAL ASSESSMENT DURING LABORLABOR

1) Auscultate the fetal heart rate1) Auscultate the fetal heart rate

- at posterior chest wall- at posterior chest wall

- every 30 minutes during beginning labor- every 30 minutes during beginning labor

every 15 minutes during active laborevery 15 minutes during active labor

every 5 minutes during 2every 5 minutes during 2ndnd stage stage

- use either a) ordinary stethoscope- use either a) ordinary stethoscope b) fetoscopeb) fetoscope

c) dopplerc) doppler d) external electronic d) external electronic

monitoringmonitoring e) internal electronic e) internal electronic

monitoringmonitoring f) Telemetryf) Telemetry

B. EXTERNAL FETAL MONITORINGB. EXTERNAL FETAL MONITORING

C. INTERNAL FETAL MONITORINGC. INTERNAL FETAL MONITORING

Normal value: 120-160 BPM for 10 minutesNormal value: 120-160 BPM for 10 minutes

Fluctuates slightly 5-15 BPM when fetus moves Fluctuates slightly 5-15 BPM when fetus moves or sleeps or sleeps

Accelerations occur when fetus moves or with Accelerations occur when fetus moves or with compression of umbilical vein during labor compression of umbilical vein during labor contractioncontraction

Early decelerationsEarly decelerations- Due to pressure of fetal head during Due to pressure of fetal head during

contractionscontractions parasympathetic response parasympathetic response vagal nerve compressionvagal nerve compression reflex bradycardia reflex bradycardia

- Normal if during late in laborNormal if during late in labor

Late decelerationsLate decelerations- Those delayed until 30-40 seconds after onset Those delayed until 30-40 seconds after onset

of contraction and continue beyond end of of contraction and continue beyond end of contractioncontraction

- Lowest point of deceleration is near end of Lowest point of deceleration is near end of contractioncontraction

- Due to uterine placental insufficiencyDue to uterine placental insufficiency

Nursing responsibilityNursing responsibility

- discontinue or slow down Oxytocin drip if - discontinue or slow down Oxytocin drip if presentpresent

- change patient’s position- change patient’s position

-administer IVF or oxygen-administer IVF or oxygen

-Prepare for “E” CS-Prepare for “E” CS

Prolonged decelerationsProlonged decelerations -last longer than 2-3 minutes but less than 10 -last longer than 2-3 minutes but less than 10

minutesminutes

- Due to cord compression Due to cord compression maternal hypotensionmaternal hypotension

-Nursing responsibility: refer ASAP-Nursing responsibility: refer ASAP

2) Fetal Movements2) Fetal Movements- Fetal movement counting is the easiest and Fetal movement counting is the easiest and

most reliable screening method to determine most reliable screening method to determine fetal distressfetal distress

- 3 ways:3 ways:

a) Cardiff-count-ten Methoda) Cardiff-count-ten Method

-begin count at 9 am , TID 20-30 -begin count at 9 am , TID 20-30 min/session,and count up to 10 movementsmin/session,and count up to 10 movements

-less than 3 movements per session, extend count for -less than 3 movements per session, extend count for 1 hr or more1 hr or more

-if less than 10 movements are counted in 12 hrs, -if less than 10 movements are counted in 12 hrs, refer ASAPrefer ASAP

b. Sadovsky’s Counting after mealsb. Sadovsky’s Counting after meals

- count fetal movements 1-2 hours after meals- count fetal movements 1-2 hours after meals

-should be at least 10 movements in 120 min-should be at least 10 movements in 120 min

c. Counting before sleepingc. Counting before sleeping -count at night between 9-10 PM before -count at night between 9-10 PM before

sleepingsleeping

- note duration for fetus to move 10 times- note duration for fetus to move 10 times

- if longer than 2 hours to move 10 times, - if longer than 2 hours to move 10 times, need further testing: UTS BPPneed further testing: UTS BPP

3) Meconium staining of Amniotic fluid3) Meconium staining of Amniotic fluid

-green opaque fluid-green opaque fluid

FETAL DANGER SIGNSFETAL DANGER SIGNS

1) Fetal bradycardia and tachycardia1) Fetal bradycardia and tachycardia

> 110 BPM <160 BPM> 110 BPM <160 BPM

Nursing responsibility:Nursing responsibility:

Monitor FHR in between uterine Monitor FHR in between uterine contractionscontractions

2) Meconium- stained amniotic fluid or bag of 2) Meconium- stained amniotic fluid or bag of waterwater

-fetal hypoxia-fetal hypoxia stimulation of vagal stimulation of vagal reflexreflexincreased bowel motilityincreased bowel motility relaxation relaxation of external anal sphincterof external anal sphincterpassage of passage of meconium(green color in amniotic fluid)meconium(green color in amniotic fluid)

3) Abnormal fetal movements3) Abnormal fetal movements

3a: hyperactivity3a: hyperactivity

3b: decreased or no activity3b: decreased or no activity

4) Fetal acidosis4) Fetal acidosis

Monitor blood pH using scalp capillary Monitor blood pH using scalp capillary techniquetechnique

pH lower than 7.2pH lower than 7.2

C. POWERC. POWER- refers to the frequency, duration, - refers to the frequency, duration,

and strenght of uterine contractions and strenght of uterine contractions to cause complete cervical to cause complete cervical

effacement and dilationeffacement and dilation

1) Uterus1) Uterus

-smooth muscle contractions-smooth muscle contractions

a) irregular to regular rhythma) irregular to regular rhythm

b) from weak to strong intensityb) from weak to strong intensity

c) from short to long durationc) from short to long duration

d) from long to short frequencyd) from long to short frequency

UterusUterus -thick at fundus, thin at low uterine segment-thick at fundus, thin at low uterine segment

-straightens -straightens

-cervix undergoes-cervix undergoes a)dilatationa)dilatation

b)effacementb)effacement

2) Abdomen2) Abdomen

-skeletal muscles contraction-skeletal muscles contraction

Note: should follow if with full cervical Note: should follow if with full cervical dilatationdilatation

Augmentation of uterine contractions via:Augmentation of uterine contractions via:a)a) Nipple stimulationNipple stimulationb)b) DrugsDrugs Uterine stimulants like Buscopan and Uterine stimulants like Buscopan and

OxytocinOxytocinc)c) Manual fundal pushManual fundal pushd)d) Amniotomy Amniotomy e)e) Cervical canal strippingCervical canal stripping

D. PSYCHE – refers to the client’s D. PSYCHE – refers to the client’s psychological state , available support psychological state , available support systems, preparation for childbirth, systems, preparation for childbirth, experiences, and coping strategiesexperiences, and coping strategies

- This is the mother’s mindsetThis is the mother’s mindset eg anxiouseg anxious angryangry fearfulfearful aweawe excitedexcited

implication: affects mother’s ability to cooperate to instructions during implication: affects mother’s ability to cooperate to instructions during labor and deliverylabor and delivery

affects her outlook regardingaffects her outlook regarding future pregnancies, labor and deliveryfuture pregnancies, labor and delivery

E. PERSON / POSITION OF THE E. PERSON / POSITION OF THE MOTHERMOTHER

Positioning the woman in a manner that allows Positioning the woman in a manner that allows gravity to assist her efforts is helpfulgravity to assist her efforts is helpful

Squatting or using a semi seated position is Squatting or using a semi seated position is more effective than a supine position more effective than a supine position