PPN 301 - CLASS 4(5) LABOUR AND DELIVERY

What is the process of labour

• labour is the process of moving the fetus, placenta and membranes out of the uterus and through the birth canal

• usually begins between the 37th and 42 week of gestation

• changes occur in the woman’s reproductive system in days and weeks before labour begins

• BEFORE LABOUR BEGINS - prep phase

  • increase Braxton hicks contraction

  • cervical ripening (softens)

    • oestrogen, relaxin, and prostaglandins break down in cervical connective tissue

  • increase in the excitability of the uterine musculature

  • Mechanical stretching of the uterus also helps to increase contractility

  • increase oxytocin receptors and levels of oxytocin (ferguson reflex)

uterus becomes more sensitive and is ready to contract

Onset and signs preceding labour

• These are signs before true labour that are getting the body ready for labour - baby moving towards the pelvis, small blood vessels break, and bloody discharge occurs

• lightening or dropping

• increase vaginal discharge; bloody show

• backache

• stronger braxton hicks contractions

• weight loss of 0.5-1.5 kg (before labour starts)

• surge of energy (also called nesting)

• flulike symptoms

• increased vaginal discharge; bloody show

• cervical ripening

• possible rupture of membrane

True labour

TRUE LABOUR

• CONTRACTIONS

  • increase in intensity

  • increase in duration

  • discomfort begins in back, radiates around abdomen

  • become progressively closer together (ask time contractions)

  • do not dissapear with walkin

• CERVICAL

  • begins to efface and dilate

• SHOW

  • may or not be present

FALSE LABOUR

• CONTRACTIONS

  • do not increase in intensity

  • do not increase in duration

  • discomfort usually in abdomen(alone)

  • do not become progressively closer

  • may disappear with walking

• CERVIX

  • no cervical change

• SHOW

  • not present

WHAT ARE THE 5 P’S OF LABOUR

labour is a combination of all of these factors

• powers (contractions) 

  • strength and pushing

• passageway

  • birth canal

• passenger (fetus and placenta)

• position of mother

  • baby and alignment

• psychological response

  • mothers emotional state

5 P’S OF LABOUR - Powers 

• primary powers

  • contractions

    • frequency, duration, intensity

  • effacement

  • dilation

  • ferguson reflex

• secondary powers

  • bearing-down efforts (pushing and adding onto that force)

cervical effacement (cervix thins out) and dilation (cervix opens out)

diagram

5 P’S OF LABOUR - passenger (baby and placenta)

• fetal presentation

  • cephalic/vertex - head as presenting part (head down feet up) - common and favourable position

  • breech - buttox as presenting part (butt down)

  • shoulder/transverse - shoulder as presenting part (or shoulder in the way)

• size of fetal head

• fetal lie - baby aligned with mothers spine - look at vertebrae for the mom - longitudinal align vertically transverse - across, slanted - oblique

• fetal attitude - how baby holds self - ideally chin tucked in

• fetal position

  • station - how far baby’s head has descended into pelvis

  • engagement

fetal vertex presentation

• vertex presentation

  • occiput typically is anterior and thus is the optimal position to negotiate the pelvic cure by extending the head

    • ROA- right occiput anterior - back of the head

    • LOA - left occiput anterior

fetal presentations: Breech 

• fetal presentations, A to C

• breech (sacral) presentation. D: shoulder presentation

Fetal lie

• relationship of long axis of fetus to long axis of mother

  • longitudinal - long axis of fetus is parallel to long axis of mother

  • transverse - long axis of fetus is perpendicular to long axis of mother

  • oblique - fetal lie is at an angle between transverse and longitudinal lie

Fetal attitude (baby’s head in relation to spine)

• relation of fetal head to its spine

  • complete flexion

    • when the chin of the fetus is flexed and touches the sternum

  • moderate flexion

    • military position - chin is not touching the chest but is in an alert position (head diameter is wider) 

  • deflection or extension

    • back is arched and head is extended (relate to face presentation - harder to delivery  

fetal station

• relationship of presenting part ot an imaginary line drawn between maternal ischial spines 

• measurement of fetal head in relation to level of maternal ischial spines

  • measure in cm

  • ranges form -5 to +5 (birth imminent at +4 or+5)

• O station refers to the head at the level of the ischial spines

  • presenting part higher than the spines: negative sign (if head is higher negatives

  • below the spines - positive sign

5 P’S OF LABOUR - passageways (structures the babay moves through during birth 

• 4 basic types of pelves

  • gynecoid (classic female type)

  • android (resembling the male pelvis)

  • anthropoids (resembling the pelvis of anthropod apes)

  • platypelloid (the flat pelvis)

• soft tissue of the cervix

• pelvic floor

• vagina

• introitus (external opening to the vagina)

comparison of pelvic types and shapes

5 P’S OF LABOUR - position

• position of a labour woman

  • position affects a woman’s anatomical and physiological adaptations to labour

  • frequent changes in position 

    • relieve fatigue

    • increase comfort

    • improve circulation

  • labouring woman should be encouraged to find most comfortable position

  • gravity promotes descent of the fetus

5 P’S OF LABOUR - psychological response

• patient extremely anxious (emotional stress)

• emotional factors related to the patient

• amount of sedation required for the patient 

stages and process of labour

• first stage

  • onset of contractions to full dilation of the cervix

  • latent phase

  • active phase 

• second stage

  • full dilation of cervix to birth

  • pushing

• third stage

  • birth of the fetus until delivery of the placenta

• fourth stage

  • 2 hours post delivery of the placenta

stages and process of labour - latent and active phase

• latent phase

  • onset of regular contraction, progress in effacement of the cervix and little increas ein descent

    • up to 3-4 cm of dilation (depending on whether nullipara or multiparous)

• active phase

  • rapid dilation of the cervix and increased rate of descent of the presenting part

  • 4-10 cm of dilation (baby descends more rapidly)

Nursing care during the first stage of labour

• assessment

  • determination of true or prelabour

• psychosocial factors

  • history of sexual abuse

  • stress in labour

  • caring for trans and gender nonconforming persons

  • cultural factors

• physical examination

  • general systems assessment

  • vital signs

Assessment of uterine contraction

• assessment of uterine activity

  • measured by palpation, external , internal monitoring

• Intensity- strength of contraction

  • mild contraction - uterus can be indented with gentle pressure at the peak of the contraction - this feels like the tip of your nose (rigid)

  • moderate contraction - uterus can be indented with firm pressure at the peak of the contraction - this feels like the tip of chin

  • strong contraction - uterus feels firm and cannot be indented at the peak of the contraction - feels like forehead

• frequency

  • number of contractions in 10 min period averaged out over 30 min (more fre and shorter span between)

• duration

  • is the time between the onset to the end of one contraction (in seconds)

• resting tone (muscles relax before onset of the next wave

• the tension in the uterine muscles between contractions; relaxation of the uterus

vaginal examination: effacement and dilation

physical nursing care

• provides encouragement, feedback for relaxation, companionship

• helps to cope with contractions

• provides distractions

• encourages use of focusing techniques

• helps to concentrate on breathing techniques if required

• uses comfort measures

• assists patients into comfortable position

• informs patient of progress; explains procedures and routines

• gives praise

• offers fluids, ice chips as ordered

• support patient who has nausea and vomiting ; give oral care as needed

• reassure regarding signs of end of first stage

• panting respirations

• if patient begins to push prematurely

• giving praise ex. you’re doing great

positions for labour and birth

second stage of labour

• infant is born

  • vegins with full cervical dilation (10cm) and complete effacement

  • ends with baby birth

  • nulliparous patients

    • 3 or more hrs with no regional anaesthesia

    • 4+ hrs with regional anaesthesia

  • multiparous woman

    • 2 hrs with no regional anaesthesia

    • 3 hrs with regional anaesthesia

second stage of labour = two phases

• passive

  • delyayed pushing, labouring down, pasive descent

  • 0 to +2

• active (descent) - active pushing and urge to bear down 

  • ferguson reflex

  • 4-5 contractions every 10 mins lasting 90 seconds

  • rate of descent increases adn ferguson reflex is activated

  • fetal head becomes visible at introitus(crowning) and birth occurs

molding of fetal skull

• only in vaginal delivery 

• cardinal movements of the mechanisms of labour (happens in certain order

• engagement - head into pelvic inlet

• descent - fetal head is forced downwards on to the cervic

• flexion - fetus flexes the ehad so that the vertex is leading (chin to chest)

• internal rotation - of fetal head (usually to OA)

• extension - delivery of head - occiput face then chin

• restitution and external rotation - realigns head wtih back and shouldersS

types of episiotomies

nursing during the second stage of labour

• passive

  • help patient to rest in a position of comfort - encourage relaxation to conserve energy

  • promotes progress of fetal descent and onset of urge to bear down by encouraging position changes, pelvic rock , ambulation, and showering

• active pushing (descent) phase

  • help patient to change position adn encourage spontaneous bearing down efforts

  • help patient to relax and conserve neergy between contractions

  • provide comfort and pain relief measures as needed

  • provide comfort and pain relief as needed

  • cleanse perinium proptly if fecal material is expelled

  • coach pt to pant during contractions and to gently push between contractions when head is emerging

  • provide emotional support , encouragement, positive reinforcements

  • keep patient informed regarding process

  • offer mirror to watch birth or encourage patient to feel top of fetal head as they are pushing 

assessment and care of newborn

• care focused on assessing and stablizing the newborn

• agar score

• immediate skin to skin recommended for healthy term newborn after vaginal or c section 

  • positively affect parent-infant bonding

  • breast feeding duration

  • cardiorespiratory duration

  • cardiorespiratory stability

  • body temperature

• delayed cord clamping recommended until 1-3 mins after birth or until after the cord stops pulsating

• improves both the short and long term hematological status of the newborn

• physiological transfer of the blood to new born

• palcental transfusion of up to 30% of the total fetal placental blood volume

• stem cells, rbc, whole blood

• ask if aprtner would like to cute the cord is so instruct to cut it 2.5 cm above the clamp

third stage of labour

• placental separation and explusion

  • firmly contracting fundus

  • change in shape of uterus

  • sudden gush of dark blood form introitus

  • apparent lengthening of umbilical cord

  • vaginal fullness

• occurs 15 mins after birth of baby

  • if third stage is not completed within 30 mins of

  • placenta considered retained and interventions to ahsten its separation and explusion are initiated

third stage of labour - passive and active management

• passive management (expectant)

  • invovles patiently watching for signs that the placenta has separated from the uterine wall spontaneously and monitoring for spontaneous expulsion

  • no oxytocic (uteronic) medications are given

  • Separation and expulsion is facilitated by gravity or nipple stimulation promotes the release of endogenous oxytocin

• active management

  • administration of an oxytocic medication after the birth of the anterior shoulder of the fetus

  • recommend active management of the third stage of labour

    • decreases the rate of postpartum hemorrhage cause by uterine atony

  • gentle and control cord traction following uterine contraction and seperation of the placenta

examination of placenta

• ensure that no portion remains in the uterine cavity (ex. no fragments of the placenta or membranes are retained

• contains about 15-20 lobes

• vessels (2 arteries and 1 vein)

• membranes should be complete with no holes 

fourth stage of labour

• begins with the expulsion of the palcenta and lasts until the patient is stable within the first 2 hrs

  • crucial time for the patient and newborn to acquaint with each other and family memebers

• nursing care include assessment - vital signs, uterus , bladder, bleeding, perineum

• vital signs

  • first hour every 15 mins

  • if all parameters are stabalized within the normal range repeat once every second hour

uterine assessment AFTER BIRTH - FUNDUS

• firm with uterus located midline

• fundus not firm = massage it gently to contract

  • place hands appropriately massage gently only until firm 

• observe perineum for amount and size of expelled clots

• expel clots while keeping hands placed over the uterus

  • with the upper hands, firmly apply pressure downward toward the vagina

  • observe perineum for amounts and size of expelled clots

• accompanied by discomfort advise pt to take deep breaths throughout

bladder - after birth 

• assess distension by noting location and firmness of uterine fundus

  • suprapubic rounded bulge that is dull to percussion and fluctuates like water filled balloon

• distended bladder is accompanied by a boggy uterus, located above the umbilicus and deviated to the patient right side

• assist patient to avoid spontaneously and measure urine voided - catheter as necessary

• reassess after voiding or catherization to make sure that the bladder is not palpable and the fundus is firm in the midline

managing pain during labour and birth

• visceral pain - distension of the lower uterine segment, stretching of cervical tissues as it effaces and dilates, pressuer and traction on adjacet structures (ex. fallopian tubes, ovaries, ligaments) and nerves, and uterine ischemia. located over lwoer portion of abdomen

• referred pain - originates in uterus, radiates to abdominal wall, lumbosacral area of the back, iliac creasts, gluteal area, down thighs

• somatic pain - intense , shapr, burning and well localized

  • second stage of labour pain

  • distension of and traction on peritoneum and uterocervical supports during contractions

  • pressure against the bladder and rectum

  • stretching and distension of perineal tissues and the pelvic floor to allow passage of the fetus

  • laceration of soft  (ex. cervix)

responses to pain

• perception of pain

• pain threshold is remarkably similar in all persons, regardless of gender, social, ethnic or culturla differences

  • pain tolerance

• expression of pain

  • increasing anxiety, writhing, crying, groaning, gesturing (hand clenching, wriging), excessive muscular excitability

• factors influencing pain resp

  • physiological factors

  • culture

  • anxiety and fear

  • previous expereince

  • gat control theory of pain

  • supportive

  • environment

  • child birth preparation methods

  • expereince of trauma

non pharmacological pain management

• comfort measures

  • relaxation

  • imagery and visualization

  • music

  • touch and massage

  • breathing techniques

  • effleurage and counter pressure (long stroking mvoements) and counter pressure

  • hydrotherapy - water birth

  • laughing has (nitric oxide)

• transcutaneous electrical nerve stimulation (TENS)

• acupressure and acupuncture

• application of heat and cold

• hypnosis

• biofeedback

• aromatherapy

• intradermal sterile water block

• maternal position and movement

pharmacologicla management

• first stage

  • systemic analgesia

    • opioid agonist analgesics

    • opioid agonist-antagonist analgesics

      • Opioids decrease the heart rate, RR, BP of labouring pt which affects fetal oxygenation

      • monitoring vital signs, FHR pattern before and after administration of opioids critical

  • epidural (block) analgesia

    • combined spinal- epidural (CSE) analgesia

    • nitrous oxide (laughing gas)

    • pudendal block

potential side effects spinal and epidural anaesthesia

• hypotension 

  • 20%drop from preblock baseline level ro less than 100 mmhg systolic

  • fetal bradycardia

  • absent or minimal fetal HR variability

  • imparied placental perfusion

  • infeffective breathing pattern may occur during

• interventions

  • turn pt to lateral position or palce pillow wedge under one hip to displace uterus off the ascending vena cava and descending aorta.

  • Maintain intravenous (IV) infusion at rate specified or increase administration to provide fluid bolus per hospital protocol.

  • Administer oxygen by nonrebreather face mask at 8 to 10 L/min if signs of hypoxia or hypovolemia in labouring patient.

  • Elevate labouring patient’s legs.

  • Notify the primary health care provider and anaesthesiologist.

  • Administer IV vasopressor (e.g., ephedrine 5 to 10 mg or phenylephrine 50 to 100 mcg) as per primary health care provider’s order if previous measures are ineffective.

  • Remain with the patient; continue to monitor maternal blood pressure and FHR every 5 minutes until conditio

  • Local anaesthetic toxicity

  • Lightheadedness

  • Dizziness

  • Tinnitus (ringing in the ears)

  • Metallic taste

  • Numbness of the tongue and mouth

  • Bizarre behaviour

  • Slurred speech

  • Convulsions Loss of consciousness

  • High or total spinal anaesthesia

  • Fever Urinary retention Pruritus (itching)

  • Limited movement

  • Longer second-stage labour

  • Increased use of oxytocin

  • Increased likelihood of forceps- or vacuum-assisted birth

  • Postdural puncture headache