Labor and Birth Process
and
Nursing Management
Chapter 13 & 14
Mary L. Dunlap MSN
Fall 2015
Labor Definition
• Coordinated sequence of involuntary
uterine contractions
• Contractions 3 minutes apart or less
lasting 60 seconds or longer
• Resulting in effacement and dilatation
of the cervix and delivery of the fetus
and placenta.
Possible Causes of Labor
Maternal
• Uterine muscle • Estrogen/Proges
stretching
terone ratio
change
• Pressure on the
cervix
• Fetal cortisol
concentration
• Oxytocin
• Placental aging • Prostaglandins
Possible Causes of Labor
Fetal
• Placental aging
• Fetal Cortisol concentration
• Prostaglandin
4
Signs Preceding Labor
• Lightening
• Increase vaginal
discharge
• Cervix softening
• Rupture of
membranes
• Energy burst
• Braxton-Hicks
contractions
• Weight loss
• Bloody show
False Labor
• Does not cause
• Irregular
cervical change
contractions
• Activity does not
• No regular pattern
increase
• Discomfort in lower
contractions
abdomen and groin
•
Sedation
will
stop
• Show is not present
or decrease
contractions
True Labor
• Regular
contractions
• Contractions
Progresses to a
pattern
• Discomfort begins
in back and
radiates to the
abdomen
• Activity increases
contraction
frequency
• Sedation does not
diminish contraction
pattern
• Causes cervical
changes
• Show usually
present
Factors That Affect Labor
The Five P’s:
• Passageway (birth canal)
• Passenger (fetus and placenta)
• Powers (contractions)
• Position of the mother
• Psychologic response
Passageway
• Pelvic structure and shape
• Soft tissues
cervix
Pelvic floor
Vagina
Passenger
•
•
•
•
•
Size of the fetal head
Presenting part
Fetal lie
Fetal attitude
Fetal position
Passenger: Fetal Skull
• Largest and least compressible structure
• Sutures: allow for overlapping and
changes in shape (molding); help identify
position of fetal head
• Fontanels: intersections of sutures; help
in identifying position of fetal head and in
molding
Fetal Skull
12
Passenger: Presenting Part
• Cephalic
• Breech
Frank
Full or complete
Footling or incomplete
• Shoulder
Breech Presentations
Fetal Lie
• Fetal lie is the relationship of the
spine of the fetus to the spine of the
mother
• Longitudinal
• Transverse
Fetal Attitude
• Fetal attitude is flexion or extension
of the joints and the relationship of
fetal parts to one another
18
Passenger: Fetal Position
• Fetal position- relationship of the
presenting part of the fetus to a
designated point of the maternal
pelvic structure
20
Powers
Contractions primary force
• Frequency
• Duration
• Intensity
Pushing secondary force
Maternal Position
• Affects woman’s anatomic and
physiologic adaptations to labor
• Frequent changes in position
Relieve fatigue
Increase comfort
Improve circulation
Facilitates decent and rotation
Psychological Response
Factors Influencing a Positive Birth
Experience
• Clear information on procedures
• Support, not being alone
• Sense of mastery, self-confidence
• Trust in staff caring for her
• Positive reaction to the pregnancy
• Personal control over breathing
• Preparation for the childbirth experience
Factors That Affect Labor
5 Additional P’s
• Philosophy
• Partner
• Patience
• Pain management
Cardinal movements of Labor
•
•
•
•
•
•
•
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation (restitution)
Expulsion (birth)
Four Stages of Labor
First Stage starts with Onset of labor to
complete dilation
• Latent phase Dilatation 0 to 3 cm
Effacement 0 to 40%
• Active phase Dilatation 4 to 7 cm
Effacement 40 to 80%
• Transition
Dilatation 8–10 cm
Effacement 100%
Stages of Labor
• Second stage–complete dilation to
birth
• Third stage–birth to placental
separation and expulsion
• Fourth stage–four hours following
delivery of the placenta
29
Initial Maternal Assessment
•
•
•
•
•
•
•
Presenting complaint
EDC
Gravida/Para
Contraction Pattern
Membrane status
Presence of fetal movement
Complications
Fetal Assessment
• FHR provides information about the fetal
oxygen status.
• Locations for auscultating
• Doppler Nursing Procedure 12.1 pg. 355
• Continuous FHR via ultrasound
transducer
• Fetal movement
Doppler
Doppler
Continuous Fetal Monitoring
Contraction Assessment
•
•
•
•
Frequency
Duration
Strength/Intensity
Resting tone
Contraction Phases
39
Pelvic Exam
•
•
•
•
•
Effacement
Dilation
Presenting part
Station
Status of membranes
42
General Systems Assessment
• Vital signs
• General physical assessment
• Leopold’s maneuvers
Procedure 14.1 pg. 424
• DTR and clonus
• Review prenatal record for lab results
and history
Leopold’s Maneuver
Video12310
• Leopold's Maneuver
Physiologic Adaptation to Labor
Maternal Adaptation
• Cardiovascular changes
• Respiratory changes
• Musculoskeletal changes
• Gastrointestinal changes
Physiologic Adaptation to Labor
Fetal adaptation to labor
• Fetal heart rate changes due to
contractions
• Fetal circulation & respiratory changes
preparing for birth
• Fetal heart rate baseline and variability
• Fetal heart rate response to contractions
Nurses Role
• During labor and delivery fetal assessment
includes determining fetal well-being and
interpreting signs and symptoms of
possible compromise
• Nurse needs to be knowledgeable of the
different FHR categories and the
appropriate interventions that may be
required
Monitoring Techniques
Electronic fetal monitoring
• External monitoring
FHR—ultrasound transducer
UCs—Toco transducer
• Internal monitoring (invasive)
Spiral electrode (FSE)
Intrauterine pressure catheter (IUPC)
Amnio Hook
Fetal Scalp Electrode
Placement of FSE
IUPC
Internal Fetal Monitoring
FHR Categories
• Category I normal
• Category II indeterminate
• Category III Predictive of abnormal fetus
acid base status
Tab. 14.1 pg.429
Determining FHR Patterns
Fetal assessment
• Baseline FHR
• Variability
• Accelerations
• Periodic changes (decelerations)
Early (head compression)
Late (placental insufficiency)
Variable (cord compression)
Baseline Fetal Heart Rate
• Baseline Rate is the average FHR that
occurs during a 10-minute segment
excluding periodic or episodic rate
changes
• Normal 110-160
• Bradycardia <110
• Tachycardia >160
Fetal Heart Rate Variability
• Irregular Fluctuations in FHR baseline
measured as amplitude of the peak to
trough in bpm
• Absent fluctuation undetectable
• Minimal <5 bpm
• Moderate (normal) 6-25 bpm
• Marked >25bpm
Fetal Heart Rate Patterns
Changes in fetal heart rate
• Periodic occur with Contractions
• Episodic (non-periodic) not associated
with contractions
• Accelerations
• Decelerations
Accelerations
• Positive sign of fetal wellbeing
• Abrupt increase in FHR above the base
line lasting <30 sec from onset to peak
• Term 15 bpm above baseline & duration
>15 sec. but <2min
• Prior to 32 weeks 10 by 10
• Prolonged 2 min. to <10min
Decelerations
•
•
•
•
Early decelerations
Late decelerations
Variable decelerations
Prolonged decelerations
Early Decelerations
• Gradual decrease in FHR, nadir
coincides with the peak of the
contraction
• Mirror image of the contraction
• Head compression/vagal response
• No treatment required/benign pattern
Late Decelerations
• Gradual decrease in FHR with the nadir
of the deceleration occurring after the
peak of the contraction. The FHR does
not return to baseline until the
contraction has ended
• Caused by uteroplacental insufficiency
• Fetus is in distress
• Interventions Box 14.1 pg.432
68
Variable Decelerations
• Abrupt decrease in FHR below the
baseline. The decrease is at least 15
bpm, lasting between 15 sec and
under 2 minutes. They can vary with
contractions.
• Shaped like a “V” or a “W”
• Associated with cord compression
Prolonged Deceleration
• Abrupt decrease in FHR of at least 15 bpm
lasting longer than 2 minutes, but less
than 10 minutes.
• FHR usually drops to less than 90 bpm
Decelerations
Fetal Heart Rate
•
•
•
•
V
E
A
L
Variable
Early
Acceleration
Late
•
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C Cord
H Head Compression
O Oxygenated fetus
P Placental problems
Fetal Assessment Methods
• Umbilical Cord Blood Analysis
• Fetal Scalp Stimulation
Pain Management
• Nonpharmacologic
• Pharmacologic
Nonpharmacologic Management
• Simple, safe, and inexpensive
• Provide sense of control over childbirth
• Natural child birth requires practice for
best results
• Try variety of methods and seek
alternatives, including pharmacologic
methods if needed
Nonpharmacologic Management
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•
Imagery and visualization
Position Changes
Table 14.2 pg.437
Music
Touch and massage
Breathing techniques
Effleurage and counter pressure
Water therapy (hydrotherapy)
Pharmacologic Management
• Systemic Analgesia
• Regional Analgesia/Anesthesia
Systemic Analgesia
• Use of one or more drugs administered
orally, IM, or IV. These meds are
distributed via the circulatory system.
• Pain relief can occur within a few min.
and last up to several hrs.
• Side effect can be respiratory depression
in the mother as well as the newborn
after birth
Systemic Analgesia
•
•
•
•
Opioids
Ataractics/Antiemetics
Benzodiazepines
Drug Guide 14.1 pg. 441
Regional Analgesia/Anesthesia
•
•
•
•
Pudendal never block
Epidural (Vaginal Del or C/S)
Spinal (C/S)
General (C/S)
Epidural Analgesia
•Combination of local anesthetic
(lidocaine) & an opioid (morphine or
fentanyl)
•Injected into the epidural space
•Medication can be balanced to provide
pain relive and the ability to ambulate
Epidural Analgesia
General Anesthesia
• Reserved for emergency cesarean births
when there is not enough time to do a
spinal or epidural for anesthesia
• Combination of IV injection and
inhalation agents
Epidurals/Spinals/General
Anesthesia
• Anesthesia interview
• Consent form
• Labs (platelets less than 100,000 can
place an epidural/spinal)
Nursing Responsibilities
During 1st Stage of Labor
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Vital signs
Hydration and nutrition
Elimination
Assessment of contractions and FHR
Labor Support
Comfort measures/Pain management
Education
Second Stage of Labor
•
•
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•
•
Assessment of contractions and FHR
Fetal descent
Psychological considerations
Maternal positioning
Coaching maternal breathing and
pushing efforts
Preparation for Delivery
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Prepare instrument table
Adequate lighting
Oxygen and suction equipment
Radiant warmer, blankets,
identification for newborn
Pitocin
Delivery Table
Preparation for Delivery
• Positioning of mother for birth
• Gown, gloves, and protective
equipment for personnel
• Cleansing of the perineum
• Deliver the newborn
Second Stage of Labor
• Perineal Lacerations (Depth)
* 1st degree
* 2nd degree
* 3rd degree
* 4th degree
• Episiotomy
* midline
* mediolateral
Third Stage of Labor
Delivery of the placenta
• Assess for perineal trauma
• Repair of episiotomy/Perineal
lacerations
• Newborn care
• Emotional support /Foster bonding
Episiotomy
Episiotomy Repair
Third Stage of Labor
Placental separation and expulsion
• Firmly contracting fundus
• Change in uterus
• Sudden gush of dark blood from
introitus
• Apparent lengthening of umbilical cord
• Vaginal fullness
Fetal Side
Maternal Side
Third Stage of Labor
Newborn care
• Time of birth noted
• Drying, stimulation, suctioning of the
newborn
• Respiratory effort, heart rate, color, tone
noted
• One- and five-minute Apgar scores
• Cord blood obtained
• Identification
Apgar Score
Assessment
0 Point
1 Point
2 Point
Heart Rate
Absent
< 100 bpm
> 100 bpm
Respiratory effort
Apneic
Slow, irregular,
shallow
Regular 30-60
breaths/min
Strong, good cry
Muscle Tone
Limp, Flaccid
Some flexion,
limited resistance
to extension
Tight flexion,
good resistance
to extension with
quick response to
flexed position
Reflex irritability
No Response
Grimace or frown
when irritated
Sneeze, cough,
or vigorous cry
Skin color
Cyanotic or Pale
Appropriate body
color; blue
extremities
Completely pink
Apgar Score
• http://www.youtube.com/watch?v=hdNVh
DuD4wU
Fourth Stage of Labor
Maternal Assessment
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Uterus
Lochia
Perineum
Bladder
Vital signs
Pain
Newborn-family attachment
Breastfeeding initiated