Normal L&D: Labor Birth and Processes

Maternity Deserts

US maternal mortality rates is worse than others despite expensive healthcare

people have to travel farther to get prenatal care of go to a hospital

abortion law, budget cuts in medicare can be reason for hospital/maternal ward closures

mostly happens in rural areas

Emergency Delivery

if perineum bulging

leave foot rail up, pitocin given IV or IO in hospital setting

if outside hospital, start breastfeeding so oxytocin can be secreted to contract uterus

warm, dry, stimulate

LR given (500-1000mL) before epidyral bcs risk of epidural dropping bp

5 Ps: Passenger

fetus and placenta

5 Ps: Passageway

birth canal

5 Ps: Powers

primary and secondary

strength of contraction

5 Ps: Position of the laboring

different positions that aid in delivery/birth

5 Ps: Psychologic Response

emotions experienced

Fetus: Head

Size, bones, sutures, fontanels

Fetus: Presentation

The part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor

Fetus: Lie

Relation of the long axis (spine) of fetus to the long axis of mother

longitude lie (good)

transverse lie

Fetus: Attitude

Relation of the fetal body parts to one another

ex. fetal head relation to other parts

flexion (good)

extension (bad)

Fetus: Position

The relationship of a reference point on the presenting part to the four quadrants of the mother’s pelvis

Passenger: Presentation

vertex, breech, shoulder

Vertex

head down

Breech

butt down

Shoulder

transverse

Occipitoanterior

good

head down w/face facing mothe’s back

can be left or right

Ocipitoposterior

bad

baby’s back is facing mother’s back

can cause back pain labor and cause more back pain

can be right or left

Station

relationship of presenting part to maternal ischial spine and degree of descent of presenting part of fetus

Engagement

indicates the largest transverse diameter of the presenting part has passed through the maternal pelvic brim or inlet, into the true pelvis

stage 3 of Lepolds maneuver

Leopold’s Maneuver: 1

palpate fundus to see if butt or head

Leopold’s Maneuver: 2

locate baby’s back and extremities

Leopold’s Maneuver: 3

check engagement

is movable or fixed?

Leopold’s Maneuver: 4

check for attitude

nurse stands to face pt’s feet; make bunny

flexion (good)

extension (bad)

Pasageway

consists of the maternal pelvis and its soft tissues.

bony pelvis is more important to the outcome of labor, because the bones and joints do not readily yield to the forces of labor.

Softening of the cartilage linking the pelvic bones increases as term approaches and the hormone relaxin increases

cervix surgery can leave scar tissue and may need to be cut during labor

Relaxtin

relaxes the tissue and helps open up passageway

Powers: Primary

happens w/o the pt thinking about it

uterine contractions (effacement and dilation); primary force that moves fetus through the maternal pelvis

1st stage of labor- through dilation

continues into second stage

Effacement

shortening and thinning of cervix

Dilation

enlargement or widening of the cervical opening and the cervical canal

Powers: Secondary

pushes w/contractions

bearing down efforts (after full dilation)

second stage of labor- dilation through birth

Voluntary pushing efforts propel the fetus through the pelvis

Ferguson reflex

Ferguson reflex

stretch receptors cause release of oxytocin, triggers urge to bear down

involuntary like vomiting

may not feel w/epidural

Position of Laboring Woman: Frequent Changes

Relieve fatigue

Increase comfort

Improve circulation

Position of Laboring Woman: Different Positions

Upright: often most helpful for descent

“All fours”

Lithotomy

Semirecumbent

Lateral

Psyche

Crucial aspect of childbirth.

Marked anxiety, fear, or fatigue decreases a woman's ability to cope with labor pain.

Maternal catecholamine secreted in response to anxiety or fear.

Inhibit uterine contractility and placental blood flow.

Relaxation augments the natural process of labor.

Signs Preceding Labor

-Braxton Hicks Contractions: Watch out for dismissing contractions that may truly be causing cervical change

-Lightening or dropping: drops to pelvis

-Increase in clear and nonirritating vaginal secretions

-"Bloody show": mucousy bleeding, cervical plug

-Energy spurt: nesting instinct (ex. wanting to paint room)

-Small weight loss - 0.5-1.5 kg

Does losing mucous plug indicate labor

no

Onset of Labor

Onset of true labor cannot be ascribed to single cause

Factors include changes in maternal uterus, cervix, and pituitary gland

Typically determined by cervical change

How is onset of labor determined?

dilation

First Stage of Labor

onset contractions to full dilation of the cervix

contains latent/early phase and active/transition phase

1st Stage: Latent/Early Phase

0-5cm dilation

Onset of labor, characterized by regular, painful uterine contractions that cause cervical change to the beginning of the active phase

More progress in effacement of cervix and little increase in descent

1st Stage: Active/Transition Phase

starts at 6cm

Period during which the greatest rate of cervical dilation occurs, begins at 6 cm and ends with complete cervical dilation at 10 cm

More rapid dilation of cervix, increase rate of descent on presenting part

transition is most intense before going to 2nd stage

2nd stage of Labor

full dilation to birth

latent phase, active phase

nurse must be aware for signs of impending birth: baby is coming, grunting sounds, bearing down, check perineum (bulging?)

vertex presentation (birth of head, shoulders, extremities)

2nd Stage: Latent Pahse

passive fetal descent

2nd Stage: Active Phase

pushing phase

laboring down/bearing down

3rd Stage of Labor

birth of the fetus until delivery of the placenta

Placental Separation and Expulsion

Placental Separation and Expulsion

Firmly contracting fundus

Change in shape of uterus from a discoid to globular

Sudden gush of dark blood from introitus

Apparent lengthening of umbilical cord

Vaginal fullness

4th Stage of Labor

Delivery of the placenta and until the woman’s condition is stable.

Typically, 2 hours after giving birth.

Assessment

Post anesthesia recovery

Care of the new mother

Care of the family

Mechanism of Labor: Cardinal Movements

seven cardinal movements that occur in a vertex presentation:

Engagement

Descent

Flexion

Internal rotation

Extension

External rotation

Expulsion