Chapter 16 Giving Birth Copyright © 2018 Elsevier Inc. All rights reserved. Issues for New Nurses Pain associated with birth Inexperience or negative experience May be difficult for the nurse An expected part of childbirth In particular for the nurse who has never given birth Unpredictability Intimacy of the birth experience Copyright © 2018 Elsevier Inc. All rights reserved. 2 Physiologic Effects of the Birth Process Maternal response Labor contractions are intermittent, allowing placental blood flow and exchange of oxygen, nutrients, and waste products between maternal and fetal circulation during the interval. The upper uterus contracts actively during labor as it pushes the fetus down. These actions bring about cervical effacement and dilation. Copyright © 2018 Elsevier Inc. All rights reserved. 3 Contraction Cycle Copyright © 2018 Elsevier Inc. All rights reserved. 4 Uterine Contractions: Opposing Characteristics Copyright © 2018 Elsevier Inc. All rights reserved. 5 Cervical Dilation and Effacement Copyright © 2018 Elsevier Inc. All rights reserved. 6 Physiologic Effects of the Birth Process Fetal response Placental circulation • Enough reserves to tolerate labor Cardiovascular system • Reacts quickly Pulmonary system • Fetal lung fluid production decreases, and its absorption into lung tissue increases during late pregnancy and labor. • Thoracic compression during labor aids in the expulsion of additional fluid. Copyright © 2018 Elsevier Inc. All rights reserved. 7 Components of the Birthing Process Powers Passage Passenger Natural mechanisms of labor favor efficient passage of the fetus through the mother’s pelvis. Presentation and position further describe the relation of the fetus (passenger) to the maternal pelvis. Psyche Copyright © 2018 Elsevier Inc. All rights reserved. 8 Powers The two powers of labor are uterine contractions and the maternal pushing efforts. During the first phase of labor (onset through dilation) uterine contractions are the primary force moving the fetus through the maternal pelvis. During the second stage of labor (dilation through birth) the woman uses her voluntary pushing efforts to propel the fetus through the pelvis. Copyright © 2018 Elsevier Inc. All rights reserved. 9 Passage The passage for birth of the fetus consists of the maternal pelvis and its soft tissues. The bony pelvis is more important to the outcome of labor, because the bones and joints do not readily yield to the forces of labor. Softening of the cartilage linking the pelvic bones increases as term approaches and the hormone relaxin increases. Copyright © 2018 Elsevier Inc. All rights reserved. 10 Pelvic Divisions and Measurements Copyright © 2018 Elsevier Inc. All rights reserved. 11 Passenger Fetal head Fetal lie Attitude Presentation Cephalic Breech Position Copyright © 2018 Elsevier Inc. All rights reserved. 12 Fetal Head: Bones, Sutures, Fontanels Copyright © 2018 Elsevier Inc. All rights reserved. 13 Lie Copyright © 2018 Elsevier Inc. All rights reserved. 14 Attitude Copyright © 2018 Elsevier Inc. All rights reserved. 15 Cephalic Presentations Copyright © 2018 Elsevier Inc. All rights reserved. 16 Variations of a Breech Presentation Copyright © 2018 Elsevier Inc. All rights reserved. 17 Four Quadrants of the Maternal Pelvis Copyright © 2018 Elsevier Inc. All rights reserved. 18 Fetal Presentations Copyright © 2018 Elsevier Inc. All rights reserved. 19 Psyche The state of the mother’s psyche is a crucial aspect of childbirth. Marked anxiety, fear, or fatigue decreases a woman’s ability to cope with labor pain. Maternal catecholamines are secreted in response to anxiety or fear They inhibit uterine contractility and placental blood flow. Relaxation augments the natural process of labor. Copyright © 2018 Elsevier Inc. All rights reserved. 20 Individual and Cultural Values A woman’s culture gives her cues about how she should behave and react to labor and how she should interact with her newborn. Knowledge of the values and practices of cultural groups that the nurse encounters provides a framework to assess and care for the woman and her family. Birth is an emotional experience. Copyright © 2018 Elsevier Inc. All rights reserved. 21 Normal Labor Theories of onset Changes in maternal estrogen Prostaglandin secretion Increased secretion of oxytocin Oxytocin receptors increase Fetal role Stretching, pressure, and irritation of the uterus Copyright © 2018 Elsevier Inc. All rights reserved. 22 Premonitory Signs of Labor Braxton Hicks contractions Lightening Increase in clear and nonirritating vaginal secretions “Bloody show” Energy spurt (nesting) Small weight loss Copyright © 2018 Elsevier Inc. All rights reserved. 23 True Labor and False Labor The conclusive difference between true and false labor is progressive effacement and dilation of the cervix. Some woman do not have symptoms typical of true labor. The patient should enter the birth center for evaluation if she is uncertain or has concerns. Copyright © 2018 Elsevier Inc. All rights reserved. 24 How to Know When Labor Is Real Copyright © 2018 Elsevier Inc. All rights reserved. 25 Mechanisms of Labor Descent Engagement of the presenting part Flexion of the fetal head Internal rotation Extension of the fetal head External rotation Expulsion of the fetal shoulders and body Copyright © 2018 Elsevier Inc. All rights reserved. 26 Descent, Engagement, Flexion and Expulsion Copyright © 2018 Elsevier Inc. All rights reserved. 27 Stages of Labor First stage Latent phase Active phase Transition phase Second stage Third stage Fourth stage Copyright © 2018 Elsevier Inc. All rights reserved. 28 Labor Curve Copyright © 2018 Elsevier Inc. All rights reserved. 29 Placenta Copyright © 2018 Elsevier Inc. All rights reserved. 30 Duration of Labor Total duration is different for Women who have never given birth Women who have given birth previously Parous women usually deliver more quickly. Each woman labors differently. History of rapid delivery Copyright © 2018 Elsevier Inc. All rights reserved. 31 When to Go to the Hospital or Birth Center Copyright © 2018 Elsevier Inc. All rights reserved. 32 Fetal Oxygenation Promoting Placental Function Persistent contractions may reduce placental blood flow and fetal oxygen, nutrient, and waste exchange. A maternal supine position can reduce placental blood flow, because the uterus compresses the aorta and inferior vena cava. Copyright © 2018 Elsevier Inc. All rights reserved. 33 Conditions Associated with Fetal Compromise Copyright © 2018 Elsevier Inc. All rights reserved. 34 Providing Comfort Measures Promotes the woman’s ability to relax and cope with labor Lighting and temperature Cleanliness and mouth care Bladder Positioning Water Providing encouragement Pharmacologic pain relief Copyright © 2018 Elsevier Inc. All rights reserved. 35 Maternal Positions for Labor Copyright © 2018 Elsevier Inc. All rights reserved. 36 Impending Birth The nurse must be alert for signs of impending birth. “The baby’s coming.” Grunting sounds Bearing down Check the perineum Copyright © 2018 Elsevier Inc. All rights reserved. 37 Responsibilities During Birth Preparation of the sterile table Perineal cleansing preparation Initial care and assessment of the newborn, including calling neonatal staff if indicate. Administration of medication such as oxytocin to contract the uterus and control blood loss Copyright © 2018 Elsevier Inc. All rights reserved. 38 Sequence for Delivery Copyright © 2018 Elsevier Inc. All rights reserved. 39 Vaginal Birth Copyright © 2018 Elsevier Inc. All rights reserved. 40 Responsibilities After Birth Care of the infant Promote normal respirations Support thermoregulation Identify the infant Care of the mother Observe for hemorrhage Promote further uterine contraction Promote parent–infant attachment Copyright © 2018 Elsevier Inc. All rights reserved. 41 Turning Over Care Copyright © 2018 Elsevier Inc. All rights reserved. 42 Promoting Early Family Attachment First hour after birth is ideal for bonding. Neonate is alert and responsive. Provide privacy Initial assessments can be done in the mother’s arms. Place the infant at the breast. Consider cultural variations. Copyright © 2018 Elsevier Inc. All rights reserved. 43 Question A pregnant woman is at 38 weeks of gestation. She wants to know if any signs indicate “labor is getting closer to starting.” The nurse informs the woman that which sign of labor may begin soon? Weight gain of 1.5–2 kg (3–4 lb) B. Increase in fundal height C. Urinary retention D. Surge of energy A. Copyright © 2018 Elsevier Inc. All rights reserved. 44
