labour and delivery

what is the process of labour?

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

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

when does labour begin

• 37th and 42nd week of gestation

what happens before labour begins?

• increase braxon hicks contraction

• cervical ripening (flexible and ready for dilation)

• hormones released

• uterine muscles becomes more excitability

what hormones are released before labour begins

• oestrogen, relaxin and prostaglandin

  • loosen and break down in connective tissue in cervix

• relaxin makes pelvic joints and liagments more flexible

• prostaglandin helps ripen the cervix

what are signs that labour is coming

• lightening or dropping

  • baby moves lower in pelvis

• increase vaginal discharge ; bloody show

  • as cervix softens, small blood vessels break

• backache

  • trouble breathing

• stronger braxon hicks contractions

• weight loss of 0.5 to 1.5kg

• surge of energy aka nesting

  • sudden burst of energy

• flu like symptoms

• cervical ripening

• possible rupture of membrane

  • water membrane; either voluntary or spontaneous

what do you see in true labour

• contractions 

  • increase in intensity

  • increase in duration

  • discomfort begins in back, radiates around abdomen

  • become progressively closer together

  • do not disappear with walking

• cervix

  • begins to efface and dilate

• show

  • may/not be present

what do you see in false labour

• contractions

  • do not increase in intensity

  • do not increase in duration

  • discomfort usually in abdomen

  • do not become progressively closer

  • may disappear while walking

• cervix

  • no cervical change 

• show

  • not present 

what are the 5 p’s of labour

• power (contractions)

• passageway (birth canal)

• passenger (fetus and placenta)

• position of the mother

• psychological response 

what is powers ?

• primary powers 

• secondary powers

what is primary powers

• primary powers 

  • uterine contractions

    • frequency, durations, intensity

  • effacement

    • thinning of cervix

  • dilation

  • ferguson reflex

    • more oxytocin to release for stronger contractions

what is secondary powers

• secondary powers

  • bearing-down efforts

    • how mother pushes

how should you teach a mother to push?

• when they have a contraction, breathe in like your smelling flour and hold and then push like your going to poop 

• make sure to relax during relaxation(no contractions) to reduce exhuastion

what is passenger consist of?

• fetal presentation  

• size of fetal head 

• fetal lie 

• fetal attitude 

• fetal postion 

  • station

  • engagement

what are the types of fetal presentation

• fetal presentation 

  • cephalic/vertex

    • head as presenting part, down, ideal 

  • breech 

    • buttocks as presenting part 

  • shoulder/transverse

    • shoulder as presenting part 

what fetal presentation is high risk

• breech

• shoulder/transverse

vertex presentation

• occiput typically is anterior and is optimal position to negotitate the pelvic curve by extending the head

  • ROA; right occiput anterior- back of head or 

  • LOA; left occiput anterior

what is frank breech

• lie; longitudal or vertical

• presentation; breech (incomplete)

• presenting  part; sacrum 

• attitude; flexion, except from legs at knees

what is single footling breech

• lie; longitudal or vertical

• presentation; breech (incomplete)

• presenting part; sacrum 

• attitude; flexion, except for one leg extended at hip and knee

what is complete breech

• lie; longitudinal or vertical

• presentation; breech (sacrum and feet presenting)

• presenting part; sacrum (with feet)

• attitude; general flexion 

what is shoulder presentation

• lie; transverse or horizontal

• presentation; shoulder

• presenting part; scapula 

• attitude; flexion

what does breech presentation need

• special management

  • c-section

what is fetal lie

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

what are the types of fetal lies

• longitudunal

• transverse

• oblique

what is longtidual lie

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

what is transverse lie

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

what is oblique fetal llie

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

what is fetal attitude

• relationship of fetal head to its spine 

what is part of the fetal attitude

• complete flexion 

• moderate flexion

• deflection or extension 

what is complete flexion

• when chin of fetus is flexed and touches sternum 

• chip tucked in

what is moderate flexion

• military postion, chin is not touching chest but in an alert postion

• chin not fully tucked out

what is deflection or extension

• back in arched and head is extended

• head titled back

what is fetal station

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

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

• measured in cm 

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

what does O station refer to

• refers to fetus head at the level of ischial spines

  • presenting parts higher than spines; negative 

  • below spine ; postive sign 

passageways, the structure baby moves through

• four basic types of pelves 

  • gynecoid

    • classic female type 

  • android

    • resembling male pelvis 

    • heart shape

  • anthropoid

    • resembling pelvis of anthropoid apes

    • oval

  • platypelloid

    • flat pelvis 

  • soft tissues of cervic

  • pelvic floor

  • vagina

  • intronitus

    • external opening to vagina

gyneocoid

• slightly ovoid or transversely rounded

• roung

• depth; moderate 

• side walls; straight 

• ischial spine; blunt, somewhat widely seperated

• sacrum; deep, curved

• subpubic arch; wide

• usual mode of birth; vaginal; spontaneous, occiptoanterior postion

andrioid

• heart shaped, angulated

• depth; deep 

• side walls; convergent 

• ischial spine; prominent, narrow interspinous diameter 

• sacrum; slightly curved, terminal portion often beaked

• subpubic arch; narrow

• usual mode of birth; caesarsan, vaginal- difficult with forceps 

anthropoid

• oval, wider anteroposteriorly

• depth; deep

• side walls; straight

• ischial spines; prominent, often with narrow interspinous diameter

• sacrum; slightly curved

• subpubic arch; narrow

• usual mode of birth; vaginal- forceps/spontaneous, occipitoposterior or occipitoanterior position 

platylpelloid

• flattened anteroposteriorly, wide transversely

• depth; shallow

• side walls;straight

• ischial spines; blunt, widely seperated

• sacrum; slightly curved

• subpubic arch; wide

• vaginal/spontaneous

position

• postion affects woman’s anatomical and physiological adaptions to labour 

• frequent changes in postion 

• labour woman should find positions comfortable for her 

• gravity promotes devent of fetus

why is frequent changes in postions beneficial

• relieves fatigue

• increase comfort

• improves circulation

what are some postions that can help

• walking

• sitting/leaning

• tailor sitting

• semirecumbent

• hands and knees

• standing

• squatting

• kneeling and leaning forward with support

• lithotomy

• lateral recumbent

• use gravity to help fetal downwards

psychological response of a pt?

• amount sedation needed for pt. 

• pt. very anxious

• emotional factors related to pt. 

• past experiences with healthcare

• impact of SDOH

how might SDOH affect person’s psychological response to labour?

• racism 

• culture and ethnicity 

• access to health 

how many stages of labour is there

• 4

what is the first stage

• onset of contractions to full dilation of cervix

what two phases are in the first stage

• latent phase

• active phase

what happens in the latent phase

• onset of regulation contractions

• process in effacement of cervix and little increase in descent

• up to 3-4 cm of dilation ; depends on whether they nuliparaous or multiparous

what happens in the active phase

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

  • 4-10 cm of dilation

nursing care during first stage of labour

• assessment 

• psychosocial factors

• physical examination 

what is part of assessment

• determine if its true or pre-labour

what is part of psychosocial factors

• history of sexual abuse

• stress in labour 

• previous obsteric history/birthing history 

• caring for trans and gender-conforming persons 

• cultural factors

• SDOH?

what is part of physical examination

• general system assessment

• vital signs 

assessment of uterine contraction/fetal HR

• assess uterine activity

• intensity; strength of contractions 

  • mild

  • moderate

  • strong

• frequency 

• duration 

• resting tone 

• FHR

how to assess uterine activity

• measured by palpation, external, internal monitoring 

intensity; what is a mild contraction

• uterus can be indented with gentle pressure at the peak of contraction 

  • feels like pressing the tip of ur nose

intesity; what is a moderate contraction

• uterus can be indented with firm pressure at the peak of contraction 

  • feels like pressing on the tip of your chin 

intensity; what is a strong contraction?

• uterus feels firm and cannot be indented at the peak of contraction 

  • feels like pressing on your forehead

what is frequency?

• the number of contractions in a 10-min period averaged out over 30 mins

• shorter frequency +stronger = delivery coming soon

what is duration?

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

what is resting tone?

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

what is included in physcial nursing care

• encourage, feedback for relaxation, companionship 

• help cope with contractions

• provide distractions 

• encourage use of focusing techniques

• helps to concentrate on breathing techniques if required 

• comfort measures

• assist patient into comfortable postion 

• inform pt. of progress; explains procedures and routines 

• gives praise 

• offers fluid; ice chips as ordered 

• supports patients who had n/v, give oral care as needed

• reassure regarding signs of first stage 

  • panting resp

  • if pt. begins to push prematurely.

vaginal examination; effacement and dilation

• 1cm = 1 finger

• measured in cm, max is 10cm = fully dilated

second stage of labour?

• infants born 

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

  • ends with baby birth

how long does it take for second stage of labour for nulliparous patients

• 3 or more hours with no regional anaesthesia

• 4 or more hours with regional anasthesia 

how long does it take for second stage of labour for mulitparous patients

• 2 hours with no regional anaesthesia

• 3 hours with regional anaesthesia

what are the 2 phases of second stage of labour

• passive

• active

what is passive

• delayed pushing, labouring down, passive descent

• 0 to +2

what is active (descent)?

• active pushing and urge to bear down

• ferguson reflex

• 4 to 5 contractions every 10 mins lasting 90 seconds

• fetal head +2 to +4

• rate of descent increases and ferguson reflex is activated

• fetal head becomes visible at introitus - CROWNING and birth will occur

what is crowning

• occurs when widest part of head the biparietal diameter) distends the vulva

molding of fetal skull?

• molding is good because it allows the bones to overlap 

• ONLY happens with vaginal birth

what are the cardinal movements of the mechanisms of labour

• engagement 

• descent 

• flexion

• internal rotation

• extension

• restitution and external rotation

what is engagement

• head into pelvic inlet

what is descent

• fetal head is forced downwards to cervix

what is flexion

• fetus flexes the head so that the vertex is leading 

• chin to chest

internal rotation?

• of the fetal head, usually to OA 

• to line up with pelvis

extension?

delivery of head, occiput, face, then chin

restitution and external rotation?

• realigns head with back and shoulders 

• so the rest of the body can come out 

what is an epistiotomies

• small cuts made sometimes to make easier 

• epistomy→ if you see ooze and tears→consent must be signed

what are the two types of episiotomies

• mediolateral

• median (or midline)

mediolateral

• more painful

• heals slower

median or midline

• heals faster

• towards anus

• might tear rectum

nursing during passive phase in second stage?

• help pt. to rest in position of comfort, encourage relaxation and conserve energy

• help the baby descend down by encouraging mother to change positions, pelvic rock, walking, showering

nursing during active pushing phase in second stage labour

• help pt. change positions and encourage spontaneous bearing-down efforts, pushing during labour 

• help pt. relax conserve energy between contractions

• provide comfort and pain relief as needed

nursing during second stage of labour

• comfort and pain relief measures

• clean perineum right away if stool released

• pant during contractions, and gently push between contractions when crowning occurs

• provide emotional support, encourgae, postive reinforcement 

• keep pt. informed regarding progress

• calm and quiet environment 

• have a mirror for them so they can watch birth, encourage 

what is the main focus of care right after birth

• foucs on assessing stablizing nrwborn

• APGAR score

why is immediate skin-to-skin contact after birth needed

• postivelt affect parent-infant bonding

• breastfeed duration 

• cardiorespiratory stability

• body temp

why is delayed cord clamping recommended

• improves both short and longterm hematological status of newborn

• physiological transfer of. blood to newborn

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

how long should you wait until clamping

• 1 to 3 mins after birth or until cord stops pulsating

where do u cut the cord?

• 2.5 cm above clamp

what happens during the third stage of labour after baby is born?

• placenta usually comes out within 15 mintues

what are signs that placenta is seperating?

• uterus feels firm and smaller

• shape of uterus changes

• sudden gush of dark blood from vagina 

• umbilical cord looks longer

• mother feels fullness or pressure on vagina

what happens if placenta does not come out within 30 mins of birth

• called a retained placenta 

• HCP take steps to remove it 

  • light traction that aligns with contractions

  • oxytocin given 

  • make sure entire placenta then comes out, no retained placenta

what are the two mangement phases called in third stage?

• passive management (expectant)

• active management

what does passive management include

• patiently watching for signs that placenta seperated from uterine wall spontaneously and monitoring for spontaneous expulsion

• no oxytocin (uterotonic) medications are given to speed things up 

• placenta comes out naturally 

  • gravity

  • nipple stimulation that help body release oxytocin and make uterus contract

what is done in active management

• given oxytocin after the birth of anterior shoulder (baby front shoulder)

• recommended to deliver placenta safety

  • reduce risk of heavy bleeding after birth (postpartum hemorrhage) caused by weak or soft uterus (uterine atony)

• use gentle pulling of umbilical cord after uterus contracts and seperation of placenta

how to examine the placenta

• check carefully to see nothing was left behind 

• ensure no portion remains in uterine cavity (no fragments of placenta or membranes are retained)

• contains 15-20 lobes 

• vessel (2 arteries and 1 vein)

• membranes should be complete with no holes

what happens during fourth stage of labour?

• starts after placenta is delivered, and lasts until mother is stable

  • usually 1-2 hours after birth

• important time for mother-baby bond and family interactions 

what are the nursing care assessments in fourth stage of labour?

• vital signs

• uterus (make sure its firm and contracted)

• bladder (make sure its not full)

• bleeding (amount and colour)

• perineum (check for swelling, tears or bleeding)

what do you do if the uterus feels soft and spongy 

• uterine massage to make sure its contracted 

vital signs monitoring?

• every 15 mins in the first hour 

• if all parameters are stabilized within normal range, repeat once every second hour