Slide 1

Introduction to labor

PRESENTED BY Bidhya Gupta Lecturer., Chitwan Medical College College 0f Nursing Labour Definition Series of events that takes place in the genital organ in an effort to expel the viable products of conception out of the womb through the vagina into the outer world is called labour. Normal labour (Eutocia)Labour is called normal if it fulfills the following criteria:Spontaneous in onset and at term. With vertex presentationWithout undue prolongationNatural termination with minimal aids Without having any complications affecting the health of mother and/or baby. Abnormal labour (Dystocia)Any deviation from the definition of normal labour is called abnormal labour. False labour painFeatures Dull in nature and usually confined to the lower abdomen and groin.2. Continuous and unrelated with hardening of the uterus 3. Without any effect on dilatation of the cervix. 4. Usually relieved by medicationsTrue labour painFeatures of true labour pain: Painful uterine contractions (labour pain) at regular intervals Contraction with increasing intensity and duration Show Progressive effacement and dilatation of the cervix Formation of the bag of water.

Niggling / Spurious labor / False labor True laborUterine contraction : Not always present Lasts for 3 to 4 minutes Irregular Felt in lower back radiates to lower Portion of abdomen May or may not be painful Can stop with comfort measures No back ache Intensity stop with position changes, WalkingCervix : No shortness , Soft No dilatation No tensed membrane Posterior position No show

Fetus : No head engagement Uterine contraction : Always present Not exceed > 90 seconds Regular and rhythmic Felt in back or abdomen above navel Abdominal tightening ,discomfort and Pain will not stop with comfort measures May have back ache Increase intensity with walking

Cervix : Shortening Dilatation Tensed membrane Anterior position Show presents

Fetus : Head engagement Difference between True labor and False labor

8STAGES OF LABOR First stage (or) Dilating stageSecond stage (or) Pushing stage (or) pelvic stageThird stage (or) Placental stageFourth stage (or) Recovery stage

FIRST STAGE OF LABOUR

DEFINITIONIt starts with regular and rhythmic uterine contractions till completion of full cervical dilatation (10cm).

DURATION :For primi gravida 16hrs to 18hrs.For multi gravida 6hsrs to 10hrs.

There are two phases of first stage of labour: Latent phase Active phase

11SECOND STAGE OF LABOUR / PUSHING STAGE / PELVIC STAGE 12

DEFINITIONIt starts from the full dilation of the cervix and ends with expulsion of fetus from the birth canal.

DURATION : Primi gravida -2 hours.Multi gravida - 30 minutes.

Third stage/PLACENTAL STAGEDEFINITIONIt starts with separation of placenta till expulsion of placenta .

DURATION :Primi gravida :15 minutesMulti gravida : 5 15 minutes

15FOURTH STAGE / RECOVERY STAGEDEFINITION The fourth stage begins with the delivery of the placenta and ends two hours later.

DURATION

1 to 2hours after the expulsion of placenta .

17Factors affecting labor process: 4 Ps [Powers of Labor]PassengerPassagewayPowerspsychePassenger: [infant]Fetal head: widest part of body; most difficult to pass thru vaginal canal; passage depends on bones, sutures, fontanelles.

Cranium - 8 bones meet @ suture linesCranial bones move & overlap, allows skull to pass thru birth canal. Fontanelles: soft spaces created by junctures of suture lines - covered by membranes; compress during delivery to aid in passage of fetus. Molding of infant head.1919Passenger cont.Skull widest @ antero-posterior diameter [front to back] than @ transverse diameter [across]. Antero-posterior diameter measures differently @ different locations.

Occipitomental diameter- widest - measured from chin to posterior fontanelle = 13.5 cmSmallest diameter - lower occiput to anterior fontanelle (suboccipitobregmatic) = 9.5 cm

Complete flexion allows smallest diameter of fetal skull to enter pelvis most easily.

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B. Fetal Attitude: degree of flexion of fetal head; chin touches sternum.

Complete flexion: allows smallest diameter of skull to pass thru pelvic cavity. Best position!Moderate flexion: head less flexed making diameter wider Poor flexion: brow or face presentation; presents skull diameter too wide making delivery difficult. 2222C. Fetal lie: [position of fetus in utero] relationship of long axis of fetus [spine] to long axis of mother:

1. Longitudinal vertex/breech; vertical in relation to mom; ~ 99%. 2. Transverse horizontal in relation to mom; < 1 %. C/S; ^ in grand multip stretched uterine muscles; try version.3. Oblique - diagonal

D. Fetal presentation: part of fetal head enters pelvis; 1. Cephalic 95.5%2. Breech 3.5%3. Face 0.3% 4. Shoulder 0.4% [transverse lie]

2323E. Fetal position: occiput is landmark

Described in 3 letters: 1st : presenting part in relation to mothers R or L. Middle: presenting part [occiput, mentum, sacrum] Last: landmark is anterior, posterior, transverse in relation to mothers spine. Anterior (A) back of head against symphysis pubis & face towards spine. Posterior (P) Back of head = mothers spine; painful contxs. Transverse (T) = fetus sideways.

Common positions in vertex presentations: *LOA, ROT, ROP, ROA, LOT, LOP. 2424Passageway: Refers to fetus passing thru uterus, cervix, vaginal canal. Single most important determinant to mechanism of labor.A. 4 Types of pelvis: 1. Gynecoid 50% of women; rounded, oval shape; easy vaginal delivery; considered normal female pelvis

25252. Android 20 % of women; vaginal delivery difficult; prob. C/S; true male pelvis

3. Anthropoid oval; assisted vaginal birth usually with forceps; 20-25%

26264. Platypelloid < 5 % of women; flattened pelvis; vag. del. difficult

2727 B. Structure of Pelvis: bones held together by ligaments. Supports/protects organs inside.

False Pelvis: Outer - broader. Hip bones.True Pelvis: Internal narrower. Holds bladder, rectum, & reprod. Organs.

True pelvis - 3 parts - inlet, midpelvis, outlet. [Most important in childbirth] If pelvis too small, home birth not done. CPD - cephalopelvic disproportion > C/S.

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PELVIC INLET:

Antero-posterior diameter - front to back ~ 12.5 cm. (diagonal conjugate)

True conjugate - actual opening of outlet. Subtract width of symphysis pubis [1.5 cm] from diagonal conjugate. 12.5 1.5 = 11.0 cm.(complete flexion = 9.5cm diameter)

Transverse diameter [across] ~ 13.5 cm

3030MIDPELVIS: narrowest part of pelvis that fetus must pass through - ischial spines

PELVIC OUTLET: Trouble passing through pelvic opening, pelvis too small or poor fetal attitude. Soft Tissue: Ligaments, Uterus, cervix, vaginal canal

3131Powers:Uterine contxs: primary force moving fetus thru maternal pelvis during 1st stage of labor.Maternal Efforts: woman adds voluntary pushing force to force of contx.s during 2nd stage of labor to propel fetus thru pelvis.

3232Psyche:Psychologic Response to birth process:

Prepared for childbirth - Childbirth classes-Prenatal care.Previous childbirth experience - Complicated?Support from significant other - Separated? Marital strain? Abuse?Emotional status - anxious/depressed, drug use, psych history Culture - background may influence response to pain. Some moan, some stoic, some verbally expressive. Fear/anxiety exacerbate pain uterine dysfunction & ineffectual labor & posttraumatic stress disorder3333