The Process of Labor and Birth

What are the 5 Ps?

Powers (contractions) & pushing

Passenger (fetus)

Passageway (birth canal)

Position of birthing person & fetus

Psyche (psychological response)

Additional considerations for 5 Ps

All forces must work together for a successful birth

For psyche, anxiety delays cervical dilation

Uterine contractions

Primary force of labor

Help move fetus down birth canal

Aid in cervical effacement in dilation

Assist w/ uterine involution after birth

Note w/ cervical effacement and dilation

Need head to be well-applied to prevent delay in effacement & dilation

Increment

Building of contraction

Acme

Peak of contraction

Decrement

Decrease of contraction

Patient pushing

Involuntary "bearing down" or intense rectal pressure

Strong urge with effective pushing

When should patients push?

Patients should bear down/push at acme

Note w/ fetal station and pushing

Want baby to be at least a +2 before they start pushing

Labor down -- resting for 1-2 hours after cervix is fully dilated before actively pushing w/ contractions, allows for passive descent into birth canal

Frequency of contractions

Beginning of one contraction to beginning of next contraction (in min as a range) -- find contractions closer together and furthest apart to give you your range

Duration of contractions

Beginning of one contraction to its end (find one wide and one narrow, gives range, document in seconds)

Strength of contractions

Need an IUPC to really know strength of contractions, palpate at peak of contraction, want it to be strong to make cervical change

Pt must be on monitor for at least...

10 min

Powers -- Assessing Contractions

Patient reporting, palpation, or tocodynamometer (TOCO) -- TOCO goes at top of fundus where contraction is strongest

Palpating to assess contraction intensity/strength

Mild -- like palpating tip of nose

Moderate -- like palpating shin

Strong -- like palpation forehead

Effacement

Shrinking and softening of cervix (thinning), want it to be paper thin

Measured from 0-100%

Dilation

Cervix opens up

Measured from 0-10 cm

Fetal station

Fetus moves down in station, measured in relation to ischial spine

Top of baby's head at ischial spine = 0

One above ischial spine = -1, higher negative number, higher up in uterus baby is, we want + numbers

Measured from -5 to +5

Progression of cervical change

1. Patient is closed, long, and high

2. Patient is 10 cm, 100%, and +2

3. Patient is complete and pushing or C&P

Passenger

Fetus and fetal membranes

Molding of head

Bones, A&P fontanelles, and sutures of head change shape as baby moves through birth canal

Fetal attitude

Refers to position or posture of baby in women, describes how baby is flexing or extending its body parts, such as the head, arms, and legs

Most common & ideal fetal attitude

When the baby is curled up w/ the chin tucked down towards the chest (head completely flexed), arms, and legs pulled in close to the body -- helps the baby fit better through the birth canal during delivery

Fetal lie

Fetal spine in relationship to maternal spine

Examples of fetal lie

Longitudinal (cephalic or breech), transverse (c/s), oblique

Fetal presentation

Refers to fetal part that enters the pelvis first

Desired fetal presentation

Want baby to be cephalic or vertex w/ head down

Breech presentation method of delivery

A c/s 99.9% of the time, can try to do an external version to manipulate baby by turning clockwise to turn head down, sometimes successful

Types of fetal presentations

Cephalic (head down) - 95%, breech, shoulder (transverse)

Types of cephalic presentations

Vertex/occiput, sinciput/military, brow, mentum/chin

Types of breech presentations

Frank, complete, footling

Way baby is facing

Want back of baby's head to be in anterior position (facing down)

Posterior position is when baby is sunny side up and looking up at ceiling instead of floor

Breech presentation

Buttocks enter maternal pelvis first, sacrum is landmark

Frank breech

Legs extended toward the shoulder

Complete breech

Legs flexed

Footling breech

One or both feet present first into maternal pelvis

Disadvantages of breech presentation

Risk of cord prolapse

Presenting part less effective in cervical dilation

Risk of cord compression

Risk of prolonged labor

Shoulder presentation

Occurs when fetus in transverse lie - rare % of births

Fetus cannot be delivered vaginally unless rotation occurs

Fetal skull

Bones, fontanelles, sutures

Structures of fetal skull

Moldable to fit down the bony pelvis

Palpating these structures are landmarks that help the provider determine fetal presentation

Note w/ fontanelles and fetal presentation

Will feel posterior fontanelle if baby is looking down at floor (anterior position)

Will feel anterior fontanelle if baby is looking up at ceiling (posterior position)

Fetal position

Refers to the location of fixed reference point of fetal presenting part in relation to specific quadrant of maternal pelvis

Maternal pelvis divided into 4 quadrants to help describe position

Types of positions

Vertex: occiput

Face: chin (mentum) or brow

Breech: frank, complete, footling

Shoulder: acromion process

Abbreviations used for fetal position

First letter is which way the baby's head is facing (R or L)

Second letter is presenting part of fetus (e.g., O for occiput)

Third letter describes where back of baby's head is facing (anterior/transverse/posterior, we want anterior)

Summary of abbreviations used for fetal position

First and last letter refer to maternal pelvis

Middle letter refers to presenting part of fetus

ROA

Right occiput anterior

ROP

Right occiput posterior

LSP

Left sacrum posterior

Relationship between passageway and passenger

Engagement and station

Engagement

Widest diameter of fetal presenting part has passed through the pelvic inlet

Station

Maternal ischial spines: O station

Above ischial spines: (-) minus station

Below ischial spines: (+) plus station

4 classic pelvic types

Gynecoid, android, anthropoid, platypelloid

Gynecoid

Normal female pelvis

Android

Heart-shaped pelvis, male, makes birth a bit more difficult

Anthropoid

Oval brim and a slightly narrow pelvic cavity -- makes it easier if baby comes out in posterior position

Platypelloid

Flat oval, baby will not fit, c/s

Engagement w/ gynecoid pelvis

Engagement w/ this type of pelvis occurs most frequently w/ fetus in a transverse position, followed in frequency by anterior and posterior positions

Anatomy of gynecoid pelvis

Spacious and well-rounded posterior segment

Pelvic inlet w/ slightly ovoid or round shape

Wide, well-rounded foreplevis (anterior segment)

Straight side walls in pelvic midcavity

A sacrosciatic notch of medium size

Average sacral inclination and curvature

Wide suprapubic arch

Wide interspinous and intertuberous diameters

Bones ranging from medium to delicate in structure

Engagement w/ android pelvis

Engagement in this type of pelvis occurs most frequently w. the fetus in a transverse position, followed by the posterior and anterior positions. The clinician should be alerted by this type of pelvis that the possibility of posterior positions exists

Anatomy of an android pelvis

Wedge-shaped pelvic inlet

Narrow retropubic angle (anterior segment)

Flat, wide posterior segment

Narrow sacrosciatic notch

Forward sacral inclination

Narrow, wedge-shaped "Gothic" subpubic arch

Converging side walls, narrow interspinous and intertuberous diameters

Narrow forepelvis

Bones ranging fro medium to heavy in structure

Engagement w/ anthropoid pelvis

Engagement in this type of pelvis occurs w. fetus in either an anterior or transverse position, but the anterior position appears to be more characteristic

Anatomy of anthropoid pelvis

A long, narrow, oval-shaped inlet​

A long, narrow, well-rounded anterior segment

​A long, narrow posterior segment​

A very wide, shallow sacrosciatic notch​

A long, narrow sacrum with average inclination and curvature

​A slightly narrow subpubic arch​

Straight & narrow side walls with below-average interspinous and intertuberous diameters

​Medium to delicate bones​

Narrow transverse diameter of pelvic inlet

Wide AP diameter of pelvic inlet

Divergent forepelvis

Wide inclination of sacrum

Engagement w/ platypelloid pelvis

Will almost always occur with the fetus in a transverse position

Because of the flatness of the pelvis, the internal rotation of the vertex can be limit, causing deep transverse arrest --> c/s

Anatomy of platypelloid pelvis

A transverse, oval-shaped inlet

A very wide, round retropubic angle

A very wide, flat posterior segment

A narrow sacrosciatic notch

Average sacral inclination

A very wide subpubic arch

Straight & wide side walls with very wide interspinous and intertuberous diameters

Bones ranging from medium to delicate in structure

Narrow AP diameter of pelvic inlet

Straight forepelvis

Narrow inclination of sacrum

Different positions of birthing person

Spinning babies, peanut ball, exercise ball, etc.

Position of birthing person for epidural vs. no epidural

Can be walking around if no epidural

If they have an epidural, help them change positions in bed

How often should birthing people change positions?

At least q 30 min, staying stationary in bed not good for 7 cardinal movements

Negative psyche

If a birthing person is afraid, tense, stressed, anxious, angry, feels unsafe or unsupported, they may have a longer dysfunctional labor -- this may impede cervical dilation, fetal descent, or prevent the birthing person from pushing effectively

Why is a good emotional state key during labor and birth?

Helps birthing person cope w/ pain

Helps them tune into their body

Allows the other 4 Ps to sync up effectively

Empowerment

Give them confidence that their body can do this

Be positive support for them

Provide a calm, safe holistic birthing space

Be approachable

How often should a patient be making cervical change?

Should be making cervical change at least q2h if in active labor

A pregnant person walks into triage and is complaining of labor symptoms. What do we do/ask?

What time did contractions start​

How frequent are contractions​

Can they talk through the contractions - not strong enough to make cervical change if they can talk through​

GTPAL, any medical complications​

Did your water break, amount, color, how long ago​

Pregnancy complications​

Gestational age - preterm​

Vaginal bleeding - did you have intercourse in last 72h, cervix becomes friable (may bleed after cervical exam), what time did it start, amount, where is placenta (placenta previa - what number bleed is this for you)​

When was the last time you felt the baby move - unless actively giving birth or hemorrhaging, this patient always comes first in coming back to triage (decreased fetal movement)

S/Sx of labor

Braxton Hicks contractions (false contractions, prodromal labor) -- not strong enough to make cervical change

Lightening (approx. 2 weeks before onset)

Loss of mucus plug

Bloody show

Cervical changes

ROM

Energy spurt (nesting)

Weight loss, GI disturbances

Purpose of mucus plug

Blocks bacteria from going up during pregnancy, lost when cervix ripens

True labor

Leads to dilation and effacement of cervix

Regular contractions

Contractions increase in duration, frequency, and intensity

Contractions increase with activity

5 contractions in 1 hour lasting 60 sec or longer

Contractions are lower down, may even feel in the thighs

A posterior baby will cause...

Back pain d/t riding of coccyx

False labor

Braxton-hicks

No cervical changes

Contractions felt in abdominal region, do not increase in intensity, and often stop with activity

Maternal factors in triggering labor

1. Uterine muscles are stretched to the threshold point, causing release of prostaglandins and oxytocin that stimulate contractions

2. Increased pressure on the cervix stimulates the nerve plexus, causing the release of oxytocin by the maternal pituitary gland, which then stimulates contractions

3. Estrogen levels increase, enhancing the ability of uterine myometrium to produce contractions

4. Progesterone is functionally withdrawn.

5. Oxytocin and prostaglandins, which have been previously inhibited by progesterone, together soften the cervix and stimulate myometrial contractions

Fetal factors in triggering labor

1. Prostaglandin synthesis by the fetal membranes and the decidua stimulates contractions

2. Produced by the fetal hypothalamic-pituitary-adrenal axis, fetal cortisol levels increase, and acting on the placenta, cause an inflammatory response and an increased level of prostaglandins, stimulating uterus to contract

Admission procedures for L&D

1. Establish positive relationship, manage goals & expectations, and review birth plan

2. Collect admission data

3. Initial admission assessments --> focused, psychosocial assessment (IPV and depression screening), cultural assessment (aversion to cold? Women only?), labs (missing prenatal labs, CBC/plts, T&S, syphilis, CMV)

Friedman curve

Identify whether a woman's cervical dilation is progressing at the expected rate -- some use this guide in practice

Stages of dilation during the first stage of labor

Three stages --> latent, active, transition

Latent phase of dilation

0-6 cm dilated, contractions q 5-20 min, irregular, lasting 30-40 sec

Active phase of dilation

6-7 cm dilated, contractions q 2-5 min, lasting 40-60 sec

Transition phase of dilation

8-10 cm dilated, contractions q 1.5-2 min, lasting 60-90 sec, may start to feel pushy

Prolonged latent phase

20 or more hours for prime, 14 or more hours for multip

Length of labor

12-24 hours prim, 8-10 multip

Duration of active phase

Usually 4-8 hours

Duration of transition phase

15 min to 3 hours

Arrest of labor

Absence of cervical change for > 4 hours in the presence of adequate contractions or six hours with inadequate contractions -- may warrant clinical intervention

Protracted labor

Labor abnormality that occurs when labor progresses more slowly than expected

Secondary arrest of dilation

Condition that occurs when cervical dilation stops for a period of two hours or more, following a hx of normal dilation

Membrane sweep

Run finger inside cervix to separate amniotic sac from lower uterine segment, increases prostaglandins to stimulate labor

Nursing care during labor & birth

Ongoing assessment, facilitate positive birth experience, manage discomfort, keep bladder empty, advocate for pt needs, provide anticipatory guidance

Personal hygiene for labor support

Continuous peri care

Supportive relaxation techniques during labor

Lamaze, hypnobirthing, Bradley method, Birthing from Within

Fetal assessment

Position and fetal heart tones (FHTs)

Assessing fetal position

Done by using Leopold's Maneuvers

Significance of FHTs

Important for oxygenation