Stages of Labor Nursing Considerations & Interventions The process of labor and birth are divided into three

stages and in this post well discuss the changes and the nursing interventions and considerations for each. 1. First Stage The first stage starts at the onset of regular uterine contractions and ends at full dilatation and effacement. The first stage of labor is divided into three phases: the latent, the active, and the transition phase.

Analgesia given too early during this period may prolong this phase Woman who is psychologically prepared for labor only have minimal discomfort Best time to reinforce health teachings B. Active Phase During the active phase, cervical dilatation occurs more rapidly and contractions grow stronger. Contractions Stronger, longer and causes true discomfort Duration of Cervical Contractions Dilation 40 to 60 4 to 7 cm seconds every 3 to 5 minutes Duration Nullipara: 3 hoursMultipara: 2 hours

Nursing Considerations:

It is an exciting time because a woman realizes something dramatic is happening Administration of analgesic at this point has little effect on the progress of labor Show and spontaneous rupture of membranes occur during this time C. Transition Phase During this phase, the contractions reach their peak intensity, cervix to maximum dilatation and to full effacement. Contractions At peak intensity Duration of Contractions Cervical Dilation Duration Until full cervical dilation

A. Latent Preparatory Phase The latent stage starts at the onset of regularly perceived uterine contractions and ends when rapid cervical dilation begins. This is also called the preparatory phase. Contractions Duration of Cervical Contractions Dilation Mild and 20 to 40 0-3 cm short seconds Duration Nullipara: 6 hoursMultipara: 4.5 hours

60 to 90 8 to 10 cm seconds every 2-3 minutes

Nursing Considerations:

Nursing Considerations

Woman with a non-ripe cervix will have a longer than usual latent phase

If membranes have not previously ruptured or been ruptured by amniotomy, they will rupture as a rule at full dilation. Both full dilation and cervical effacement have occurred at this stage Woman may have intense discomfort and may be accompanied by nausea and vomiting. Woman may experience a feeling of loss of control, anxiety, panic or irritability. Her focus is on the entirety of delivering her baby. This stage ends at 10 cm of dilatation and feels a new sensation (i.e., irresistible urge to push).

3. Third Stage The third stage is called the placental stage. It begins with the birth of the infant and ends with the delivery of the placenta. Two separate phases are involved: placental separation and placental expulsion. After birth, the uterus can be palpated as a firm round mass just inferior to the level of the umbilicus. After a few minutes, the uterus begins to contract again and assumes a discoid shape. It retains this shape until placenta is separated, approximately 5 minutes after birth of the infant. A. Placental Separation As the uterus further contracts down on an almost empty interior causing disproportion between the placenta and the contracting wall of the uterus ultimately causing separation of the placenta. The following are the signs indicating that placenta has loosened and is ready to deliver:

Cervical Effacement 2. Second Stage The second stage starts from full dilatation and cervical effacement to birth of the infant; with uncomplicated birth, this stage takes about 1 hour. Contractions change to an overwhelming, uncontrollable urge to push or bear down with each contraction as if to move her bowels. Patient may experience nausea and vomiting at this point.

Lengthening of the umbilical cord Sudden gush of vaginal blood Change in the shape of the uterus Firm contraction of the uterus Appearance of the placenta at the vaginal opening Bleeding occurs as a normal consequence of placental separation. The normal blood loss is 500 mL. B. Placental Expulsion After separation, the placenta is delivered either by the natural bearing-down effort of the mother or by gentle pressure on the contracted uterine fundus by the physician or nurse-midwife (Credes maneuver).

The fetal head touches the internal side of the perineum; the perineum begins to bulge and appears tense. The anus may become everted and stool may be expelled. As the fetal head pushes against the perineum, the vaginal introitus opens and the fetal scalp appears at the opening to the vagina. At first, it appears slit-like then becomes oval and then circular. This is called crowning. All of her energy and her thoughts are being directed towards giving birth. As she pushes, using her abdominal muscles to aid the involuntary uterine contractions, the fetus is pushed out of the birth canal.

Pressure must never be applied to post-partal uterus in a non-contracted state, because doing so would cause uterus to evert and maternal blood sinuses are open and gross hemorrhage could occur. If the placenta does not deliver spontaneously, It can be removed manually. Incomplete abortion - Introduction A miscarriage is a pregnancy that ends before the baby can survive outside the womb because it has not yet reached viability.

A miscarriage may be early - during the first 14 weeks of pregnancy, or late. The vast majority are early - only about 1% of abortions are late. An Incomplete abortion is an inevitable abortion and some of the products of the pregnancy are still present in the uterus. The definition of a abortion is a spontaneous loss of a pregnancy before 24 weeks: in the UK we calculate the duration of a pregnancy from the first day of the last period (LMP). A abortion - the medical term for an early pregnancy loss is abortion - tends to start with bleeding, and pain may then develop. A spontaneous abortion occurs naturally and contrasts with an induced abortion or pregnancy termination. Types of abortion

A threatened abortion is characterized by bleeding early in the pregnancy but the pregnancy continues. An inevitable abortion means that the pregnancy cannot be salvaged. It may be incomplete, with pregnancy products still in the cavity of the womb or complete with nothing remaining. The combination of modern pregnancy tests and ultrasound will usually determine the situation quite quickly. Pregnancy tests these days should become positive within ten days of conception (i.e. even before the first missed period). Ultrasound begins to show a pregnancy within the uterus by five or six weeks (a week or two after the first missed period). On occasion, it may be too early to diagnose the situation accurately and tests may need to be repeated to see what changes occur.

Table 12.1 indicates the various terms most frequently associated with abortion. Type of abortion Spontaneous abortion Induced abortion Threatened abortion Inevitable abortion Complete abortion Incomplete abortion Missed abortion Septic abortion Recurrent or habitual abortion Early abortion Late abortion First trimester abortion Second trimester abortion Description This is when the abortion occurs naturally as opposed to being induced. The pregnancy is terminated artificially. There is bleeding and sometimes pelvic pain but the cervix is closed and ultrasound indicates an ongoing pregnancy within the uterus. The pregnancy is not continuing. An inevitable abortion and the uterus has completely emptied itself. An inevitable abortion with products of the pregnancy still present in the uterus. There are no reasons to have suspected that the pregnancy is not going to continue but the embryo has died. The abortion has been complicated by infection. Most authorities recommend that these terms should be used only for three or more consecutive abortions although there is a tendency towards two. abortion in the first few weeks of the pregnancy. abortion after the first few weeks. abortion before thirteen weeks of pregnancy. abortion after thirteen weeks and before twenty four weeks.

abortion symptoms The first abortion symptom is vaginal bleeding, which can range from spotting to being heavier than a period. A little spotting may be an early sign of abortion although fortunately this may amount to no more than a threatened abortion and the pregnancy continues. The second abortion symptom is pelvic pain. The third abortion symptom is cessation of pregnancy symptoms including breast tenderness, morning sickness and having to pass urine more frequently than usual. Sometimes there may be no sign or symptom to suggest abortion and pregnancy symptoms continue, and the abortion is only discovered in a routine scan. This is a missed abortion. A threatened abortion occurs when there is vaginal bleeding but ultrasound confirms a viable pregnancy. Cause of abortion Often the cause of a miscarriage remains unknown. The most common cause for abortion is a blighted ovum - the afterbirth type tissues develop but there is no baby. Another common cause is a genetic defect and nature decides not to allow the pregnancy to continue. Smoking and obesity may contribute to abortion but do not cause abortion by themselves. Similarly, stress may play a role in pregnancy loss, but it hasn't been shown to cause abortion on its own. The cause for recurrent abortions is discussed Q12.16 to Q12.21. Prevalence Of abortion It is thought that between 10 and 20% of pregnancies miscarry. Most abortions occur in the early weeks of pregnancy. Ultrasound screening for fetal anomaly has shown the incidence of non-viable pregnancy at 10-13 weeks to be 2.8%

Unsuspected pregnancy loss in healthy women (1983) Blighted Ovum Normally the fertilised egg divides and part becomes the embryo (future baby) and part becomes the afterbirth type tissue (trophoblast) and the membranes that form a fluid filled bag around the baby. When there is a blighted ovum, the afterbirth tissues develop alone without the development of the baby. Blighted ovum hasalso been referred to as an 'anembryonic pregnancy'. Nearly half of early abortions are associated with a blighted ovum. It is likely that abnormal chromosomes are more prevalent.

Cytogenetic findings in echographically defined blighted ovum abortions. (1993-01) Pregnancy Tests Pregnancy tests are designed to determine the presence of the pregnancy hormone HCG. Until twenty years ago, pregnancy tests were biological, relying on the affects of the hormone on animals. There could be a cross-reaction with other hormones, notably LH. Many women reaching the menopause could have a false alarm as LH levels rise at the menopause and when they missed their periods their pregnancy tests could be falsely positive. Modern pregnancy tests are monoclonal they react only with the specific hormone they are designed to detect. In the early weeks of pregnancy, the HCG level doubles every two days. Whereas the old pregnancy tests would become positive with a concentration of 3,000 IU (about two weeks after the missed period) the monoclonal tests show a positive result at between 25 and 50 IU and these levels are reached before a period is missed. The accuracy of modern pregnancy tests are not only useful in the early detection of pregnancy but also in assisting in the management of early pregnancy problems such as Incomplete abortion or possible ectopic pregnancy. A lady presented with vaginal bleeding and left sided pelvic pain. Her pregnancy test was positive and ultrasound did not show any sign of a pregnancy either within or outside the uterus (ectopic pregnancy). Her beta HCG level was 365 units suggesting a very early pregnancy at most. Two days later the level had fallen to 180 units which indicated that the pregnancy was not continuing. We could not say for certain whether this had been an intra-uterine pregnancy that miscarried or a possible ectopic pregnancy that was being resolved by nature but no operative intervention was required.

The prevalence of non-viable pregnancy at 10-13 weeks of gestation. (1996-01) Incidence of early loss of pregnancy (1988)

Treatment of abortion The options for managing abortion are outlined in Figure 12.1. If abortion is threatened, you will usually be advised to rest for a few days and a repeat scan will confirm whether the pregnancy is continuing. There have been several important developments in the management of abortion in recent years. The combination of highly sensitive pregnancy tests and ultrasound will usually assist in providing an accurate diagnosis. Many hospitals now have an early pregnancy assessment unit that specialise in these problems. This should allow you to see an expert in a dedicated area where you can receive sympathetic assistance away from busy, and often fraught, accident and emergency departments. Pregnancy after abortion. If you are pregnant after a previous abortion, the chances are that the pregnancy will be successful. Even after three abortions, your chance of a successful pregnancy is 55%. Usually nature has detected some problem such as a chromosome abnormality (genes - chromosomes) and decides that it is in your interests to discontinue this pregnancy and give you an early chance to start a successful one. A blighted ovum (Q12.4), or an embryo with an abnormality would be reasons for spontaneous abortion. Occasionally there may be a different and perhaps remedial cause which would need consideration if you have three abortions.

Influence of serum luteinising hormone concentrations on ovulation, conception, and early pregnancy loss in polycystic ovary syndrome (1988) Risk factors for spontaneous abortion and its recurrence. (1988-03) Drinking during pregnancy and spontaneous abortion. (1980-01) How can we ensure that I will not miscarry again? It is an understandable cry from the heart from couples who experience the devastation of recurrent pregnancy loss that there must be one explanation and one perfect treatment. Even if a cause is identified we are unlikely to achieve success rates better than 75% within the foreseeable future. Half of the fifteen percent of pregnancies that miscarry can be attributed to a genetic problem of the embryo and we do not have a remedy for this. It is only in the last ten years that we have begun to find some treatable explanations for recurrent abortions. For those with identified antiphospholipid antibody problems aspirin alone or in combination with heparin has been shown to be beneficial. Twenty percent of women have PCOS (Q7.2) and this syndrome may perhaps account for a greater proportion of recurrent abortions. Metformin looks promising on theoretical grounds but we still lack the scientific proof that is required. The role of bacterial infection and the possible benefit of antibiotics is an example of a new area that is being investigated. There is a suggestion that 'tender loving care', with frequent assessment during pregnancy, may help. There is no evidence that hormone support in pregnancy or low-dose aspirin for those without evidence of antiphospholipid antibody problems improves the outcome. There is some evidence that metformin treatment for PCOS may be beneficial but more robust research is required before it can be implemented in routine clinical care.

Maternal smoking predicts the risk of spontaneous abortion. (2006-01) Obesity in pregnancy. (2006-02) Paternal age and spontaneous abortion. (2006-03) Cocaine and tobacco use and the risk of spontaneous abortion (1999) The role of consanguinity and inbreeding as a determinant of spontaneous abortion in Karachi, Pakistan (1998) Determinants of risk of spontaneous abortions in the first trimester of pregnancy. (1997) A prospective study of work-related physical exertion and spontaneous abortion. (1997) Caffeinated beverages, decaffeinated coffee, and spontaneous abortion (1997) Fre quency of abnormal karyotypes among abortuses from women with and without a history of recurrent spontaneous abortion (1996) Tree-based, two-stage risk factor analysis for spontaneous abortion (1996) Incidence of spontaneous abortion among normal women and insulin-dependent diabetic women whose pregnancies were identified within 21 days of conception.(1988)