LABOR AND BIRTHLABOR AND BIRTH

COMPONENTS OF THE COMPONENTS OF THE BIRTH PROCESSBIRTH PROCESS

PassagePassage PassengerPassenger Relationship Relationship

between the between the passage and the passage and the fetusfetus

PowersPowers PsychePsyche

Final weeks of pregnancy: mother/baby prepare for birth. Five important factors : the passage, the fetus, the relationship between the passage and the fetus, the forces of labor,and psychosocial considerations.

Often called the 5 “P”s of Labor: Passageway, Passenger, Powers, Position, and Psychological responses

THE BIRTH PASSAGETHE BIRTH PASSAGE

Ability of pelvis and cervix to Ability of pelvis and cervix to accommodate passage of fetusaccommodate passage of fetus

PASSAGE : Birth passage – 3 sections of “true pelvis” – inlet, pelvic cavity (midpelvis), & outlet. Four classifications : gynecoid , android, anthropoid, & platypelloid.

The Birth Passage

Implications of Pelvic types for Labor and Delivery Table 15-2, p 310

THE FETUSTHE FETUS

Ability of the fetus to complete the Ability of the fetus to complete the birth process:birth process:

fetal skullfetal skull

molding: cranial bones overlap molding: cranial bones overlap under under pressure of the powers of pressure of the powers of labor and labor and demands of unyielding demands of unyielding pelvispelvis

PASSENGER: Fetal head: Considerations: face, base of skull, & vault of cranium (roof). Bones in face fused but vault has movable bones; overlap under pressure –

molding.

Sutures –membranous spaces between bones; intersections –

fontanel's (‘soft spot”)Landmarks: mentum – chin;

sinciput – brow; vertex – space between fontanel's; occiput –

occipital bone

The Fetus Head

Relationship between the passage and the fetus

Engagement Station Fetal position

The Fetus

Attitude Lie Presentation

Top: Fetal Attitude flexion, fetal lie longitudinal

Bottom: Fetal Attitude flexion, fetal lie transverse

Fetal attitude – relationship of fetal parts to one another: norm: mod flexion of head, flexion of arms unto chest, & flexion of legs to abdomen Fetal lie – relationship of cephalocaudal axis (spinal column) of fetus to c. a. of motherlongitudinal: parallel transverse: fetal c.a. is 90° to woman’s spine  Fetal Presentation – determined by fetal lie and by the body part that enters the pelvic passage first. The portion of the fetus is referred to as the presenting part. Fetal presentation may be cephalic, breech, or shoulder. 

EngagementEngagement – when largest diameter of – when largest diameter of presenting part reaches or passes through pelvic presenting part reaches or passes through pelvic inlet.inlet.Figure 15-7, p 314Figure 15-7, p 314The biparietal diameter (BPD) of fetal head The biparietal diameter (BPD) of fetal head settles into inlet of pelvis. In most instances, the settles into inlet of pelvis. In most instances, the occiput is at the level of the ishial spines () occiput is at the level of the ishial spines () station. station.   StationStation –refers to the relationship of presenting –refers to the relationship of presenting part to an imaginary line drawn between the part to an imaginary line drawn between the ischial spines of the maternal pelvis. If the ischial spines of the maternal pelvis. If the presenting part is higher than the ischial spines, presenting part is higher than the ischial spines, the station has a negative #, referring to the station has a negative #, referring to centimeters above 0 station. Minus 5 is at the centimeters above 0 station. Minus 5 is at the pelvic inlet. Positive #s = presenting part has pelvic inlet. Positive #s = presenting part has passed the ischial spines. Positive (+) 4 is at the passed the ischial spines. Positive (+) 4 is at the outlet.outlet. See Figure 15-8, p 315See Figure 15-8, p 315

   Fetal positionFetal position – relationship of the designated – relationship of the designated

landmark of fetal presenting part to the left or landmark of fetal presenting part to the left or right side of the maternal pelvis. The designated right side of the maternal pelvis. The designated landmarks are vertex: the occiput; in face landmarks are vertex: the occiput; in face presentation: the mentum. In breech: the sacrum; presentation: the mentum. In breech: the sacrum; for shoulder: the acromion process of the scapula. for shoulder: the acromion process of the scapula. If directed to side, it is designated as If directed to side, it is designated as transverse. transverse.

The landmark on the fetal presenting part r/t four The landmark on the fetal presenting part r/t four imaginary quadrants: left anterior, right anterior, imaginary quadrants: left anterior, right anterior, left posterior, and right posterior, meaning: Is the left posterior, and right posterior, meaning: Is the presenting part directed toward the front, back, presenting part directed toward the front, back, left or right of the passage? left or right of the passage?

Three notations:Three notations: Right ® or left (L) side of maternal pelvisRight ® or left (L) side of maternal pelvis The landmark of fetal presenting part: occiput The landmark of fetal presenting part: occiput

(O); mentum (M), sacrum (S), or acromion (O); mentum (M), sacrum (S), or acromion process (A).process (A).

Anterior (A), posterior (P), or transverse (T )Anterior (A), posterior (P), or transverse (T )

PHYSIOLOGIC FORCES OF PHYSIOLOGIC FORCES OF LABORLABOR

characteristics of contractions and characteristics of contractions and effectiveness of expulsion methodseffectiveness of expulsion methods

Primary and secondary forcesPrimary and secondary forces

PSYCHOLOGICAL PSYCHOLOGICAL CONSIDERATIONSCONSIDERATIONS

Preparation for childbirthPreparation for childbirth Support systemsSupport systems Present emotional statusPresent emotional status Beliefs and valuesBeliefs and values

“Pa…I think it’s time to go!”

PHYSIOLOGY OF LABORPHYSIOLOGY OF LABOR

Progesterone and estrogenProgesterone and estrogen Thinning of the cervixThinning of the cervix ContractionsContractions

PREMONITORY SIGNS OF LABORPREMONITORY SIGNS OF LABOR

Lightening: fetus Lightening: fetus descends into descends into pelvic inletpelvic inlet

Braxton hicks Braxton hicks contractions: contractions: irregular irregular intermittent intermittent contractionscontractions

PREMONITORY SIGNS PREMONITORY SIGNS

Cervical changes: cervix begins to Cervical changes: cervix begins to soften and weakensoften and weaken

Bloody show: loss of cervical mucous Bloody show: loss of cervical mucous plugplug

PREMONITORY SIGNSPREMONITORY SIGNS

RUPTURE OF MEMBRANESRUPTURE OF MEMBRANES SUDDEN BURST OF ENERGYSUDDEN BURST OF ENERGY WEIGHT LOSSWEIGHT LOSS DIARRHEADIARRHEA

DIFFERENTIATE BETWEEN TRUE LABOR DIFFERENTIATE BETWEEN TRUE LABOR AND PRE LABORAND PRE LABOR

PHYSIOLOGICAL AND PSYCHOLOGICAL PHYSIOLOGICAL AND PSYCHOLOGICAL CHANGES OF EACH STAGE OF LABORCHANGES OF EACH STAGE OF LABOR

Latent phaseLatent phase

Active phaseActive phase

TransitionTransition

LATENT PHASELATENT PHASE

Psychological changesPsychological changesRegular mild contractionsRegular mild contractions

Cervical effacement and dilation beginCervical effacement and dilation begin

Psychological changesPsychological changes

relief that labor has begunrelief that labor has begun

excitement and anxietyexcitement and anxiety

ACTIVE PHASEACTIVE PHASE

Physiological changesPhysiological changes Contractions increase in intensity, frequency & Contractions increase in intensity, frequency &

durationduration

Cervical dilation changes from 4 to 7 cmCervical dilation changes from 4 to 7 cm

Fetus descends into pelvisFetus descends into pelvis

Psychological changesPsychological changesfear of loss of controlfear of loss of control

increased anxietyincreased anxiety

TRANSITION PHASETRANSITION PHASE

Physiological changesPhysiological changes Contractions continue to increase in Contractions continue to increase in

intensityintensity Cervix dilates from 8-10 cmCervix dilates from 8-10 cm Fetus descends rapidly into the birth Fetus descends rapidly into the birth

passagepassage Women may experience rectal pressure, Women may experience rectal pressure,

n/vn/v

Psychological changesPsychological changes Increased feelings of anxietyIncreased feelings of anxiety IrritabilityIrritability Eager to complete birth processEager to complete birth process Need to have support person or nurse at Need to have support person or nurse at

sideside

SECOND STAGESECOND STAGE

Physiologic changesPhysiologic changes Begins with complete cervical dilation and Begins with complete cervical dilation and

ends with birth of the infantends with birth of the infant Women pushes Women pushes Perineum begins to bulge, flatten and move Perineum begins to bulge, flatten and move

anteriorlyanteriorlyPsychological changesPsychological changes

may feel out of controlmay feel out of control may feel sense of purposemay feel sense of purpose

THIRD STAGE OF LABORTHIRD STAGE OF LABOR

Physiological changesPhysiological changes Placental separationPlacental separation

Psychological changesPsychological changes

women may feel relief women may feel relief

usually focused on infantusually focused on infant

THIRD STAGE OF LABORTHIRD STAGE OF LABOR

S/S placental S/S placental separationseparation

globular shaped uterusglobular shaped uterus rise of the fundus in the rise of the fundus in the

abdomenabdomen a sudden gush or a sudden gush or

trickle of bloodtrickle of blood further protrusion of further protrusion of

the umbilical cord out the umbilical cord out of the vaginaof the vagina

FOURTH STAGE OF LABORFOURTH STAGE OF LABOR

INTRAPARTAL NURSING INTRAPARTAL NURSING ASSESSMENTASSESSMENT

DISCUSS HIGH RISK SCREENING AND DISCUSS HIGH RISK SCREENING AND INTRAPARTAL ASSESSMENT OF INTRAPARTAL ASSESSMENT OF MATERNAL AND MATERNAL AND PSYCHOSOCIOCULTURAL FACTORSPSYCHOSOCIOCULTURAL FACTORS

HIGH RISK SCREENINGHIGH RISK SCREENING

Obtain maternal history and note Obtain maternal history and note high risk factorshigh risk factors Name and age of motherName and age of mother LMP & EDBLMP & EDB

attending physician or CNMattending physician or CNM

Personal dataPersonal data

PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT

Integral part of admission procedure Integral part of admission procedure and essential for ongoing care.and essential for ongoing care.

Assessment of body systemsAssessment of body systems

Actual labor progressActual labor progress

Laboratory findingsLaboratory findings

CULTURAL ASSESSMENTCULTURAL ASSESSMENT

Address and honor values and beliefs of Address and honor values and beliefs of laboring womenlaboring women

Nurses are more effective when aware ofNurses are more effective when aware of Cultural beliefs of a specific groupCultural beliefs of a specific group The impact individual differences may have on The impact individual differences may have on

laboring womenlaboring women

Be aware of stereotypingBe aware of stereotyping

PSYCHOLOGICAL ASSESSMENTPSYCHOLOGICAL ASSESSMENT

Laboring client may have Laboring client may have preconceived ideas, knowledge and preconceived ideas, knowledge and fears about childbirthfears about childbirth

Support system what are their Support system what are their planned caretaking activitiesplanned caretaking activities

Intrapartal Nursing Assessmentcont’d

Contractions Frequency Intensity Duration

Vaginal exam

Need to consider possibility that Need to consider possibility that women has experienced domestic women has experienced domestic violenceviolence Use ACOG (1998) guidelines when Use ACOG (1998) guidelines when

interviewing and interview aloneinterviewing and interview alone Do an anxiety assessmentDo an anxiety assessment

ASSESSMENT TOOLSASSESSMENT TOOLS

Vital signsVital signs

CONTRACTIONSCONTRACTIONS

Uterine assessments are assessed by Uterine assessments are assessed by palpation or continuous monitoringpalpation or continuous monitoring

Assess at least three contractionsAssess at least three contractions Good time to assess laboring mother’s Good time to assess laboring mother’s

perception of painperception of pain

Intrapartal Nursing Assessmentcont’d

Contractions Frequency Intensity Duration

Vaginal exam

ASSESSMENT OF CONTRACTIONS BY ASSESSMENT OF CONTRACTIONS BY PALPATIONPALPATION

Assess contractions for frequency, duration, and Assess contractions for frequency, duration, and intensity by placing one hand on the uterine intensity by placing one hand on the uterine fundusfundus

Determine frequency-note the time from the Determine frequency-note the time from the beginning of the contraction to beginning of next beginning of the contraction to beginning of next contractioncontraction

Determine contraction durationDetermine contraction duration Note time when tensing of fundus is felt and again when Note time when tensing of fundus is felt and again when

it relaxesit relaxes

Intensity can be determined by estimating indent Intensity can be determined by estimating indent ability of fundusability of fundus

TOOLS CONTINUEDTOOLS CONTINUED

Electronic fetal monitoringElectronic fetal monitoring Provides continuous data and Provides continuous data and

is routine for high risk clientsis routine for high risk clients

TOOLS CONTINUEDTOOLS CONTINUED

Cervical assessmentCervical assessment Dilation and effacement evaluated Dilation and effacement evaluated

by doing a vaginal exam-also by doing a vaginal exam-also provides information aboutprovides information about

Membrane statusMembrane status Characteristic of amniotic fluidCharacteristic of amniotic fluid Fetal positionFetal position StationStation

TOOLS CONTINUEDTOOLS CONTINUED

assessment of fetal membranesassessment of fetal membranes

12% of women at term rupture 12% of women at term rupture prior to onset of laborprior to onset of labor

If membranes ruptured longer If membranes ruptured longer than 12-24 hours labor inducedthan 12-24 hours labor induced

Ruptured membranes increase risk of Ruptured membranes increase risk of infectioninfection

Spontaneous rupture of membranes Spontaneous rupture of membranes occurs at the height of the occurs at the height of the contraction with a gush of fluid out of contraction with a gush of fluid out of vaginavagina

Artificial rupture of membranes called Artificial rupture of membranes called amniotomyamniotomy

ASSESSMENT OF ASSESSMENT OF MEMBRANESMEMBRANES

Assess for ruptureAssess for rupture Nitrazine paperNitrazine paper FerningFerning CHECK FETAL HEART TONES FIRSTCHECK FETAL HEART TONES FIRST

FERNINGFERNING

Fluid assessmentFluid assessment

Assess character of fluid forAssess character of fluid for ConsistencyConsistency Amount of fluidAmount of fluid OdorOdor Color of fluidColor of fluid Assess fht frequentlyAssess fht frequently

TOOLS CONTINUEDTOOLS CONTINUED

Freidman’s GraphFreidman’s Graph DilationDilation StationStation

FOURTH STAGE OF LABORFOURTH STAGE OF LABOR

Care of the motherCare of the mother

AssessmentsAssessments