Transcript Labor and delivery

Lecture 5
delivery is the physiologic process by which a
fetus is expelled from the uterus to the outside
world.
Changes in the uterine cervix tend to precede
uterine contractions.
What causes Labor?
• The process begins between 38 and 40th
week.
• The exact cause of onset is not understood.
• There are several hypothesis: Progesterone
withdrawal → relaxation of the myometrium,
whereas estrogen stimulates myometrial
contractions and production of
prostaglandins.
• Oxytocin, a hormone produced by the
pituitary, stimulates the uterus to contract.
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SIGNS OF IMPENDING LABOR
1.
2.
3.
4.
5.
6.
7.
Lightening
contractions
Cervical changes: Effacement
Bloody show: labor 24-48 hrs
Rupture of membranes (ROM)
GI disturbance: N/V, diarrhea, weight loss
Sudden burst of energy (nesting)
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Uterine contractions have two major goals:
To dilate cervix
To push the fetus through the birth canal
Success will depend on the four P’s:
 Powers
 Passenger
 Passage
Psyche
Uterine contractions
• Power refers to the force generated by the contraction of the
uterine myometrium
• Uterine contractions increase intrauterine pressure, causing
tension on the cervix. This tension leads to cervical dilation and
thinning, which in turn eventually forces the fetus through the
birth canal.
•Uterine contractions during labor are monitored by palpation
and by electronic monitoring.
Generally 3-5 contractions in a 10 minute
period is considered adequate labor
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Contractions
•
•
•
•
DURATION OF CONTRATION
10:00
45 seconds
10:10
45 seconds
10:15
60 seconds
10:20
60 seconds
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Passenger =fetus
Fetal variables that can affect labor:
•Fetal size
•Fetal Lie – longitudinal, transverse or oblique
•Fetal presentation – vertex, breech, shoulder,
compound (vertex and hand).
Position
Station – degree of descent of the presenting
part of the fetus, measured in centimeters from
the ischial spines
Passage = Pelvis
Consists of the bony pelvis and soft tissues of the birth
canal (cervix, pelvic floor musculature)
Small pelvic outlet can result in cephalopelvic
disproportion
X-ray pelvimetry to determine the smallest A-P diameter
through which the fetal head must pass.
Fetal presentation-the part of the fetus that enters
the maternal pelvis first.
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Descent
• Fetal head descends
through the birth canal
• Defined relative to the
ischial spines
• 0 station = top of head at
the spines (fully engaged)
• +2 station = 2 cm past
(below) the ischial spines
Fetal Descent Stations
.
• Measured in neg. & pos. numbers.
(Centimeters)
• The ischial spine is in (0) Station
• If the presenting part is higher
than the ischial spine, the station
has a (-) neg.
• Positive = presenting part has
passed the ischial spine.
• Positive (+) 4 is at the outlet.
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Cervical Effacement and Dilatation
• Cervical Effacement: the
progressive shortening
and thinning of the cervix
during labor. 0 – 100%
• Cervical Dilatation: the
increase in diameter of
the cervical opening
measured in centimeters.
0 – 10 cm.
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True and False Labor Contractions
True Labor
False Labor
•Result in progressive cervical dilation
•Do not result in progressive cervical
dilation
• Occur at regular intervals
• Occur at irregular intervals
•Interval between contractions
decreases
•Interval between contractions remains
the same or increases
•Frequency, duration, and intensity
increase
•Intensity decreases or remains the
same
•Located mainly in back and abdomen
•Located mainly in lower abdomen and
groin
•Generally intensified by walking
•Generally unaffected by walking
•Not easily disrupted by medications
•Generally relieved by mild sedation
MATERNAL SYSTEMIC RESPONSES TO LABOR
• CV system–cardiac output increases.
• Respiratory system–oxygen consumption during labor equals
moderate to strenuous exercise.
• Renal system–with engagement, bladder pushed forward and
upward.
• GI system–peristalsis and absorption decrease.
• Fluid and Electrolyte balance–body temperature increases and
client perspires profusely.
• Immune system–white blood count increases
• Integumentary system–vagina and perineum have great ability to
stretch.
• Musculoskeletal system–relaxation of pelvic joints, may result in
backache.
• Neurological system–endorphins increase pain threshold,
sedative effect.
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Stage of labor :
1. First stage
2. Second stage
3. Third stage
4. fourth stage
Stages of Labor
• First stage: early, active, transition
– Dilatation
• Second stage
– Pushing and birth
• Third stage
– Delivery of placenta
• Fourth stage
– Postpartum
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Stages of labor
The Labor Curve
First stage - A: latent phase; B + C + D: active phase; B: acceleration; C:
maximum slope of dilation; D: deceleration; E: second stage.
Adapted from: Friedman. Labor: Clinical evaluation and management,
2nd ed, Appleton, New York 1978.
Dilation from 0 to 10 cm.
Begins with the first true labor contractions and ends with
complete effacement and dilation of the cervix (10 cm dilation).
The first stage of labor averages about 13½ hours for a nullipara
and about 7½ hours for a multipara.
It has three phases:
- Latent or Early
- Active
- Panting or transition
• Dilates from 0 to 3 cm.
• Contractions are usually every 5 to 20 minutes,
lasting 20 to 40 seconds, and of mild intensity.
• The contractions progress to about every 5
minutes and establish a regular pattern.
•Deficient Fluid Volume related to decreased oral intake
•Anxiety related to concern for self and the fetus
•Acute Pain related to uterine contractions or position of the
fetus
Maintaining Nutrition and Hydration
•Provide clear liquids and ice chips as allowed.
•Evaluate urine for ketones and glucose.
•Administer I.V. fluids as indicated.
Relieving Anxiety
•Establish a relationship with the woman/support persons.
•Provide information on the health care facility's policies
and procedures.
•Inform the woman of maternal status and fetal status and
labor progress.
•Explain all procedures and equipment used during labor.
•Answer any questions the woman has.
•Review the birth plan and make appropriate revisions.
•Monitor maternal vital signs.
•Remember the individual patient condition is used to
determine frequency of vital signs and FHR assessment.
Controlling Pain
Encourage ambulation as tolerated regardless of membrane
status as long as presenting part is engaged. (This may vary
according to health care provider.)
Encourage diversional activities, such as reading, talking,
watching TV, playing cards, listening to music.
Review, evaluate, and teach proper breathing techniques.
Encourage a warm shower.
Laboring woman can sit on a chair in the shower with the
water running continuously over her lower back.
Encourage relaxation techniques.
Provide comfort measures.
Use of Jacuzzi or shower for relaxation if available.
Reposition external monitors as needed.
Dilates from 4 to 7 cm.
Contractions are usually every 2 to 5
minutes; lasting 30 to 50 seconds and of
mild to moderate intensity.
After reaching the active phase, dilation
averages 1.2 cm/hour in the nullipara and1.5
cm/hour in the multipara.
Dilates from 8 to 10 cm.
Contractions are every 2 to 3 minutes,
lasting 50 to 60 seconds and of moderate
to strong intensity. Some contractions may
last up to (but not exceed) 90 seconds.
First stage – Active and Transitional
phase : role of the nurse
-- Nursing diagnosis
-- Nursing intervention
• Anxiety related to concern for self and
fetus
• Acute Pain related to uterine contractions
• Impaired Urinary Elimination related to
epidural anesthesia or from pressure of the
fetus
• Ineffective Coping related to discomfort
• Risk for Infection related to rupture of the
membranes
• Impaired Physical Mobility related to
medical interventions and discomfort
• Ineffective Breathing Pattern related to pain
and fatigue
Relieving Anxiety
Monitor maternal vital signs and FHR, and keep the
woman/couple informed of the maternal and fetus status.
Maternal temperature every 2 to 4 hours unless elevated
or membranes ruptured, then every 1 hour.
Blood pressure, pulse, respirations usually every 30 to 60
minutes or as indicated by policy or maternal status.
Evaluate FHR every 30 minutes if low-risk patient or
every 15 minutes if high risk patient regardless if
monitoring is continuous or intermittent.
Provide encouragement and support.
Involve the support person in the woman's care.
Minimizing Pain
Encourage position changes for comfort.
Assist the woman with breathing and
relaxation techniques as needed.
Provide back, leg, and shoulder massage as
needed.
Assist with preparation for analgesia and
anesthesia

Monitor the woman following administration of
analgesia/anaesthesia.
 Monitor the woman's blood pressure, pulse, and
respiratory rate after initiation or re-bolus of
regional block every 5 minutes for the first 15
minutes.
 Assess neonate for effects of maternal medication
(neurobehavioral change, such as decreased motor
tone and decreased respiratory rate).
Begins with complete dilation (10 cm cervix
dilation) and ends with birth of the baby.
The second stage may last from 1 to 4 hours in
the nullipara and from 20 to 45 minutes in the
multipara.
Characterized by descent of the presenting part
through the maternal pelvis and expulsion of the
fetus.
Indications of second stage:
Pelvic/rectal pressure
Mother has active role of pushing to aid in fetal
descent.
Examining the fetal head during the second
stage may become difficult due to molding
Molding is the alteration of the fetal cranial
bones to each other as a result of compressive
forces of the maternal bony pelvis.
Caput is the localized edematous area on the
fetal scalp caused by pressure on the scalp by
the cervix.
Fear or Anxiety related to impending delivery
Acute Pain related to descent of the fetus
Risk for Infection related to episiotomy and
tissue trauma
Minimizing Fear and Anxiety
 Monitor maternal vital signs as follows:
- Blood pressure every 5 to 15 minutes
depending on the woman's status.
- Pulse and respirations every 15 to 30 minutes.
- Temperature every 1 hour when membranes
have ruptured.
 Monitor FHR and uterine contractions every 15
minutes in low-risk women and every 5 minutes in
high-risk women.
 Explain procedures and equipment during
pushing and delivery.
 Keep the woman or couple informed of their
status.
Promoting Comfort
 Assist the woman to a comfortable
position.
Left or right lateral, or semi-sitting positions
may be used.
 Teach the woman to put her chin to her
chest so her body forms and shape while
pushing.
 Evaluate bladder fullness, and encourage
voiding or catheterize as needed.
 Evaluate effectiveness of anaesthesia as
indicated.
Preventing Infection and Promoting Safety
• Prepare the delivery room using aseptic technique
• allowing ample time for setup before delivery.
• Prepare the infant resuscitation area for delivery.
• Prepare necessary items for neonatal care.
• Notify necessary personnel to prepare for delivery.
 If delivery room is to be used, transfer the primigravida to
the delivery room when the fetal head is crowning. The
multigravida is taken earlier depending on fetal size and speed
of fetal descent.
• Place all side rails up before moving. Instruct the woman to
keep her hands off the rails, and move from the bed to the
delivery table between contractions.
Clean the vulva and perineal areas
when the woman is positioned for
delivery.
Guide the woman step by step during
the delivery process.
Practice standard precautions during
labor and delivery.
Episiotomy
• Avoids lacerations
• Provides more room for
obstetrical maneuvers
• Shortens the 2nd Stage Labor
• Midline associated with
greater risk of rectal
lacerations, but heals faster
• Many women don’t need
them.
Begins with delivery of the baby and ends with delivery of
the placenta.
The third stage may last from a few minutes to 30 minutes.
Three signs of placental separation:
• Lengthening of umbilical cord
• Gush of blood
• Fundus becomes globular and more anteverted against
abdominal
Placenta is delivered using one hand on umbilical cord with
gentle downward traction. Other hand on abdomen
supporting the uterine fundus.
Risk factor for aggressive traction is uterine inversion.
Clamp and Cut the Cord
• Clamp about an inch from the
baby’s abdomen
• Use any available instruments or
usable material
• Check the cord for 3-vessels, 2 small
arteries and one larger vein
-
Impaired Tissue Integrity related to
placental separation
Risk for Injury related to potential
hemorrhage
Promoting Tissue Integrity
 Ask the woman to bear down gently.
 Observe for the signs of placental separation.
• The uterus rises upward in the abdomen.
• The umbilical cord lengthens.
• Trickle or spurt of blood appears.
• The uterus becomes globular in shape.
 Evaluate the placenta for size, shape, and cord
site implantation.
Preventing Hemorrhage
• Ensure accurate measurement of intake and output
maintained throughout labor and delivery.
Immediately after delivery of the placenta.
• Administer oxytocin (Pitocin 10 to 40 units/L at 100
mU/min) either I.V. or I.M. as directed by facility policy
and provider.
Infuse as bolus initially, then titrate to uterus (ie, if
uterus is firm, decrease the infusion; if boggy, leave as
bolus). Pitocin should never be administered I.V. push as
it can cause cardiac dysrhythmia and death.
• Immediately after initiating Pitocin, massage uterine fundus
until firm. Uterine massage is done with two hands, one at
the lower uterine segment above the symphysis pubis and
the other hand gently massages the fundus.
• Check to see that the placenta and membranes are
complete.
• Evaluate and massage the uterine fundus until firm.
• If bleeding continues and uterus is firm, notify health care
provider for evaluation of lacerations or retained placental
fragments.
• Inspection and repair of lacerations of the vagina and
cervix are made by the health care provider.
If still no relief, notify health care
provider and prepare patient for
possible surgery (dilation and
curettage, blood Transfusion)
• Ineffective Airway Clearance related
to nasal and oral secretions from
delivery
• Ineffective Thermoregulation related
to environment and immature ability
for adaptation
• Risk for Injury related to immature
defenses of the neonate
Promoting Airway Clearance and Transitioning of the
Neonate
1. Transitioning/close observation of the neonate is
essential for at least 6 to 12 hours after birth.
2. Wipe mucus from the face and mouth and nose.
Aspirate with a bulb syringe.
3. Clamp the umbilical cord approximately 1 inch
(2.5 cm) from the abdominal wall with a cord
clamp.
4. Evaluate the neonate's condition by the Apgar
scoring system at 1 and 5 minutes after birth
Promoting Thermoregulation
1. Dry the neonate immediately after delivery, remove wet
towels, and place infant on warm dry towels. A wet, small
neonate loses up to 200 cal/kg/min in the delivery room
through evaporation, convection, conduction, and radiation.
Drying the infant cuts this heat loss in half.
2. Cover the neonate's head with a cotton stocking cap to
prevent heat loss.
3. Wrap the neonate in warm blankets.
4. Place the neonate under a radiant heat warmer, or place the
neonate on the mother's abdomen with skin-to-skin contact.
5. Provide a warm, draft-free environment for the neonate.
6. Take the neonate's axillary temperature a normal temperature
is between (36.4 and 37.2 C).
Preventing Injury and Infection
1. Administer prophylactic treatment against ophthalmia neonatorum
(gonorrheal or chlamydial).
2. Administer a single parental prophylactic injection of vitamin K within 1
hour of birth.
This is done to prevent a vitamin K-dependent hemorrhagic disease of
the neonate.
If the parents do not want the vitamin K administered, inform the
parents that circumcision may not be performed. However, inform
parents that the Vitamin K levels will reach their peak (without
neonatal injection) at 8 days after birth.
While in the delivery room (DR), place identical
identification bracelets on the mother and the neonate.
The nurse in the DR should be responsible for preparing
and securely fastening the bands on the neonate.
Information includes the mother's name, hospital /
admission number, neonate's sex, race, and date and
time of birth.
Foot printing and finger printing the neonate are not
adequate methods of patient identification.
Complete all identification procedures before the
infant is taken from the delivery room.
Weigh and measure the infant shortly after birth.
Normal neonate weight is (2,700 to 4,000 g).
Normal neonate length is (48 to 53 cm).
No later than 2 hours after birth, nursery/mother-baby
personnel should evaluate the neonate's status and assess
risks.
Administer hepatitis B vaccine according to your facility's
policy.
Vitamin K administration is not a requirement for home
deliveries.Vitamin K levels naturally increase at 8 days of
life. If infant is a boy, and parents desire circumcision, the
procedure is withheld until after day 8.
Lasts from delivery of the placenta until the postpartum
condition of the woman has become stabilized (usually 1
hour after delivery).
Blood pressure, uterine blood loss and pulse rate must be
monitor closely ~ 15 minutes
High risk for postpartum hemorrhage from:
Uterine atony, retained placental fragments, unrepaired
lacerations of vagina, cervix or perineum.
Occult bleeding may occur – vaginal hematoma
Be suspicious with increased heart rate, pelvic pain or
decreased BP
1. Risk for Injury related to uterine atony and
hemorrhage
2. Deficient Fluid Volume related to decreased oral
intake, bleeding, and diaphoresis
3. Acute Pain related to tissue trauma and birth
process, intensified by fatigue
4. Impaired Urinary Elimination related to epidural or
spinal anaesthesia and tissue trauma
5. Disturbed Sensory Perception (tactile) related to
effects of regional anaesthesia
6. Risk for Impaired Parenting related to inexperience
Promoting Uterine Contraction and Controlling
Bleeding
• Monitor blood pressure, pulse, and respirations
every 15 minutes for 1 hour, then every
½ hour to 1 hour until stable or transferred to the
postpartum unit.
• Vital signs are taken more frequently if
complications encountered.
• Take temperature every 4 hours unless elevated,
then every 1 to 2 hours.
Maintaining Fluid Volume
• Maintain I.V. fluids as indicated.
• Provide oral fluids and a snack or meal as
tolerated.
• Encourage drink and food before assisting the
woman out of bed.
Relieving Discomfort and Fatigue
• Apply a covered ice pack to the perineum during
the first 24 hours for an episiotomy, perineal
laceration, or edema.
• Administer analgesics as indicated.
• Assure that epidural catheter has been removed.
• Assist the woman in finding comfortable positions.
• Assist the woman with a partial bath and perineal
care, and change linens and pads as necessary.
• Allow for privacy and rest periods between
postpartum checks.
• Provide warm blankets.
Encouraging Bladder Emptying
• Evaluate the bladder for distension.
• Encourage the woman to void.
- Provide adequate time and privacy.
- The sound from a running faucet may stimulate
voiding.
- Gently squirting tapid water against the
perineum in a perineal bottle may help.
• Catheterize the woman (in and out) if the bladder
is full and she is unable to void.
Birth trauma, anesthesia, and pain from lacerations
and episiotomy may reduce or alter the voiding
reflex.
Assessing return of sensation
• Evaluate mobility and sensation of the lower
extremities.
• Evaluate vital signs.
• Remain with the woman, and assist her out of
bed for the first time.
• Evaluate her ability to support her weight and
ambulate.
• Show the neonate to the mother and father or
support person immediately after birth when
possible.
• Encourage the mother and father to hold the
infant as soon as possible.
• Teach the mother or parents to hold the neonate
close to their faces when talking to the baby.
• Have the mother or parents look at and inspect
the infant's body to familiarize themselves with
their child.
• Assist the mother with breast-feeding during
the first 30 minutes, then 2 hours, after birth.
This is typically a period of quiet alert time for
the neonate, and he or she will usually take to
the breast.
• Provide quiet alone time in a low-lighted room
for the family to become acquainted.
• Observe and record the reaction of the
mother or parents to the neonate.
Any question?
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Student Practice 3
• Write about Umbilical Cord Care?
• Write about Using Nitrous Oxide During
Labor: Benefits and Risks?
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