LABOR and DELIVERY

Also known as Parturition, childbirth, birthing. Is the process by which the fetus & placenta are expelled from the uterus and the vagina into the external environment. PROSTAGLANDIN THEORY A parturient is a woman in labor. It has been known that when fetus has Toco - and toko- (Gr.) are combining reached maturity, the fetal membranes forms meaning childbirth. produce large amount of arachidonic acid Eutocia normal labor which is converted by maternal decidua Dystocia difficult labor into a prostaglandin, a hormone that Normally, labor begins when the fetus is initiates uterine contractions. sufficiently mature, yet not too large to During labor the level of arachidonic acid cause difficulties in delivery. in the amniotic fluid is very high resulting In some instances, labor begins before in increased productions of the fetus is mature (premature birth); in prosttaglandin. others labor is delayed (postmature birth). It is unknown why this occurs 1. THEORY OF THE AGING PLACENTA As the placenta ages, it becomes less THEORIES ON THE ONSET OF LABOR efficient, producing decreasing amount of progesterone. 1. FETAL ADRENAL RESPONSE THEORY This progesterone decline allows the Hippocrates, the father of medicine, concentration of prostaglandin and was the first person to propose this estrogen to rise steadily. theory which states that certain hormones produced by the fetal adrenal and pituitary gland initiates labor contraction. 1. OXYTOCIN STIMULATION THEORY Studies have shown that as pregnancy near term, oxytocin production by the posterior pituitary gland while the production of oxytocinase by the placenta . Oxytocin stimulates uterine contractions while oxytocinase inhibits uterine contractions. As a result the uterus becomes increasingly sensitive to oxytocin. 1. UTERINE STRETCH THEORY According to this theory any hallow organ stretched, will always contract & expel its content. A pregnancy advances, the uterus becomes increasingly distended by the growing fetus, placenta and amniotic fluid, distention of the uterus creates pressure on the nerve endings which stimulates uterine contractions. 1. PROGESTERONE DEPRIVATION THEORY Progesterone helps maintain pregnancy by its relaxant effect on the smooth muscles of the uterus, thereby, preventing uterine contractions. PRELIMINARY SIGNS OF LABOR 1) LIGHTENING (The baby dropped) or descent of the fetal presenting part into the pelvis, occurs approximately 10 14 days before labor begins. Engagement descent of the biparietal
plane of the fetal head to a level below that of the pelvic inlet. Fixation is descent of the fetal head to the inlet to a level below that of the pelvic inlet. Floating When head is still movable above the pelvic inlet on palpation

As pregnancy nears term, the production of progesterone by the placenta decreases, this decline in progesterone allows uterine contraction to occur.

2) h IN LEVEL OF ACTIVITY 3) WEIGHT LOSS 2 wks before labor, the woman experience sudden weight loss of about 2-3 lbs. 4) BRAXTON HICKS CONTRACTION 5) RIPENING OF THE CERVIX goodells sign

SIGNS OF TRUE LABOR Uterine contractions surest sign Show Bloody show, blood mixed with mucus (operculum). Rupture of the membranes

Bending of the head onto the chest making the smallest anterior-posterior diameter (suboccipitobregmatic) present to the birth canal. Effacement softening & thinning of cervix. Use % in unit of measurement Primigravidas usually efface more quickly than they dilate. Multiparas typically will experience effacement and dilatation at the same time. Dilatation widening of cervix. Unit used is cm.

INTERNAL ROTATION Occiput rotates until it is superior or just below the symphysis pubis bringing the head into the best relationship with the pelvic outlet; shoulder enterd the pelvic inlet. EXTENSION Extension of the head; face and chin are born. 5 Ps of LABOR (Factors of Labor) EXTERNAL ROTATION 1. PASSAGES (Pelvic Area) or Restitution Hard passages: Bony pelvis Head rotates back to diagonal or Soft passages: Lower uterine segment, transverse position, shoulders cervix, vagina, pelvic floor and enter the outlet and are born. perineum. EXPULSION 2. POWER Rest of the baby is born. Primary force: Involuntary uterine contractions. MANEUVER Secondary force: Voluntary use of thoracic, diaphragm and abdominal 1. RITGENS MANEUVER Insertion muscles when the mother bears of the hand and application of down. upward pressure on the fetal chin 3. PASSENGER (Baby) and as to the other hand applies Fetal positions, presentation gentle downward pressure on the and attitude. fetal occiput to allow controlled 4. PERSON (Mother) delivery of the fetal head. Maternal attitude during labor 5. POSITION 2. BRANDT ANDREWS MANEUVER Maternal position during labor is a manual technique to help and delivery facilitate the delivery of the MECHANISM OF LABOR Remember: ED FIRE ERE E Engagement D Descent F Flexion I Internal R Rotation E Extension E External R Rotation E Expulsion ENGAGEMENT Setting of the fetal head into the pelvis. DESCENT Downward movement of the biparietal diameter of the fetal head to within the pelvic inlet. FLEXION placenta. The technique is coiling the umbilical cord through forcep. (up, down and side technique.) 3. MODIFIED CREDES MANEUVER is a manual technique to help facilitate the delivery of the placenta. Gentle pressure on the contracted uterine fundus by the Physician/midwife.

STAGES OF LABOR FIRST SECOND THIRD FOURTH : CERVICAL DILATATION STAGE : EXPULSIVE STAGE : PLACENTAL STAGE : RECOVERY STAGE

2. EXPULSIVE STAGE

Begins with full dilation and cervical effacement to delivery of an infant. Contraction change from characteristic crescendo to decresendo pattern to an overwhelming uncontrolable urge to push or bear down with each contraction as if to move her bowels. May experience nausea and vomiting because pressure is no longer exerted on her stomach as fetus descends in pelvis. Begins with birth of the infant and ends with separation and expulsion of the placenta. Usually 5 minutes after the birth of an infant. (to 30mins)

1. CERVICAL DILATATION STAGE

Begins with the labor contraction and ends with complete dilation of the cervix. (10cm)

3 PHASES

3. PLACENTAL STAGE
LATENT (0-4 cm) ACTIVE (4-8 cm) TRANSITIONAL (8-10 cm)

1.

2.

LATENT (0-4 cm) Contractions are MILD and SHORT 5 10 minutes interval Phases last approximately 6 hrs Nullipara 4.5 hrs Multipara ACTIVE (4-8 cm) Cervical dilation occur more RAPIDLY, increase in duration If BOW not yet ruptured: Woman can take a bath/ void. Begin to cause true discomfort. Exciting time for woman. Abdominal breathing (Advice) Intensity: Moderate to strong Phases last approximately 3 hrs Nullipara 2hrs Multipara

SIGNS OF PLACENTAL SEPARATION 1) Lengthening of the umbilical cord 2) Uterus become firm an globular 3) Sudden gush of blood from the vagina 4) Firm contraction of uterus 5) Appearance of placenta from the vaginal opening. SIGNS OF PLACENTAL EXPULSION The placenta is delivered: Natural bearing effort of the mother or Gentle presure on the contacted uterine fundus by Physician/ OB. (Modified Credes Maneuver)

3.

TRANSITIONAL (8-10 cm) Maximum dilation of 8-10cm. Mood of the mother suddenly changes and the nature of contraction intensified.

4. RECOVERY STAGE

Begins from expulsion of the placenta to 2 hours after delivery.

SECOND LETTER: Denotes fetal landmark O for occiput M for mentum S for sacrum A for acromium LAST LETTER: Whether the landmark points anteriorly (A), posteriorly (P), or transversely (T).

FETAL ASSESSMENTS
FETAL LIE Relationship of fetal long axis to maternal long axis (spine). a. Transverse Shoulder presents b. Longitudinal Vertex or breech. PRESENTATION Fetal part entering the pelvic inlet first. a. Cephalic (Vertex/ Brow/ Face) b. Breech (Complete/ Frank/ Footling) ATTITUDE Relationship of fetal parts to one another. (degree of flexion) A. Complete flexion. B. Moderate flexion. C. Poor flexion. D. Hyperextension STATION Relationship of the presenting part of a fetus to the level of the ischial spine.
Each presenting part has the possibility of six positions. They are normally recognized for each position--using "occiput" as the reference point.

1. 2. 3. 4. 5. 6.

Left occiput anterior (LOA). Left occiput posterior (LOP). Left occiput transverse (LOT). Right occiput anterior (ROA). Right occiput posterior (ROP). Right occiput transverse (ROT).

POSITION Relationship of presenting fetal part to the quadrants of maternal pelvis. FOUR QUADRANTS: a. Right Anterior b. Left Anterior c. Right Posterior d. Left Posterior e. Right Transverse f. Left Transverse
POSITION is indicated by an abbreviation of 3 letters:

OBSERVATIONS ABOUT POSITIONS (a) LOA and ROA positions are the most common and permit relatively easy delivery. (b) LOP and ROP positions usually indicate labor may be longer and harder, and the mother will experience severe backache. KNOWING POSITIONS WILL HELP YOU TO IDENTIFY WHERE TO LOOK FOR FHT's. 1. BREECH. This will be upper R or L quad, above the umbilicus. 2. VERTEX. This will be lower R or L quad, below the umbilicus.

FIRST LETTER: Whether the landmark is pointing to the mothers right (R) or left (L).