Chapter 12 process of birth

contraction characteristics

• the power that advances labor

• coordinated

• cyclical

• fetus stores O2 → circulation cut off w/ contraction

• wavelike pattern

contraction coordination

• frequency

• duration

• intensity

contraction frequency

• beginning of one uterine contraction to the beginning of the next

• how often is it happening? - mins & fractions of mins

contraction duration

• beginning of a contraction → end of same contraction

• how long is it? - in sec

contraction intensity

• strength!

contraction cycle

• increment

• peak/acme

• decrement

contraction increment

• period of increasing strength

• slowly climbing

contraction acme/peak

• when contraction is most intense

• watch relationship w/ FHT

contraction decrement

• period of decreasing intensity

  • as uterus relaxes

contraction interval

• resting time!

• btwn contractions

  • notes placental perfusion

• end of one contraction → beginning of another

• not long enough? not enough O2! - tachysystole

  • FHT deceleration

uterus

• a muscle!

• upper 2/3 contracts

  • squeeezeeee

  • pushes fetus down

• lower 1/3 less active

  • w/ cervix

• contractions not strong enough? complications !

uterus retraction ring

• physiologic

• division btwn upper & lower segments

uterus during labor

• upper segment becomes thicker

• lower segment + cervix get thinnger & get pulled upward

cervical changes in labor

• happen concurrently, but at different rates

  • effacement

  • dilation

• towards end of pregnancy & start of labor

cervix

• about 2in non-effaced

cervical effacement

• thinning & shortening of uterus

• starts a lil earlier

cervical dilation

• opening

nullipara during labor

• have not completed a pregnancy to at least 20wks gestation

• cervical effacement often happens early in process of cervical changes

  • efface THEN dilates

para during labor

• has given birth after pregnancy of at least 20wks gestation

• cervix usually thicker than nullipara at any point in labor

• efface & dilate faster

  • been thru it before already

cardiovascular effects of labor

• during contractions 300-500mL of blood backs into systemic circulation

  • causes short increase in blood vol

• BP increase, HR decrease

  • only check vitals in btwn contractions! false high & low

• notice vitals are odd? check contraction timing

respiratory effects of labor

• depth & rate increases

  • too fast? may hyperventilate

• help control breathing !!

GI effects of labor

• motility slows

  • N&V

• client kept on clear liquid diet

  • to decrease N/V

  • makes emergency surgery/c-section easily accessible

  • still gets glucose, but won’t have a lot of food in stomach

urinary effects of labor

• reduced sensation of full bladder

  • none w/ an epidural

• if not emptied regularly, can add to pain of labor & keep fetus from descending

hematopoietic effects of labor

• 500-1000mL blood loss normal

  • can usually be tolerated w/o difficulty bc of increase in blood vol during pregnancy

• if client is anemic at time of delivery, may not be able to tolerate loss

  • may be symptomatic or need blood

placental circulation fetal effects during labor

• circulation is vital to make it thru labor

• during strong contractions blood supply to placenta decreases

  • spiral arteries compressed

• exchange occurs btwn contractions

• if working properly, enough O2 will be there to tolerate interruption

• fetus can have issues tolerating labor w/ placental fxn issues

  • diabetes, HTN, preeclampsia → decels

pulmonary fetal effects during labor

• lungs filled w/ fluid in utero

• as fetus nears term → production of fluid decreases to abt 65%

• labor speeds lung fluid absorption

  • 35% remains in lungs at birth

• catecholamines made by fetal adrenal glands in response to labor stress help infant adapt to land living

  • fluid squeezed out or squeezed into tissue → less to deal w/

cardiovascular fetal effects during labor

• reacts quickly to labor events

• alterations seen from labor effects/fetal intolerance

• FHT normally 110-160 for term

  • may be higher in preterm babies bc of immature parasympathetic nervous system

factors affecting labor process

• powers

• passage

• passenger

• psyche

powers & labor process

• quality, force & freqency of contraction

passage & labor process

• true pelvis/birth canal

passenger & labor process

• the fetus itself

psyche & & labor process

• anxiety

• culture

• expectations

• support

powers & labor

• contractions

• pushing efforts

contractions

• body trying to get baby out

• not strong/frequent enough? labor can stall

• should have 1min intervals in btwn

• ideally 3 min apart from start of one to next

weak contractions

• labor can stall

  • ineffective pattern

  • may need help - pictocin

    • c-section if that still doesnt work

tachysystole

• contractions too close tgt

• oxygenation problems

• not enough time for mom & fetus to recover

contraction strengths

• mild

• moderate

• strong

passage

• route through which the fetus has to travel to be born vaginally

  • true pelvis

• must be of adequate shape & size so baby can pass thru

  • if large fetus noted, measurements of pelvic outlet & baby head measured via U/S

    • if noted during labor (w/ baby not coming down), emergency c-section indicated

failure to progress

• when baby does not come down into pelvis during labor

pelvis & labor

• the birth canal passage!

  • bony pelvis & soft tissue of birth canal

• pelvic outlet & vaginal canal

pelvic outlet

• circumference of opening inside of pelvis

• small? cephalopelvic disproportion happens

  • not large enough to accomodate head → c-section !

bony pelvis

• can be measured w/ pelvimetry, but not accurate

  • has been replaced by clinical labor trial

cephalopelvic disproportion

• when the head will not fit through the pelvis

• like trying to fit a square block in a round hole

soft tissue of birth canal

• cervix

• pelvic floor musculature

passenger

• what presents to the pelvic outlet

  • fetus

  • membrane

  • placenta

fetal laboring aspects

• head

• attitude

• lie

• presentation

fetal head

• usually presents in cephalic presentation

  • optimal presentation!

• shoulders must be considered in width

fetal attitude

• posturing of fetal parts to one another

  • flexion or extention

• flexed most favorable for vaginal birth

fetal lie

• relationship of the spine of fetus to the mother

  • R, L, anterior, posterior, transitional

• anterior/longitudinal lie most optimal

  • fetal face facing mother’s spine

  • typically how baby is presented

transitional lie

• baby positioned back first

fetal presentation

• body part of fetus that enters pelvic inlet first

  • what part presents first!

• cephalic, breech, shoulder, transition

cephalic presentation

• head-first

• best positioning!

• Largest single fetal part 

• Can change shape, molding & adapting! 

• Smooth, round, hard -> helps dilate cervix 

• Further division 

cephalic presentation divisions

• Vertex (flexed, most favorable)

• military (neutral)

• brow (partly extended)

• face (fully extended)

breech variations

• Frank (legs extended)

• complete (all flexed & butt first)

• footling (feet first)

breech presentation

• pelvis first

  • butt/feet

• More common preterm, hydrocephaly, multiple gestations, uterine abnormalitites, placenta previa 

• Buttocks not smooth 

• Head last to be born -> head suject to compression

shoulder presentation

• scapula first

• Preterm, hydramnios, placenta previa, abnormal uterus 

• C-section needed

occiput posterior presentation

• baby spine facing mother’s spine

  • face to belly

• hardest position to get baby down into outlet

  • wider circumference

• longer labor on back, longer time pushing

  • increased back pain

• can be bc of pelvis tilt/odd shape

• may lead to C-section

back-lying labor

• not normally taken by epidural

pushing sessions

• FTM? about 1hr

  • later becomes quicker

positioning indication abbreviation

• 3 letters!

  • 1st: whether presenting part is toward L or R of maternal pelvis

  • 2nd: presenting part of fetus

    • occiput (O), sacrum (S), mentum (M), acromion process (A), dorsal (D)

  • 3rd: location of presenting part in relation to portions of maternal pelvis

    • anterior (A), posterior (P), transverse (T)

fetal position ex

• all longitudinal lie w/ flexion attitude

psychological response of mother during labor

• state of mind throughout birthing process is critical to positive outcomes

  • esp when mom is alone!

  • exhaused? can’t push efficiently - coaching needed

• super anxious? cant relax? labor effected!

factors promoting a positive birth experience

• clear info about procedures during labor

• support - not being alone!

• sense of master, self-confidence

• trust in staff

• positive rxn to pregnancy

• personal control over breathing

• prep for childbirth experience

false labor

• has to be sent home

  • no tylenol in hospital, alternative means at home

• can happen many times

false labor contractions

• inconsistent in frequency, duration, & intensity

• change in activity, like walking, does not alter contractions

  • may decrease them

• can be triggered by dehydration

  • give water!

false labor discomfort

• felt in abd & groin

  • in the front

• may be more annoying than truly painful

false labor cervix

• no significant change in effacement/dilation after an observation period of 1-2hrs

  • >39wks? may be admitted & given pictocin

true labor

• only pain mgmt is epidural

true labor contractions

• consistent pattern of increasing frequency, duration, & intensity usually develops

• walking tends to increase frequency & strength

• put on monitor first thing!

  • observe strength & frequency

  • look for FHT and distress

true labor discomfort

• begins in lower back & gradually sweeps around to lower abd like a girdle

• back pain may persist in some women

• often feels like menstural cramps

true labor cervix

• effacement and/or dilation of cervix happens

  • dilation itself not a sure tell

• progressing is most important characteristic!

  • vaginal exams q1h

• water is usually broken, but sometimes not

elective induction

• pt has to be at least 39wks

• decided by AWHONN

• sooner, decided induction only bc of complications

early induction complications

• preeclampsia

• IUGR

• poor placental perfusion

• gestational diabetes

mild contraction palpation

• slighty tense fundus

• feels like touching finger to tip of nose

moderate contraction palpation

• firm fundus

• feels like touching finger to chin

strong contraction palpation

• rigid, board like fundus

• feels like touching finger to forehead

labor stages

• first

• second

• third

• fourth

labor stage 1

• onset → 10 cm dilated

first stage labor work accomplishment

• effacement & dilation of cervix

first & third stage labor forces

• uterine contractions

first stage labor cervical dilation

• latent phase

• active phase

labor latent phase

• first stage

• ~0-5cm

• beginning of labor!

• excited!

• contractions okay

• coming to hospital/admitting

labor active phase

• first stage

• ~6-10cm

• omfg this is killing me

• water breaks

• epidural initiated

• increasing contractions

• mad asfff

• stuff is getting real

first stage labor uterine contractions

• initially mild & infrequent

• gradually progresses to strong intensity

  • 3-5 contractions in 10min period

first stage labor discomfort

• often begins w/ low backache & cramps like period cramps

• back discomfort then sweeps to lower abd like a girdle

  • discomfort intensifies as labor progresses

first stage labor client behaviors

• sociable, excited, somewhat anxious in early labor

• becomes more inwardly focused as labor intensifies

  • may lose control during late active phase

• often varies w/ pain-relief chosen!

labor stage 2

• 10cm → delivery

  • pushing time

second stage labor work accomplished

• expulsion of fetus

second stage labor forces

• uterine contractions

• voluntary bearing-down efforts

second stage labor cervical dilation

• 10cm!

  • complete!

second stage labor uterine contractions

• strong

  • 5-6 contractions in 10min period

• may be slightly less intense than during late first stage

• may pause briefly as second stage begins

second stage labor discomfort

• urge to push/bear down w/ contractions

  • becomes stronger as fetus descends

• distention of vagina & vulva may cause stretching/splitting sensation

second stage labor client behaviors

• intense concentration on pushing w/ contractions

• often oblivious to surroundings & appears to doze btwn contractions

labor stage 3

• delivery of baby → delivery of placenta

third stage labor work accomplished

• separation of placenta

third & fourth stage labor uterine contractions

• firmly contracted

third stage labor discomfort

• little

• sometimes slight cramp felt as placenta is passed

third stage labor client behaviors

• excited & relieved after baby’s birth

• usually very tired

• often cries

labor stage 4

• recovery!

  • 1-4hrs

• based on whats happening to mom

fourth stage labor work accomplished

• physical recovery

• bonding w/ newborn