LABOR PROCESS

Theories of Labor Onset Combination of factors from mother and fetus:

Uterine

muscle stretching, which result in prostaglandin release

on the cervix, which stimulates the release of oxytocin from the postgerior pituitary stimulation which works together with prostaglandin to initiate contractions in the ratio of estrogen and progesterone (increasing estrogen in relation to progesterone stimulates uterine contractions)
Placental Rising Change Oxytocin

Pressure

age, which triggers contractions at set point

fetal cortisol levels, which reduce progesterone formation and increase prostaglandin formation
Fetal

membrane production of prostaglandin, which stimulates contractions and time influence

Seasonal

SIGNS OF LABOR: PRELIMINARY SIGNS OF LABOR

is the descent of the fetal presenting part into the pelvis, occurs approximately 10-14 days before the labor begins. - Discomforts: shooting leg pains from pressure to the sciatic nerve - Increase amount of vaginal discharge - Urinary frequency
LIGHTENING:

in Level of Activity: due to increase in epinephrine release that is initiated by decrease in progesterone produced by the placenta. Prepares the womans body for the work of labor ahead.
Increase Braxton

Hicks Contractions

of the Cervix (Goodells Sign): seen in pelvic examination; buttersoft, and it tips forward.
Ripening

Uterine Contractions: the surest sign that the labor has begun is the initiation of effective, productive involuntary uterine contractions

Show:

the mucus plug that filled the cervical canal during pregnancy is expelled. - Pink Tinge referred to as show or bloody show.

of membranes: Amniotic fluid continues to be produced until delivery of the membranes after the birth of the fetus (no labor is ever dry)
Rupture

rupture of membranes can be advantageous if it causes the fetal head to settle snugly into the pelvis.
Early

Two Risks Associated with Rupture of Membranes:

intrauterine Prolapse

infection

of the Umbilical Cord (which can cut off the oxygen supply to the

fetus) labor has not spontaneously occurred by 24 hours after membrane ruptures and pregnancy is at term: labor will be induced to prevent the risks.
If

THE 4 PS OF LABOR
1. Passenger fetus fetal head - is the largest presenting part common presenting part of its length. Fetal Position is the relationship of the fetal presenting part to specific quadrant of the mothers pelvis.
  

Occiput anterior (OA) commonest presentation (normal) Occiput posterior (OP) most rotate spontaneously to OA Occiput transverse(OT) leads to arrest of dilation

Types of Fetal Position Location of the presenting part in relation to the portion of the mothers pelvis
   

Right anterior Left anterior Right posterior Left posterior

Specific presenting part of the fetus (LOA, LOP, ROA, ROP.)

First

letter defines whether the landmark is pointing the mothers right (R) or left

(L)
Middle    

letter denotes the fetal landmark

O : Occiput M : Mentum or chin A : Acromuim process Sa : Sacrum

Last letter defines whether the landmark points anteriorly (A), posteriorly (P), or transversely (T)

Attitude refers to the degree of flexion a fetus assumes during labor or the
relation of the fetal parts to each other.


Good Attitude : is in complete flexion: the spinal column is bowed forward, the head is flexed forward, the arms are flexed and folded on the chest, the thighs are flexed onto the abdomen, and the calves are pressed against the posterior aspect of the thighs. Normal fetal position. Moderate Flexion : the chin is touching the chest but is in alert position. This position causes the next widest anteroposterior diameter, the occipital frontal diameter, to present to the birth canal. Poor Flexion: presents the brow. The back is arched, the neck is extended, and the fetus is extended, and a fetus is in complete extension, presenting the occipitomental diameter of the head to the birth canal (face presentation). This may occur if there is less than normal amniotic fluid (oligohydramnios)

: refers to the settling of the presenting part of the fetus far enough into the pelvis to be at the level of the ischial spines, a midpoint of the pelvis.
Engagement

Station refers to the relationship of the presenting part to the level of the ischial spine
 

Presenting part at the level of the ischial spines, it is at station 0 Presenting part above the spines, it is at minus stations
-1

- -3 = floating part below the spines, it is at plus station - +3 = at the outlet (engaged)

-4 Presenting

+1

+4

Lie is the relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal) axis of a womans body
Fetal Longitudinal

Lie (Parallel)/ Vertical) fetal long axis parallel to the long axis of

the mother
Cephalic Breech

Lie (Perpendicular)/Horizontal lie fetus is lying in a horizontal or vertical position Oblique Lie

Transverse

Fetal Presentation denotes the body part that will first contact the cervix or be born first. This is determined by a combination of fetal lie and attitude. Longitudinal Lie (Parallel)/ Vertical 1. Cephalic when the fetus is completely flexed. Fetal head as the presenting part Type Vertex Brow Face Mentum Lie Longitudinal Longitudinal Longitudinal Longitudinal Attitude Good Moderate Poor Very Poor

2. Breech either the buttocks or the feet are the presenting parts that will contact the cervix. Type Lie Attitude Description Fetus has thighs tightly flexed on the abdomen; both the buttocks and the tightly flexed feet present to the cervix

Complete Longitudinal Good

Frank

Longitudinal Moderate Hips are flexed but the knees are extended to the rest on the chest. The buttocks alone present to the cervix.

Neither the thighs nor the lower legs are flexed. If one foot presents, it is a singlefootling breech; The present, it is a double3. Transverse Lie (Perpendicular)/Horizontal lie if both longest fetal axis is perpendicular to that of the mother. footling breech part is usually one of the The presenting shoulders, an iliac crest, a hand, or an elbow Footling

Longitudinal Poor

MECHANISMS OF LABOR (CARDINAL MOVEMENTS)

a. Descent. Is the downward movement of biparietal diameter of the fetal head to within the pelvic inlet. Full descent occurs when the fetal head extrudes beyond the dilated cervix and touches the posterior vaginal floor. b. Flexion. The head bends forward onto the chest, making the smallest AP diameter the one presented to the birth canal. c. Internal Rotation. The head flexes as it touches the pelvic floor, and the occiput rotates until it is superior, or just below the symphysis pubis, bringing the head into the best relationship to the outlet of the pelvis. The movement brings the shoulders, coming next, into the optimal position to enter the inlet. d. Extension. The head extends and the foremost parts of the head, the face and chin, are born e. External Rotation. The anterior shoulder is born first, assisted by downward flexion of the head. f. Expulsion. Once the shoulders are born, the rest of the baby is born easily and smoothly because of its smaller size.

2. Passageway vagina & pelvis 4 main pelvic types a. gynecoid round, wide, deeper, most suitable for pregnancy b. android heart shape male pelvis anterior pointed post part shallow c. Anthropoid oval ape-like pelvis AP wider transverse narrow d. Platypelloid flat transverse oval AP narrow transverse wider c/s for delivery * Problem : - mother who encounter accident - 49 - 18y/o R: pelvis not achieve its full pelvic growth

3. Power supplied by the fundus of the uterus, are implemented by the uterine contractions, a process that causes cervical dilatation and expulsion of the fetus. a. involuntary contractions b. voluntary bearing down efforts c. characteristics: wave like d. timing: requency, duration, intensity myometrium power of labor Phases of Contraction a. Increment. Intensity of contraction increases. b. Acme. The contraction is at its strongest c. Decrement. When the intensity decreases Cervical Changes a. Effecement. Is the shortening and thinning of the cervical canal. b. Dilatation. Refers to the enlargement or widening of the cervical canal from an opening a few milliliters wide to one large enough (10 cm).

Related Terminologies a. Duration beginning of contraction to the end of the same contraction b. Interval from end of contraction to the beginning of the next contraction c. Frequency from the beginning of 1 contraction to the beginning of next contraction d.Intensity strength of contraction Something to Ponder a. if contract blood vessel constricts; the fetus will get the oxygen on the placenta reserve which is capable of giving oxygen to the fetus up to 1min. b. Duration of placenta to the fetus should not exceed 1min. c. Significance During active phase, if to 1min should notify the AMD d. BP; FHT : best time to get BP & FHT just after a contraction 4. Psyche/person - psychological stress exist when the mother is fighting the labor experience. a. cultural interpretation preparation b. past experience c. support system 5. Placenta

LABOR AND DELIVERY PROCESS

Differentiation Between True and False Labor Contractions False Contractions Begin and remain Irregular True Contractions Begin irregularly but become regular and predictable Felt first in the lower back and sweep around to the abdomen in a wave

Felt first abdominally and remained confined to the abdomen and groin

Often disappear with ambulation and sleep Don not increase with the duration, frequency or intensity Do not achieve cervical dilatation

Continue no matter what the womans level of activity Increase in duration, frequency and intensity. Achieve cervical dilatation

!st Stage Dilatation

Latent 0-3 cm

Frequency Duration
5-10 mins 20-49 sec

Intensity
Mild

Nursing Interventions
Encourage walking : shortens 1st stage of labor Encourage to void q 2-3 hrs : full bladder inhibits uterine contraction breathing (chest breathing technique) y y M edications have meds ready A ssessment include: v/s, cervical dilatation & effacement, fetal monitor, etc D ry lips oral care (ointment), dry linens Breathing abdominal breathing T tires I inform of progress (to relieve emotional support) R restless support her breathing technique E encourage & praise D discomfort

Active

4-7 cm

3-5 mins

30-6 sec

Moderate

y y Transition 8-10 cm 2-3 mins 45-90 sec Strong y y y y y

A. CORD PROLAPSE - A loop of the umbilical cord slips down in front of the presenting fetal part. May occur at any time after the membranes rupture if the presenting part is not fitted firmly into the cervix Predisposing Factors:  PROM  Abnormal fetal presentation  Placenta previa  Intrauterine tumors preventing the presenting part from engaging

- Small fetus - CDP preventing engagement - Hydramnios - Multiple gestation

Assessment Presenting part has not yet engaged Fetal distress Protruding cord from vagina cerebral palsy

5 mins., irreversible brain damage mgt: CS

Nursing Care Positioning knee chest or trendelenburg, place wet sterile gauze R: to make it slippery Observe for fetal distress Provide emotional support Prepare for cesarean section

B. BREECH PRESENTATION - Fetal buttocks is the presenting part Classification:  Complete: Flexion at the knees and hips  Frank: Flexion at the hips, extension at knees  Most common type of breech presentation  The only breech presentation delivered vaginally  Footling: maybe single of double with extension at hip(s) and knee(s) so that the foot is the presenting part Etiology:  Maternal Pelvis contracted, Grand multiparity Uterus (shape abnormalities, intrauterine tumors causing compression)  Maternal-fetal Placenta previa Amniotic fluid (poly/oligohydramnios) Fetal Prematurity Multiple gestation Congenital malformations
Diagnosis:

Leopolds maneuver UTZ Management:

C. FETAL DISTRESS Assessment: Fetal heart rate above 160 or below 120 bpm Meconium-stained amniotic fluid Fetal hyperactivity Variable deceleration pattern Late deceleration Fetal pH below 7.2 Management:  Position mother by turning to the left side; elevated legs  Administer O2 via face mask as prescribed  Discontinue oxytocin as prescribed  Increase IVF as prescribed to correct hypotension  Monitor VS  prepare for emergency CS

A. SHOULDER DYSTOCIA - impaction of anterior shoulder of fetus against symphysis pubis after fetal head has been delivered (life threatening emergency). Occurs when breadth of shoulders is greater than biparietal diameter of the head Watch out for:  Turtle sign: head advances during contraction but returns to previous position at the end of the contraction  Chest compression by vagina or cord compression by the pelvis which can lead to hypoxia  Danger of brachial plexus injury (Erb palsy)  Fetal fracture (clavicle, humerus, cervical spine  Maternal perineal injury Mechanical factors: CPD Contracted pelvis Malpresentation or position Multiple gestation

Faulty uterine contraction:  Hypertonic: inc. frequency and intensity of labor, more frequent than 2 mins and >90 secs duration  Hypotonic: slowing of rate and intensity of uterine contraction Maternal complication:  Cervical trauma postpartum hemorrhage,  infections and exhaustion Nursing Interventions:  Relieve back pain  Observe for signs of maternal exhaustion  Monitor for signs of fetal distress  Have O2 suction and resuscitation equipment readily available  Administer sedatives, fluids as ordered  Constantly monitor FHR, VS while client is on oxytocin  Emotional support

b. CEPHALOPELVIC DISPROPORTION is suggested by lack of engagement at the beginning of labor, prolonged first stage of labor, and poor fetal descent.

c. MACROSOMIA A fetus who weighs more than 4000 to 4500 g (approximately 9 to 10 lb) Most frequently born to women with DM or GDM Associated with multiparity May cause uterine dysfunction during labor and delivery, fetal pelvic disproportion, uterine rupture CS as mode of delivery

a. PREMATURE RUPTURE OF MEMBRANES (PROM) Spontaneous rupture of membranes before the onset of labor. Assessment:  contraction drop in intensity even though very painful  contraction drop in frequency  uterus tense &/or contracting between contractions abdominal palpitations Diagnoatic test  Nitrasine test pH vagina 4.5 5.5 in the presence of AF, becomes more alkaline  Ferning of dried AF due to presence of chloride ions in the form of NaCl  Fat droplets from vagina smear

Nursing Care:  administer analgesics (morphine)  attempt manual rotation for ROP or LOP  bear down with contractions  adequate hydration  sedation as ordered  watch out for infection

c. PRECIPITATE LABOR rapid labor and birth <3 hrs duration. causes excessive laceration leading to profuse bleeding hypovolemic shock Assessment:  Rapid cervical dilatation/descent  Rapid uterine contraction  Decreased periods of relaxation  s/sx of hypovolemic shock HYPO TACHY TACHY  HYPOtension TACHYpnea  TACHYcardia  Cold clammy skin Nursing Interventions  Remain with the mother and monitor closely  Keep birth pack at bedside  Keep parents informed  Support and guide fetal head thru birth canal

d. UTERINE RUPTURE Complete or incomplete separation of the uterine tissue as a result of rupture of the uterus from the stress of labor. Assessment:  Complete rupture:  Pain, which is shearing, excruciating, diffused or localized  Contractions may stop or fail to progress  Relaxation between contractions is incomplete  Rigid abdomen  Signs of maternal shock  Absent FHR  Fetus palpated outside the uterus  Incomplete rupture  Abdominal pain that occurs during contraction  Cervix fails to dilate  Slight vaginal bleeding  Absent FHR Management:  Monitor maternal VS and FHR  Prepare client for CS or hysterotomy with hysterectomy  Provide emotional support  Monitor for and treat signs of shock

D. HYPOTONIC UTERINE CONTRACTION The number of uterine contractions is usually low or frequent (not increasing beyond two or three in a 10-minute period). Apt to occur during the active phase of labor. Predisposing Factors Effect of analgesia (specially if cervix is not dilated to 3 to 4 cm) Bowel/bladder distention prevents descent or firm engagement Multiple gestation LGA Hydramnios Lax uterus from grand multuparity

Assessment The resting tone of the uterus remains less than 10 mmHg, and the strength of the uterine contraction does not rise above 25 mmHg Increase length of labor Management Oxytocin Amniotomy

E. HYPERTONIC UTERINE CONTRACTION Increase in resting tone to more than 15 mmHg. Increasing intensity Occurs frequently and commonly seen in latent phase of labor More than one pace maker stimulating the contractions Muscles of the myometrium do not repolarize or relax after contraction Constant lack of relaxation Pain Tender myometrium anoxia of uterine cells

Management: Identify the cause (assess for cord porlapse) Discontinue oxytocin if infusing as prescribed change the mother's position (avoid supine position) Administer O2 via face mask Increase IVF as prescribed Notify AP Prepare to initiate continuous electronic fetal monitoring with internal devices if not contraindicated Prepare for CS if necessary

4. PROBLEMS WITH PLACENTA

A. PLACENTA PREVIA abnormal implantation of placenta Predisposing Factors: Increasing parity Advanced maternal age Rapid succession of pregnancy Previous cesarean section Types Low lying placenta on lower segment but clear of os Marginal placenta reaches the margin, but does not cover any part of the internal os Partial placenta partially covers the internal os Total placenta completely covers the internal os Diagnostic test Ultrasound Avoid: sex, IE, enema may lead to sudden fetal blood loss Double set up: delivery room may be converted to OR Assessment: Engagement (usually has not occurred) Fetal distress Presentation ( usually abnormal)

Management Expectant management if fetus is premature, (-) signs of fetal distress, (-) bleeding Complete bed rest, coitus is restricted Monitor closely VS and FHT Prepare O2 and blood No attempt on pelvic or rectal examination with painless bleeding late in pregnancy: agitation of the cervix may inittate massive hemorrhage Tocolytics Betametasone If (+) labor and bleeding is profuse, immediate delivery regardless of AOG Nursing Intervention Ensure bed rest Maintain sterile conditions for ant procedure Ascertain emergency cesarean delivery Monitor maternal and fetal VS Measure BP carefully Assess uterine tone Watch out for S/Sx of shock

B. ABRUPTIO PLACENTA Premature separation of placenta. It usually occurs after the twentieth week of pregnancy. Degrees of Separation: Grade 0 : No S/Sx from mother and fetus Diagnosis is made after delivery, (+) some degrees of separation Grade 1 : Minimal separation but enough to cause bleeding and change in maternal VS and (-) fetal distress Grade 2 : Moderate separation, (+) fetal distress, uterus tensed and tender on palpation Grade 3 : Extreme separation, shock and fetal distress Predisposing Factors: Maternal hypertension Increasing parity and maternal age Sudden release of amniotic fluid Short umbilical cord Direct trauma

Assessment: Severe, sharp, knife-like stabbing pain high in fundus Heavy bleeding Couvelaire uterus Hard, board-like uterus, rigid abdomen Signs of shock Concealed bleeding: If placenta separates first at the center Blood will pool under the placenta Bleeding will be hidden from view (Degree of hemorrhage is not congruent with the S/Sx of the shock) Blood infiltrates the uterine musculature Loss of its ability to contract Ecchymotic and copper-colored (Couvelaire uterus)

Nursing Interventions: Ensure bed rest Check maternal and fetal VS Prepare for IV infusions and blood as indicated Lateral position to prevent pressure on vena cava and additional interference with fetal circulation Monitor UO Anticipate coagulation problems (DIC) Prepare for emergency CS Provide emotional support

Placenta Previa Placenta Bleeding Uterus Abdomen Complication Abnormal implantation Painless without uterine contraction Bright red bleeding Relaxed Soft; non-tender Hypovolemic shock

Abruptio placenta Abrupt separation Painful with uterine contraction Dark red bleeding Contracted Hard; tender Hypovolemic shock

C. PLACENTA SUCCENTURIATA Has one or more accessory lobes connected to the main placenta by blood vessels. No fetal abnormality Important to recognize as small lobes may be retained in the uterus after birth causing hemorrhage

D. PLACENTA CIRCUMVALLATA The fetal side of the placenta is covered to some extent with chorion. The umbilical cord enters the placenta at the usual midpoint, and large vessels spread out from there E. BATTLEDORE PLACENTA The cord is inserted marginally rather than centrally F. PLACENTA ACCRETA Unusual deep attachment of the placenta to the uterine myometrium. The placenta will not loosen and deliver. Manual removal may lead to extreme hemorrhage. Hysterectomy as treatment.