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Labor

and

DELIVERY

LABOR
Labor (parturition) is a series of events
by which uterine contractions and
abdominal pressure expel a fetus and
placenta from a womans body.

Physiologic Effects of the Birth


Process

MATERNAL RESPONSE
Cardiovascular

System

Contraction
increase blood flow to placenta
increase blood volume
increase BP slightly and slows pulse
pressure

Respiratory

System

Labor pain
Depth and rate
respiratory alkalosis
tingling
of hands and feet, numbness,
dizziness

Gastrointestinal

Gastric motility
mouth

System

N / V , thirsty, dry

Urinary

System

Sensation of urinary bladder due


to intense contractions and
regional anesthesia
inhibits
fetal descent

Placental Response
Placental

Circulation

During strong labor contractions


the spiral arteries supplying the
intervillous spaces are compressed by
the uterine muscles

maternal blood supply to the placenta


and stops temporarily due to
compression

Cardiovascular

System

Alterations in the rate and rhythm


of the fetal heart may result from
normal labor effects or suggest
fetal intolerance to the stress of
labor

Pulmonary

System

Catecholamines produced by the fetal


adrenal glands in response to the stress
of labor appear to contribute to the
infants adaptation to extrauterine life.
- It stimulates cardiac contraction and
breathing, quicken the clearance of
remaining lung fluid and aid in
thermoregulation

The Physiology of Labor


POSSIBLE CAUSES OF LABOR
ONSET
Progesterone

Withdrawal

Hypothesis
Prostaglandin Hypothesis
Uterine stretch
Oxytocin theory

Preliminary Signs of Labor


1.

Lightening (dropping)

- or the descent of the fetal presenting


part into the pelvic inlet, occurs
approximately 10 to 14 days before
labor begins

2.

Increase in level of
activity

(energy spurt or
nesting)
- r/t an increase in epinephrine
release initiated by a decrease in
progesterone produced by the
placenta.

3. Slight loss of weight


- as progesterone falls, body
fluid is easily excreted by the
body increasing urine
production leading to weight
loss between 1 and 3 lbs.

4. Braxton Hicks Contractions


painless, erratic uterine
contractions that occur toward the
end of pregnancy. They ready the
cervix for labor, but cervical
dilatation does occur with them.

5.

Ripening of the cervix

- is an internal sign only on pelvic


examination. Throughout pregnancy
it is softer than normal like an
earlobe. At term it will be butter-soft
and it tips forward.

Signs of True Labor


1.

Uterine contractions

- a rhythmic tightening of the


uterus that aids in achieving
cervical dilatation and
effacement.
- Are the surest sign that labor has
begun

2. Show or Bloody show


- as the cervix softens and ripens
the mucus plug that filled the
cervical canal during pregnancy
is expelled.

3. Rupture of membranes
- experienced either as a sudden gush or
scanty, slow seeping of clear fluid from
the vagina.
- AF is continuously produced until
delivery.
2 risk with ROM:
Intrauterine infection
Cord prolapse

Cord prolapse is the descent of the umbilical cord


into the vagina ahead of the fetal presenting part
with resulting compression of the cord between
the presenting part and the maternal pelvis.

Factors Affecting Labor(5


Ps)
1.Passenger
- the size, presentation, and position of the fetus.
2. Passageway
- shape and measurement of maternal pelvis.
3. Powers
- forces of labor, acting in concert, to expel the
fetus and placenta.
4. Placenta
- position of placenta
5. Psyche or Psychologic Response
- A woman who is relaxed, aware, and
participating in the birth usually has a shorter,
less intense labor.

PASSENGER

1. PASSENGER- is the fetus.

vertex
si

i
c
n

t
u
p
oc
ci
pu
t

Occipitofrontal-12 cm
Suboccipitobregmatic- 9.5 cm
Occipitomental- 13.5 cm

Biparietal diameter- 9.25

Engagement- settling of the


fetal head in the pelvis.

Molding
- is a change in the shape of the
fetal
skull produced by the force of
uterine
contractions pressing the vertex of
the head
against the not yet dilated cervix.

Variations in the
Passenger
A.

Fetal Lie the orientation of the long


axis of the fetus to the long axis of
the woman
Types:

1.
2.
3.

Longitudinal
Transverse
Oblique

B.

Attitude- degree of flexion a fetus


assumes during labor or the relation of
the fetal parts to each other.

Vertex- full flexion SOM


- good attitude
Sinciput- moderate flexion OF
- military attitude
Brow- partial extension
Face- poor flexion OM
- very poor attitude

C.

Presentation the fetal part that


first enters the pelvis

Types:
1. Cephalic
2. Breech
3. Shoulder

Types of Presentation
1. CEPHALIC = the fetal head presents itself to the
passage, occurs in 97% of births
Classified as:
1. Vertex most common; fetal head is completely
flexed; smallest diameter of the fetal head
(suboccipitobregmatic ) presents to the maternal
pelvis
2. Military fetal head is neither flexed nor
extended; top of the head is the presenting part
3. Brow fetal head is partially extended; sinciput
is the presenting part
4. Face fetal head completely extended; face is
the presenting part

2. BREECH (buttocks) or (lower


extremities)
a.Frank: thighs flexed, legs extended
on
anterior surface, buttocks
presenting
b.Full or complete: thighs and legs
flexed,
buttocks and feet
presenting(squatting)
c. Footling: one or both feet are
presenting

3.

SHOULDER (Acromion)

It is also called as transverse lie


and accounts for 0.2% of births

A CS birth is necessary in a viable


fetus

Position: relationship of reference point on fetal


presenting part to maternal bony pelvis. Maternal
bony pelvis divided into 4 quadrants (R and L anterior,
R and L posterior)

Station-

refers to the relationship of the


presenting part of a fetus to the level of
the ischial spine.

2. PASSAGE

Refers to the route the fetus must travel from the


uterus through the cervix and vagina to the external
perineum.

Gynecoid
Inlet

rounded with all inlet


diameters adequate.

Midpelvis
diameters adequate with parallel
side walls.

Outlet
adequate
Favorable for vaginal birth

Android
Inlet

heart-shaped
Midpelvis diameters reduced
Descent into pelvis is slow
Not favorable for vaginal
birth

Anthropoid
Inlet

oval in shape
Outlet adequate

Platypelloid
Inlet

oval in shape
Outlet capacity inadequate
Not favorable for vaginal birth

3. POWER
Major

forces: Involuntary and


voluntary
Involuntary: includes frequency,
regularity, intensity and duration.
Voluntary: bearing-down efforts.
The contraction of levator ani
muscles.

Uterine contraction

3 phases of labor
contraction

INCREMENT building up of
the contraction (longest
phase)
2. ACME peak of the
contraction
3. DECREMENT letting up of
the contraction
1.

Terms to describe uterine


contractions during labor
DURATION

- measured from the


beginning of a contraction to the
completion of the same contraction
FREQUENCY- refers to the time between
the beginning of one contraction and
the beginning of the next contraction
INTERVAL- refers to the time between
the end of one contraction to the
beginning of the next contraction
INTENSITY refers to the strength of
the contraction during acme.

4. POSITION
Maternal

positioning during labor


Influence pelvic size and contours
Affects pelvic joints, facilitate descent
and rotation
E.g. squatting enlarges the pelvic
outlet by approximately 25%
Kneeling removes pressure on the
maternal vena cava and assists to
rotate the fetus in the posterior
position (Breslin and Lucas, 2003)

Semi-recumbent position
- woman sits with upper body elevated.
1.

2. Lateral position
- Removes pressure from the vena cava
compression and back to enhance
uteroplacental perfusion and relieves
backache.

3. Upright position
- Effect of gravity enhances the
contraction cycle and fetal
descent.

Squatting

4. Hands and knees position


- All fours.
- Facilitates internal rotation of the
fetus.

5. PSYCHE
A womans psychological outlook refers to the
psychological state or feelings that a woman brings into
labor.
The woman manage best in labor typically are those
who have a strong sense of self esteem and a
meaningful support person with them.
Women without inadequate support can have an
experience so frightening and stressful they can develop
PTSD.

true labor VERSUS false labor


TRUE LABOR

FALSE LABOR

Contraction

Regular, increasing frequency


and intensity, shortening of
interval

Irregular, no change in
frequency, duration and
intensity

Discomfort

Felt from the lower back


radiates to the abdomen in
wave

Pain remains in the


abdomen and groin

Rest/
Activity

Continue no matter what the


womans level of activity

Often disappear with


ambulation and sleep

Cervix

Achieve dilatation of cervix

Does not achieve cervical


dilatation

Four Stages of
Labor:

1. First Stage: Dilation


a. Latent or preparatory
phase
b. Active phase
c. Transition phase
2. Second Stage: Crowning
3. Third Stage: Birth of the
baby and delivery of the
placenta
4. Fourth Stage: Recovery

FIRST STAGE- begins with the initiation of true labor


contractions and ends when cervix is fully dilated.

The latent or preparatory phase


onset of regularly perceived uterine
contractions rapid cervical dilatation
begins.
Contractions
mild and short
lasting 20 to 40 seconds.

Emotional status: excited, anxious,


talkative, and ambivalent about
the ability to cope with labor; in
control

Active Phase
Rapid cervical dilatation : 4 cm
to 7 cm
Contractions
Stronger lasting 40 to 60 seconds every 3 to 5
minutes.
lasts approximately
3 hours in a nullipara
2 hours in a multipara
Show : increased vaginal secretions
Perhaps spontaneous rupture of the membranes may
occur.
Emotional status:
Intoverted, less
responsive, decreased
attention span, intense
concentration on
work of labor, some
loss of control may occur
along with a growing
irritability

Transition

Phase

Contractions peak in intensity occurring every 23mins with a duration of 60-90secs


Membranes will rupture as a rule at full
dilatation (10 cm)
Show will be present as the last of the mucus
plug from the cervix is released.
By the end of this phase, full dilatation (10 cm)
and complete cervical effacement (obliteration
of the cervix) have occurred.
Emotional status: decreased confidence, loss of
control, desire to give up and go home, fear of
death of self and fetus; does not want to be
touched and rejects help.

Comfort Measures for the Laboring


Woman
Do not leave alone in active labor.
Change soiled and damp linen promptly.
Provide mouth care.
Ice chips, lubricate lips.
Keep room cool, uncluttered, quiet and
privacy.
Promote participation of coach.

SECOND STAGE- extending from the time of full dilatation until


the infant is born

Crowning
As

she pushes, using her


abdominal muscles and the
involuntary uterine contractions,
the fetus is pushed out of the
birth canal.

Mechanism of a spontaneous
vaginal delivery/ Cardinal
movements

Definition: A mechanism of labor is


a series of passive, adaptive
movements of the fetal head and
shouldersthrough the birth canal.

Mechanisms of Labor
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion

1. Descent- downward movement of the


BPD of the fetal head to within the
pelvic inlet.
2. Flexion- the head flexes forward onto
the chest, making the smallest
anteroposterior diameter SOM present
to the birth canal.
3. Internal rotation- fetal head turns to
allow the BPD to pass between the
ischial spine

4. Extension- fetal head extends


upward when it reaches the
perineum; occiput pivots beneath
the pubic symphysis.
5. External rotation- fetal head turns,
realigning with shoulders, on
emerging from the pelvis; shoulders
move through pelvis and are
delivered from under the symphysis
pubis and the from over the
perineum.

6. Expulsion- delivery of the fetal


trunk follows the birth of its head
and shoulders.

THIRD STAGE (Placental stage)


From delivery of the baby to delivery of the placenta. This
stage usually lasts only a few minutes but may last up to
30 minutes.

Placental

Separation
Folding and separation of the
placenta occur.
Active bleeding
maternal surface of the placenta
the bleeding helps to separate the
placenta still further by pushing it
away from its attachment site.

Signs

of placental separation
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

Made up of 15-20 lobes called cotyledons


2 mechanisms of placental separation
1. SCHULTZE separates from the inside to the outer
margin; expelled with the fetal side ; Shiny
2. DUNCAN- separates from the outer margins inward,
rolls up and presents sideways with the maternal
surface; Dirty

Fourth stage
Recovery:

The woman is observed


frequently for signs of hemorrhage or
other complications; 1-4 hours after birth
Hemodynamic changes occur
Blood loss ranges from 300-500ml
Uterus remains contracted in the midline

Possible complications for


the mother include:
rupture

(tearing) of the uterus


hemorrhage (heavy bleeding)
after the delivery
bruising or tearing of the cervix
or vagina
tearing of the rectum
bruising or irritation of the
bladder.

Maternal Adaptation during


the Postpartum Period

Normal uterine involution occurs at a


predictable rate. One hour after
chilbirth, the fundus is at the level of
the umbilicus.
On the 1st postpartum day, the fundus is
approximately 1 fingerbreadth or 1 cm
below the level of the umbilicus.
Thereafter, it descends downward at
the rate of 1 cm per day until it
becomes a pelvic organ again on the
10th day postpartum.
Lochia rubra, serosa and alba.

Normal

blood loss
during NSVD 300 to
500 ml.

CS:

500 to 1,000 mL.

Maternal Role Development

Taking In Phase
Mother is dependent, has difficult making
decisions and needs assistance with self-care.
Can last several hours to days.
Taking Hold Phase
After she has rested and recovered from stress
of delivery, the new mother has energy for the
infant. Lasts 2 days to several weeks.
Letting Go Phase
Family relationships are adjusted to
accommodate the infant. Give up the fantasy
child and gets to know the real child.

Postpartum blues = a temporary depression that


usually begins on the 3rd day and lasts for 2-3 days.
S/S: tearful, difficulty sleeping and eating, and feel
generally down.
Psychological adjustment, plus fatigue, disturbed sleep
patterns, and discomfort may contribute.

Focus of early postpartum period:


1.
Preventing and detecting hemorrhage
2.
Treating pain
3.
Preventing infection
4.
Detecting and treating urinary retention
5.
Promoting sleep
6. Promoting healthy parental-newborn attachment.

POSTPARTUM COMPLICATIONS
1.

HEMORRHAGE - 1-4 hrs postpartum is the most


critical stage

Causes:

a. Laceration

b. Placental retention

c. Uterine rupture

d. Uterine inversion

e. Uterine atony

2. INFECTIONS

a. Endometritis Endometriosis is the growth


of endometrial tissue outside the uterus.
When infected, it is called endometritis.
Clinical manifestations:

foul smelling vaginal discharge

fever & chills

profuse bleeding

b. Episiotomy Infection

Operative Obstetrical
Procedures

Forceps Delivery

Forceps Delivery method of delivering infants through


the use of forceps extraction
- 2 double-crossed, spoonlike articulated blades that
are used to assist in delivery of fetal head
- may cause damage on the facial nerve of the baby

Vacuum Delivery method of delivering an


infant using a vacuum applied over the scalp of
the baby
- may cause caput succedaneum

Cesarean Section
In the case of severe obstetric emergencies, the time
from decision to delivery is ideally within 30 minutes .

3 types
a. Low Segment CS
method os choice since
lower segment is thinner,
fewer bld vessels,
passive during labor
b. Classical CS
indicated for transverse
lie, placenta previa,
adhesion of tissues
c. Pfannenstiel or bikini