Active Phase

-Stage 1 -4 to 7 cm dilation -Cervical changes: dilates more rapidly -Discomfort increases -Woman's focus increasingly inward -Contractions 2-5 mins apart, last 40-60 sec, moderate intensity -Once active, minimum progress expected is: 1.2 cm/hr for nullipara, 1.5cm/hr for multipara

Admission to Labor and Delivery

-1st: Focused assessment of mother (vital signs) and fetus (FHR) to determine their condition and whether birth is imminent -2nd: Broader assessment -Obtain essential info from mother, e.g.: History: Age, G, P, EDC, LMP, # wks, ROM, bleeding, present OB hx, past OB hx, etc. -Fetal assessment: Leopold maneuvers, Assessment of FHR and pattern -Labor status: Assessment of uterine contractions, Vaginal examination, CBC, Bld type, RH, midstream urine for protein, glucose -Physical examination

Aortocaval Compression

-aka Supine hypotension syndrome, vena cava syndrome -The supine position allows the heavy uterus to compress her inferior vena cava, reducing the amount of blood returned to the heart and can reduce placental perfusion -Frequent cause of low maternal blood pressure -If mother is in bed, lay her on side. LEFT side is optimal but right side can be used

Attitude: Extension

Attitude: Flexion

Body Changes During Labor

-Cardiovascular: BP during contractions, Supine hypotension (Aorto-caval syndrome) -Respiratory: Increased rate and depth: Increased chance of Hyperventilation -GI: Thirst, dry mouth; NPO, ice chips, popsicles -Urinary: Encourage emptying for comfort and better fetal descent, postpartum diuresis -Blood: Increase of blood volume , WBC and clotting factors (check for signs of DVT)

Bradley Method of Childbirth

-Similar to Lamaze -Originally called husband-coached childbirth, the first to include father as an integral part of labor. -Slow abd. breathing, relaxation techniques -Seeks to avoid medical interventions

Brow Presentation
-Least common of all presentation -When the forehead of the fetus becomes the presenting part. -The fetal head is slightly extended instead of flexed, with the result that the fetal head enters the birth canal with the widest diameter of the head (occipitomental) foremost. -C-section birth is preferred. *If vaginal birth is attempted the woman will probably have an episiotomy and may require an extension at birth. *Fetal mortality is increased b/c of injuries received during birth including cerbral and neck compression and damage to the trachea and larynx

Causes of Labor

-Cervical ripening: complex cascade of events (change in E/P ratio, collagenase activity, PGE2 -Myometrial activation (sensitive to oxytocin release)

Cephalopelvic Disproportion

Condition preventing normal delivery through the birth canal; either the baby's head is too large or the birth canal is too small

Comfort Measures during Labor

a. Lighting b. Keep temperature comfortable c. Attend to personal hygiene d. Provide mouth care e. Assess for bladder distention f. Assist woman to position of comfort g. Ice Chips

Contractions

-Comes from the upper 2/3 of the uterus -Frequency -Duration -Intensity (mild, moderate, severe)

Dilatation

The extent to which the cervix has opened in preparation as a result of uterine contractions -Full dilatation is 10cm.

Doulas

Non-medical, non-midwives who provide continous physical, emotional & educational support to the mother before, during & after birth...not required to be certified in the U.S.

Effacement
Shortening of the uterine cervix and thinning of its walls as it is dilated during labor

Episiotomy
a surgical incision made through the perineum to enlarge the vaginal origice to prevent tearing of the tissues as the infant moves out of the birth canal

Face Presentation
-The face of the fetus is the presenting part. -The fetal head is hyperextended even more than in the brow presentation. -Occurs frequently in multiparous women or women with a pendulous abdomen. * The risks of CPD and prolonged labor are increased which increases the risk for infection * The fetus may develop edema, the neck and internal structures may swell as a result of trauma received during descent. Petechiae swelling and facial bruising are seen int the superficial layers of the facial skin *Results in C-Section delivery

False Labor

-Irregular contractions -Interval same -Intensity same or less -Felt in abdomen -Sedation relieves pain -No show -No cervical change with contractions

Fetal Head
The fetal head is designed to work with the pelvis, in that the cranial plates can override each other when necessary as when there is a tight squeeze. Also the shortest diameter of the fetal head is when the baby's head is fully flexedthe suboccipitobregmatic diameter 9.5cm vs. 11 or 13.5 cm

Fetal Position
The location of a fixed reference point of the baby's presenting part in relation to the four quadrants of the mother's pelvis: the right and left anterior or the right and left posterior, occiput/mentum/sacrum

Footling Breech
One or both feet come first, with , Baby's bottom is at a higher position and either one or both feet come out first during delivery. This breech condition is common in premature deliveries. This position is extremely rare in full-term pregnancies.

Forceps assisted birth

A birth in which a set of instruments, known as forceps, are applied to the presenting part of the fetus to provide traction or to enable the fetal head to be rotated to an occiput-anterior position. Forceps-assisted birth is also known as instrumental delivery, operative delivery, or operative vaginal delivery.

Four P's

1. Passenger (fetus) 2. Passage (pelvis, vagina) 3. Powers (physiology of labor) 4. Psyche (psychosocial considerations)

Fourth Stage of Labor

-Till mom stabilizes (usually about 1-4 hours after birth ) -Vital signs q 15 mins first hour, assessing fundus and amount of lochia -Important for fundus to remain firm! (Pt can hemorrhage in minutes) -Physiologic changes may cause chill -Encourage parent-infant contact -Initiate breastfeeding -Ice pack to perineum

Frank Breech Position of a fetus in which the buttocks are present at the maternal pelvic outlet

Friedman Curve

-Duration of labor usually between 7-13 hours -A graphic representation of the hours of labor plotted against cervical dilation in centimeters.

Full Breech
The reversal of the usual cephalic position: everything flexed inward but butt presenting first.

Grantly Dick-Read Method of Childbirth

-Believed fear of childbirth produced tension which made the pain worse which created a fear-tension-pain cycle -Introduced relaxation methods to mothers

Intrapartum Complications

-Meconium -Inadequate uterine relaxation between contractions -Inadequate uterine contractions -CPD: cephalo- pelvic disproportion -Prolapsed cord -Shoulder dystocia

Lamaze Method of Childbirth

-Birthing method focusing on partnercoached breathing techniques and relaxation with the woman panting and using outside focal points during labor -Postpones the use of pain medications

Latent Phase

-Stage 1 -0 to 3 cm dilation -Cervical changes: primarily effacement -Contractions gradually increase, mild intensity, 5-30 minutes apart and last for 30-40 seconds

Left Occiput Anterior The most common and least troublesome birth position

Leopold Maneuvers
-Can determine fatal position, presentation, and attitude by performing leopold's maneuvers. have the patient empty her bladder, assist her to a supine position, and expose her abdomen 1. Identify what occupies the fundus 2. Identify where the baby's back is, the other side being the hands and feet 3. Attempt to grasp presenting part gently between thumb and fingers to see if the presenting part moves upward. If engaged, it will not move up 4. Face mothers feet, slide hands downward on either side of uterus. One side will be "obstructed" with cephalic prominence, if this is a flexed head, it will be on opposite side as the fetal back; extended head will be on same side as the back

Lightening

The process or time during late pregnancy when the fetal head begins to descend into the mother's pelvis, resulting in a lessening of pressure on the diaphragm

Lithotomy

The client is lying on back, w/ knees bent, thighs apart, and feet resting in stirrups. The position is used for pelvic exams in females,rectal exams& some operations.

Lochia

Discharge of blood, mucous and tissue from the uterous following delivery lasting 4-6 weeks after delivery

Longitudinal Lie When the long axis of the fetus is parallel to the long axis of the mother the fetus

Maternal Positions in Labor

-Preferred position in labor is UPRIGHT because it takes advantage of the force of gravity, improves the contraction, helps with maternal cardiac output and utero-placental flow, and increases flow to the maternal kidneys -"All Fours": good for shoulder dystocia -Lithotomy -Sitting: excellent to facilitate the progress, abdominal muscles work together in greater synchrony with uterus contractions -Squatting/Kneeling: moves the uterus forward and aligns the fetus with the pelvic inlet which increases the pelvic outlet -Lateral: goot to slow down the speed of precipitous birth and helps rotate the fetus in a posterior position

-Cardiovascular: *Cardiac output increases *Increase pulse rate *Blood pressure changes: increases during contractions, hypotension my occur from vena caval syndrome *White blood cell count increases -Respiratory system: *Increase in oxygen demand *Exhalation of more CO2 -Renal: *Tendency to concentrate urine *Full bladder increases discomfort *Proteinuria-increased metabolic activity and may be a sign of development of pre-eclampsia -GI: -Decreased motility, absorption, and gastric emptying time -Nausea and vomiting is common -Dry lips and mouth

Maternal Response to Labor

Military Presentation
-A type of cephalic presentation where the fetal head is neither flexed nor extended. -The presenting part is the top of the head.

Multiparous

Woman who has given birth two or more times

Nulliparous

Woman who has never given birth

Nurses Role in Labor

1. Comfort Measures 2. Teaching 3. Providing Encouragement 4. Caring Presence (giving of self) 5. Offering Pain Medication 6. Care for the Birth Partner
-Maternal response: labor-oriented, more inwardly focused and alert, more demanding -Duration: averages 1.2cm/ hour nullip and 1.5 cm/hr multip, range is from 810 hours nullip and 6-7 hours multip (6-10 hrs) -Comfort measures, coping techniques -Encourage voiding q 2 hours -Assist with hygiene -Provide pharmacologic pain relief as requested and ordered: anesthesia, analgesia -Assess maternal BP, HR, RR q 30 min -Rupture of membranes, meconium? -Assess temp every 4 hours until ruptured then q 1-2 hours Assess uterine activity and FHR q 15 - 30 min

Nursing Care during Active Phase of Labor

Nursing Care during Fourth Stage of Labor

-Maternal response: tired yet difficult to rest, eager to become acquainted with newborn -Observe and be aware that the mother is vulnerable for a hemorrhage -Nursing care: *Vs. q 15 mins for first hour *Firm uterine fundus, massage if not firm (boggy) *Lochia: only saturates one standard pad in an hour *Bladder: watch for distention especially if boggy uterus *Ice pack to perineum: reduces edema and limits hematoma *Warm blanket *Promote early family attachment *Initiate breastfeeding

Nursing Care during Latent Phase of Labor

-Maternal response: Happy, excited, sociable, mild anxiety, cooperative -Duration: nullip-7-8 hrs and 4-5 hrs multip -Coping techniques: *Relaxation techniques *Breathing *Effleurage *Ambulation *Position change *Diversion -Education -Review of birth plan -Encourage voiding q2 hours -Basic hygiene -Assess maternal BP, HR, RR; uterine activity, FHR q 30 - 60 min -Assess maternal temperature q4 hours until ruptured membranes then q 1-2 hours

Nursing Care during Second Stage of Labor

-20 mins to 3 hours -Maternal response: *Before baby is born: Intense concentration with pushing, dozing in between ctx, often oblivious to surroundings *After the birth: excited and relieved, very tired, may cry -Nurse responsible for: *Helping the mother bear down, positioning *Preparing delivery equipment, personnel *Cleansing of the perineum *Initial care and assessment of the newborn

Nursing Care during Third Stage of Labor

-Separation and birth of the placenta -Uterus continues to contract after the birth of the baby, causing the placenta to separate from the uterine wall -Lasts from 5 to 30 mins -Uterus must remain contracted to compress blood vessels (prevent hemorrhage) -Nurse responsible to administer pitocin and continuing care of infant

Nursing Care during Transition Phase of Labor

-Maternal response: irritable, intense concentration, may lose control, n/v -Duration: 30 mins to 3.5 hrs -Comfort measures, coping techniques -Encourage voiding q 2 hours -Assist with hygiene -Provide pharmacologic pain relief as requested and ordered -Avoid systemic analgesia, may use pudendal nerve block -Prepare for birth -Assess maternal BP, HR, RR and FHR q 15 to 30 min -Assess uterine activity q 10 - 15 min -Assist with amniotomy if membranes not ruptured

Oblique Lie

Diagonally across the uterus; between transverse and longitudinal

Pain in Labor Caused by:

-hypoxia of compressed muscle cells -compression of nerves in cervix -stretching of cervix -stretching of perineum -bladder distension -intensified w/tension/anxiety/fear -oxytocin [Pitocin]-gives stronger contractions

Passenger

-Size and number -Lie of baby -Presentation of baby (Fetal structure that enters the pelvis first) (caput swelling and molding of the head) -Fetal attitude (flexion [easier] or extension)

Pelvis
-False vs. True Pelvis -We are more concerned with the true pelvis during childbirth

Premonitory Signs of Labor

-Lightening -Braxton Hicks contractions -Cervical changes -Bloody show -Rupture of membranes -Sudden burst of energy

Primiparous

Pertaining to a woman who has given birth to her first child.

Prolapsed Cord

When the umbilical cord of the baby is expelled first during delivery and is squeezed between the baby's head and the vaginal wall. This presents an emergency situation since the baby's circulation is compromised.

Relaxin

A hormone produced by the placenta that causes softening in the collagen connective tissue of the symphysis pubis and sacroiliac joint

Rupture of Membranes

-Essential to assess FHR after rupture of membranes -Assess characteristics of amniotic fluid a. Color b. Odor c. Presence of meconium d. Amount - Assess maternal temperature hourly thereafter

Second Stage of Labor

-The pushing stage -Woman may regain self-control -It begins with complete cervical dilatation -Contractions 1.5 -3 minutes apart, lasting 40-90 sec (ctx may diminish slightly or pause) -Stages lasts 1-3 hours -Stage ends with the birth of the baby -Positional changes of the fetus (the baby twists and turns as it is coming down the birth canal)(PATH OF LEAST RESISTANCE) referred to as the Cardinal Movements

Shape of the True Pelvis

1. Gynecoid: circular, 50%, vaginal birth 2. Android: heart shaped, 23%, Cesarean or difficult vaginal delivery 3. Anthropoid: oval shaped, 24%, vaginal birth, forceps used 4. Platypoid: spherical, 3%, vaginal birth

Shoulder Dystocia

This occurs after the fetal head is delivered and the broad anterior shoulder becomes wedged behind the mother's pubis, fetus cannot expand lungs because is trapped. This difficult delivery could result in maternal lacerations & a fractured clavicle in the infant.

Stages of Labor

-First stage (beginning of labor to 10 cm) *Latent *Active *Transition -Second Stage (from 10 cm to birth of baby) -Third Stage (from birth of baby to birth of placenta) -Fourth Stage (till mother stabilizes, 1-4 hrs)

Station
-Relationship of the presenting fetal part to an imaginary line drawn between the ischial spines of the pelvis. - (-)5 to (+)5 - (+)5 would be at the birth of the baby

The Cardinal Movements of Labor (part 1)

The Cardinal Movements of Labor (part 2)

The Support Person

1. Assess support person for signs of anxiety and/or fatigue 2. Respect couple's values with regard to involvement of father 3. Include support person in the plan of care 4. Maternity care is FAMILY-CENTERED, every member of their family is your patient too

Third Stage of Labor

-Shortest stage -Placenta separates and is expelled -May take up to 30 mins -Signs of placental separation: *Gush of blood *Lengthening of cord *Change in shape of uterus from flat to round, globular -Clamp and cut cord -Skin to skin

Transition Phase

-Stage 1 -8 to 10 cm dilation -Strongest contractions -Woman may lose control -Contractions 1.5 - 2 mins apart, lasting 60-90 seconds, strong/severe intensity

Transverse Lie If the long axis of the fetus is at a right angle to the long axis of the mother -Regular contractions -Interval shortens -Increasing intensity -Back to abdomen -No effect from mild sedation -Bloody show -Progressive dilatation of the cervix

True Labor

Vacuum Assisted Birth

Monitor FHR throughout. Assist with pushing. Assess for complications. Look for lacerations. New Born- look for scalp lacerations/hematoma

Vertex Presentation
-Fetal head fully flexed -The most favorable cephalic variation because the smallest possible diameter of the head enters the pelvis. -This occurs in about 96% of births.