

 Exact mechanism unknown
 Theories:
 Uterine stretching
 Prostaglandin
 Oxytocin stimulation
 Cervical pressure
 Aging placenta
 Increased fetal cortisol levels

 Lightening
 Increased level activity
 Weight loss
 Braxton hicks contractions
 Cervical changes
 Uterine contractions
 Bloody show
 Rupture of membranes

 Differentiated ONLY by cervical changes:
 Dilation
 Effacement

3.
4.
5.
1.
2.
Passage
Passenger
Power
Psyche
Placenta

 Route fetus must travel from uterus to perineum
 Shape of pelvis
 Gynecoid
 Anthropoid
 Android
 Platypelloid

 Bony structures
 Joints, bones
 False pelvis
 True pelvis
 Pelvic diameters
 Diagonal conjugate
 Soft tissues

 Fetal skull
 Bones
 Suture lines
 Fontanelles
 Diameter
 Molding

 Presentation – fetal body part that will be first to pass through cervix
 Affects duration and difficulty of labor
 Affects method of labor
 Describe as variations of:
 Cephalic- vertex, brow, sinciput, mentum
 Breech – complete, frank, incomplete, footling
 Shoulder – shoulder, iliac crest, hand, elbow

 Lie – refers to relationship of long axis
(spine) of fetus to long axis of mother
 Longitudinal
 Cephalic, breech
 Transverse
 Horizontally, side to side
 Oblique
 45 degree angles

 Attitude
 Complete flexion – chin to chest
 Moderate flexion – military
 Partial extension – brow
 Complete extension - face


1.
2.
1.
2.
3.
Position – relationship of presenting part of fetus to specific section of mother’s pelvis
Patient’s pelvis – 4 sections
Right anterior
Left anterior
Right posterior
4.
Left posterior
Fetus parts –
1.
Occiput (O) – vertex
2.
3.
4.
Mentum (M)- face
Sacrum (S) – breech
Acromion (A) - shoulder

Fetal position described by using three letters:
1.
First letter defines whether fetal landmark pointing to mother’s right or left
2.
3.
4.
1.
Second letter designates fetal landmark
Occiput(O), mentum(M), sacrum(Sa), Acromion(A)
Last letter defines whether landmark points anteriorly(A), posteriorly(P), or transverse(T)
LOA – left occiput anterior most common

 Station – relationship of presenting part to ischial spine of mother
 -5 (pelvis)to +4(perineum)
 Station 0 is at level of ischial spines – engagement occurs
 Floating, ballotable
 crowning


4.
5.
6.
7.
1.
2.
3.
Number of fetal position changes as travels through birth canal
Engagement
Decent
Flexion
Internal rotation
Extension
External rotation
Expulsion




Force of uterine contractions
Contractions of abdominal muscles
Contraction pattern
 Begin pacemaker point upper uterine segment
 Wavelike pattern relaxation
 Phases:



Increment
Acme
Decrement
 Duration
 Contour changes

 Cervical changes – increased diameter of cervical canal and lumen occurs by pulling cervix up over present part with uterine contractions
 Effacement – shortening and thinning of cervical canal
 % - 0 to 100%
 Dilation – enlargement of cervical canal from
1 to 10cm

 Feeling woman brings to labor
 Psychological readiness for labor
 Factors affecting
 Preparation
 Support person
 Past experiences
 Task of pregnancy
 Situational control







 Cardiovascular
 Fluid and electrolyte
 Respiratory
 Hematopoietic
 GI
 Renal
 Musculoskeletal
 neurologic

 Healthy fetus adapts to stress of labor
 Periodic fetal heart rate changes
 Circulation
 Increase PCO2
 Decrease Partial PO2
 Decrease fetal breathing movements

3.
4.
1.
2.
Dilation – 0 to 10 cm
Expulsion
Placental
Immediate postpartum



Begins with true labor contractions ends with complete cervical dilation
Divided into 3 phases
1.
Latent: 0-3cm
2. Active: 4-6cm
3. Transitional: 7-10cm

 Preparatory phase
 Contractions mild and short 30-40sec
 Dilation 0-3cm
 4-6 hours
 Analgesia too early prolongs phase
 Walking, packing, preparing

 Working phase
 4-6cm
 Contractions stronger, 40-60 sec, every 3 to 5 min
 True discomfort
 2-4 hours
 Rupture of membranes
 Analgesia little effect on progress of labor

 Feeling of loss of control occurs here
 7-10cm
 Contractions peak intensity 2-3 min
 90 second duration
 Feelings of urge to push
 Intense discomfort, nausea, vomiting, anxiety, panic, irritability
 Focus inward on task of birth









Full dilation and effacement to birth of infant
20 min to 2 hours
Fetus moved by “cardinal movements of labor
Uncontrollable urge to push with contractions 2-3 min n/v, perspires, distended blood vessels, petechae
Perineum bulge
Inverted anus crowning

 Birth of infant to delivery of placenta
 Placental separation
 Bleeding on maternal side
 Lengthening of umbilical cord
 Gush vaginal blood
 Change shape of uterus
 Presentation:
 Shiny schultz
 Dirty duncan

 3 hours after delivery
 Stabilizing Mom
 Bleeding, bp, perineum, uterus, pain
 Stabilizing baby
 Acclimated extrautering life
 Promoting bonding
 Bleeding, bp, perineum, uterus, pain

 Nursing Management during labor and birth

 Maternal
 Vaginal Exam - Dilation, effacement, station, membranes
 Contraction pattern

 Phases
 Duration
 Frequency
 intensity

 Fetal
 Position – Leopold’s maneuvers
 Amniotic fluid
 Electronic fetal monitoring
 Intermittent
 Continuous
 External
 Internal

 Baseline Fetal Heart Rate
 Baseline variability
 Increased variability
 Decreased variability

Accelerations
Decelerations
 Early
 Late
 Variable

 Fetal Pulse Oximetry
 Fetal Stimulation
 Scalp Ph

 Etiology of pain
 Perception
 Fetal position

 Labor Support
 Ambulation / Position Changes
 Acupuncture / pressure
 Focused Imagery
 Breathing Techniques
 Therapeutic touch / Massage
 Effleurage

 Systemic
 IV, IM, PO
 Regional
 Epidural
 Spinal
 Regional block
 Local
 General

 Admission assessment
 Continual Assessment
 First Stage
 Second, Third, Fourth Stage

 VS
 I&O
 Pain
 Emotional support
 Sterile technique
 Teaching
 cleanliness









 calm environment
Clear liquids
Output
Ambulate
Involve support person
IV-blood samples
Position changes
Breathing techniques
Perineal care



Monitor contractions
Monitor FHR
VE

 General measures
 Obtain admission history
 Check results of routine laboratory tests and any special tests
 Ask about childbirth plan
 Complete a physical assessment
 Initial contact either by phone or in person

First Stage of Labor: Phone Assessment
 Estimated date of birth
 Fetal movement; frequency in past few days
 Other premonitory signs of labor experienced
 Parity, gravida, and previous childbirth experiences
 Time frame in previous labors
 Characteristics of contractions
 Bloody show and membrane status (whether ruptured or intact)
 Presence of supportive adult in household or if she is alone

First Stage of Labor: Admission Assessment


Maternal health history
Physical assessment (body systems, vital signs, heart and lung sounds, height and weight)
 Fundal height measurement
 Uterine activity, including contraction frequency, duration, and intensity
 Status of membranes (intact or ruptured)
 Cervical dilatation and degree of effacement
 Fetal heart rate, position, station
 Pain level

First Stage of Labor: Admission Assessment
(cont’d)
 Fetal assessment
 Lab studies
 Routine: urinalysis, CBC
 HbsAg screening, GBS, HIV (with woman’s consent), and possible drug screening if not included in prenatal history
 Assessment of psychological status


Woman’s knowledge, experience, and expectations
 Vital signs
 Vaginal examinations
 Uterine contractions
 Pain level
 Coping ability
 FHR
 Amniotic fluid

 Assessment
 Typical signs of 2 nd stage
 Contraction frequency, duration, intensity
 Maternal vital signs
 Progress of labor, crowning
 Fetal response to labor via FHR
 Amniotic fluid with rupture of membranes
 Coping status of woman and partner

Nursing Management: Second Stage
 Interventions
 Supporting woman & partner in active decision-making
 Supporting involuntary bearing-down efforts; encouraging no pushing until strong desire or until descent and rotation of fetal head well advanced
 Providing instructions, assistance, pain relief
 Using maternal positions to enhance descent and reduce pain
 Preparing for assisting with delivery

 Interventions with birth
 Cleansing of perineal area and vulva
 Assisting with birth, suctioning of newborn, and umbilical cord clamping
 Providing immediate care of newborn
 Drying
 Apgar score
 Identification


Assessment
 Placental separation; placenta and fetal membranes examination; perineal trauma; episiotomy; lacerations
 Interventions
 Instructing to push when separation apparent; giving oxytoxic if ordered; assisting woman to comfortable position; providing warmth; applying ice to perineum if episiotomy; explaining assessments to come; monitoring mother’s physical status; recording birthing statistics; documenting birth in birth book

Nursing Management: Fourth Stage
 Assessment
 Vital signs, fundus, perineal area, comfort level, lochia, bladder status
 Interventions
 Support and information
 Fundal checks; perineal care and hygiene
 Bladder status and voiding
 Comfort measures
 Parent-newborn attachment
 Teaching