NOTE 5

REPRO NOTES 5

THEORIES OF LABOR ONSET 

              Labor usually begins when a fetus is sufficiently mature to cope with extra uterine life, yet not too large to cause mechanical difficulties with birth. The cause that converts the random, painless Braxton Hicks contractions into strong, coordinated, productive labor contraction is unknown. Some instances labor begins before the fetus will mature (preterm birth). Others, labor are delayed until the fetus and the placenta have both passed beyond the optimum point for birth (post term birth). Though the number of theories has been proposed to explain why labor begins, it is believed that labor is influenced by a combination of factors from the mother and fetus. These factors includes:

• Uterine muscles stretching (resulting in the prostaglandins release) 

• Pressure on cervix (stimulating neural release of oxytocin)

• Oxytoxin stimulation (working together with prostaglandins to initiate contractions)

• Change in ratio of estrogen and progesterone (increasing estrogen in relation to progesterone stimulates uterine contractions)

• Placental age (triggering contractions) 

• Rising fetal cortisol levels (reducing progesterone formation and increasing prostaglandins)

• Seasonal and time influences (Cagnacci et. al )

SIGNS OF LABOR  

1. PRELIMINARY SIGNS OF LABOR 

Lightening. The settling of the fetal head into the pelvic brim. Results of lightening are: increase in urinary frequency, relief of abdominal tightness and diaphragmatic pressure, shooting pains down the legs because of pressure on the sciatic nerve, increase in the amount of vaginal discharges. Lightening should not be confused with engagement, engagement occurs when the presenting part has descended into the pelvic inlet. 

Increased Activity Level. Due to increase in epinephrine secreted to prepare the body for the coming work ahead.

Braxton Hicks Contraction. Painless, irregular practice contractions.

Ripening of the Cervix. From Goodell’s sign, the cervix becomes “butter-soft”.

2. SIGNS OF TRUE LABOR 

   Uterine Contractions, the surest sign that labor has begun. Pain in uterine contractions results from: contraction of uterine muscles when in an ischemic state, pressure on nerve ganglia in the cervix and lower uterine segment, stretching of ligaments adjacent to the uterus and in the pelvic joints, and stretching and displacement of the tissues of the vulva and perineum. 

Show, Due to pressure of the descending presenting part of the fetus which causes rupture of minute capillaries in the mucous membrane of the cervix.  Blood mixes with mucus when operculum is released.  Show, therefore, is only a pinkish vaginal discharge.

Rupture of the Membrane, it is IMPORTANT to remember that once membranes (BOW) have ruptured: labor is inevitable- it will occur within 24 hours, the integrity of the uterus has been destroyed, umbilical cord compression and/or cord prolapse can occur. 

COMPONENTS OF LABOR 

I. Passage. It refers to the route the fetus must travel from the uterus through the cervix and the vagina to the external perineum. Such this organ are contained inside the pelvis the fetus must also pass through the pelvic, the fetus must also pass through the pelvic ring. For the fetus to pass through the pelvis, the pelvis must be adequate size. Two pelvic measurements are important to determine the adequacy of the pelvic size. These include the diagonal conjugate (the anterior-posterior diameter of the inlet) and the transverse diameter of the outlet. At the pelvic inlet the anteroposterior diameter is the narrowest diameter; at the outlet, the transverse diameter is the narrowest. 

II. Passenger.  The passenger is the fetus. The body part of the fetus that has the widest diameter is the head. Thus, this is the part least likely to be able to pass through the pelvic ring. Whether a fetal skull can pass depends on both its structures (bones, fontanelles, and suture lines) and its alignment with the pelvis. 

       Structure of the fetal skull. The cranium, the uppermost portion of the skull, is comprised of eight bones. The four superior bones – the frontal (actually two fused bones), the two parietal and the occipital –are the important bones in childbirth. The area over the frontal bone is referred to as the siniciput. The area over the occipital bone of the skull lies at the base of the cranium.  These bones are of little significance in childbirth because they are never presenting parts. The chin referred to as by its latin name, mentum, can be presenting part. 

The bones of the skull meet at suture lines. The sagittal suture, a membranous interspace, joins the two parietal bones of the skull. The coronal suture is the line of the junction of the frontal bones and the two parietal bones. The lambdoid suture is the line of the junction of the occipital bone and the two parietal bone. Suture lines are important in birth because they allow the cranial bones to move and overlap, thus molding and diminishing the size of the skull so it can pass through the birth canal more readily. 

Significant membrane-covered spaces called the fontanelle are found at the junction of the main suture lines. The anterior fontanelle (sometimes called as bregma) lies at the junction of the coronal and sagittal sutures. Its anteroposterior diameter measures approximately 3 to 4 cm; its transverse diameter, 2 cm to 3 cm.

The posterior fontanelle lies at the junction of the lambdoidal and sagittal sutures. Posterior fontanelles are triangular. It is smaller than the anterior fontanelle, measuring approximately 2 cm across its widest part. Fontanelle spaces compress during birth to aid in molding of the fetal head. The space between the fontanelle is what we call a vertex. 

               Diameter of the fetal Skull. The space of the fetal skull causes it to be wider in its anteroposterior diameter than its transverse diameter. The fetus must present the smaller diameter (transverse diameter) to the smaller diameter of the maternal pelvis. The diameter of the anteroposterior fetal skull depends on where the measurement is taken. The narrowest diameter (approx. 9.5 cm) is from the inferior aspect of the occiput to the center of the anterior fontanelle (the suboccipitobregmatic) diameter. The occipitofrontal diameter, measures from the bridge of the nose to the occipital prominence, approximately 12 cm. the occipitomental diameter, which is the widest anteroposterior diameter (approximately 13.5 cm), is measured from the chin to the posterior fontanelle. 

At the pelvic inlet, the fetus must present the narrowest diameter- the biparietal diameter, which is approximately 9.25 cm to the anteroposterior diameter of the pelvis, a space approximately 11 cm wide. At the outlet, this narrow diameter must be presented to the transverse diameter, space approximately 11 cm wide. If the anteroposterior diameter of the skull (a measurement wider than the biparietal diameter) is presented to the anteroposterior diameter of the inlet, engagement, or the settling of the fetal head into the pelvis, may not occur. If the anteroposterior diameter of the skull is presented to the transverse diameter of the outlet, arrest of progress may occur at a point. 

The anteroposterior diameter that will be presented to the birth canal is determined by the degree or flexion of the fetus head. In full flexion, the head flexes so sharply that the chin rest on the thorax and the smallest anteroposterior diameter, the suboccipitobregmatic will be presented to the birth canal. If the head is held in moderate flexion, the occipitofrontal diameter will be presented. 

Anteroposterior diameter of the fetal head must fit through the transverse diameter of the pelvic inlet, a space approximately 12.4 cm to 13.5 cm; and at the outlet, through the anteroposterior diameter of the pelvis, space of 9.5 cm will fit through a pelvis much more readily than if the diameter is 12.0 or 12.5 cm. 

         Molding. It is the change of the fetal skull produced by the force of uterine contractions pressing the vertex against the not –yet-dilated cervix. Molding is commonly seen in newborns. The overlapping of the sagittal suture line and generally the coronal suture line can be easily palpated in the newborn skull. 

III. FETAL PRESENTATION AND POSITION 

Attitude. This term is used to describe the degree of flexion the fetus assumes or the relation of the fetal parts to each other. A fetus in good attitude is in complete flexion: the spinal column is bowed forward, the head is flexed forward so much that the chin touches the sternum, the arm are flexed and folded on the chest, the thighs are flexed onto the abdomen and the calves of the legs are pressed against the posterior aspect of the thighs. This normal fetal position is advantageous for the birth. A fetus is in moderate flexion if the chin is not touching the chest but is in an alert or military position. The fetus in partial flexion presents the brow of the head to the birth canal. If a fetus is in poor flexion, the back is arched, the neck is extended, and the fetus is in complete extension, presenting the occipitomental diameter of the head the birth canal (face presentation). Such a position may occur if there is less than normal amniotic fluid present (oligohydrammios), which does not allow the fetus adequate movement. It may also reflect a neurologic abnormality that is causing spasticity. 

Engagement. It refers to the settling of the presenting part of the fetus far enough into the pelvis to be at the level of the ischial spines, a midpoint of the pelvis. In a primipara non-engagement of the head at the beginning of labor indicates a possible complication. In multiparas, engagement may or may not be present at the beginning of the labor. A presenting part that is not engaged is said to be floating. One that is descending but has not yet reached the iliac spines can be said to be dipping. The degree of engagement is assessed by vaginal and cervical examination. When the presenting part is at the level of the ischial spines, is at 0 station (synonymous with engagement). If the presenting part is above the spines, the distance is measured and described as minus station which range from 1 cm to 4 cm. if the presenting part is below the ischial spines, the distance is stated as plus stations (+ 1cm to + 4cm). At a + 3 cm or +4 cm station, the presenting part is at the perineum and can be seen if the vulva is separated (synonymous with crowning). 

Fetal lie. Lie is the relationship between the long (cephalocaudal) axis of the woman’s body, that is whether the fetus is lying in a horizontal (transverse) or a vertical (longitudinal) position. Approximately 99% of the fetuses assume a longitudinal lie. Longitudinal lies are further classified as cephalic, with the head as the first part to contact the cervix or breech with the breech, or buttocks, as the first portion to contact the cervix. 

TYPES OF FETAL POSITION 

POSITION. The relationship of the presenting part to a specific quadrant of the woman’s pelvis. For convenience, the maternal pelvis is divided into four quadrants according to the mothers right and left: right anterior, left anterior, right posterior, left posterior. Four parts of the fetus have been chosen as landmarks to describe the relationship of the presenting part to one of the pelvic quadrants. In a vertex presentation, the occiput is the chosen point; in a face presentation, it is the chin (memtum); in a breech presentation, it is the sacrum; in shoulder presentation, it is the scapula or the acromion process. 

Position is marked by an abbreviation of three letters. The middle letter denotes the fetal landmarks (O for occiput, M for mentum or chin, Sa for sacrum, and A for acromion process). The first letter defines whether the landmark is pointing to the mothers right (R) or left (L). The last letter defines whether the landmark points anteriorly (A), posteriorly (P), or transversely (T). 

When the occiput of the fetus points to the left anterior quadrant in a vertex position. 

Cephalic Presentation. It means that the head is the body part that first contact the cervix; it is the most frequent type of presentation – vertex, brow, face, and mentum. During labor, the area of the fetal skull that contacts the cervix often becomes edematous from the continued pressure against it. This edema is called a caput succedaneum. In the newborn infant, the point of presentation can be analyzed from the location of the caput. 

Breech presentation. It means either the buttocks or feet are the first body parts to contact the cervix. Is occur in approximately 3 % of births and are affected by fetal attitude. Breech presentations usually are difficult deliveries with the presenting point influencing the degree of difficulty. Three types of breech presentation – complete, frank, footling are possible. 

Shoulder Presentation. In a transverse lie, the fetus is lying horizontally in the pelvis so that its long axis is perpendicular to that of the mother. Presenting parts becomes one of the shoulders (acromion process), an iliac crest, a hand, or an elbow. Fewer than 1 % fetuses lie transversely. This may be caused by relaxed abdominal walls from grand multiparity that allows the uterus to be unsupported and fall forward. Another cause is pelvic contraction, in which the horizontal space is greater than the vertical space. Placenta previa (placenta is located low in the uterus, obscuring some of the vertical space) may also limit the fetus ability to turn, resulting in a transverse lie. If an infant is preterm and smaller than usual, an attempt to turn the fetus may be made. Most infants in a transverse lie must be delivered be a caesarean birth. 

IMPORTANCE OF DETERMINING FETAL PRESENTATION AND POSITION 

Four methods are used to determine fetal position, presentation and lie. These are combined abdominal inspection and palpation; vaginal examination; auscultation of fetal heart tones; and sonography. The vertex is the ideal presenting part because the skull bones are capable of molding so effectively to accommodate the cervix. The less effective labor, the longer it is, tiring the mother and reducing the excitement of the experience. If the fetus delivers vaginally after a complicated labor, there is an increased risk for perineal tears or cervical laceration, which may also increase her disability and possibly interfere with the woman’ future childbearing. When labor is threatening and unsatisfactory, it can interfere with the maternal child bonding. The presentation of the body part other than the vertex puts the fetus at risk. 

MECHANISM (CARDINAL MOVEMENTS) OF LABOR 

Passage of the fetus through the birth canal involves a number of the different position changes to keep the smallest diameter of the fetal head (cephalic presentation) always presenting to the smallest diameter of the birth canal. The position changes are termed the Cardinal movement of labor.  

Descent. Descent is the downward movement of the biparietal diameter of the fetal head to within the pelvic inlet. Full descent occurs when the fetal head extrudes beyond the dilated cervix and touches the posterior vaginal floor. The pressure of the fetus on the sacral nerves causes the mother to experience a pushing sensation. It occurs because of pressure on the fetus by the uterine fundus. Full descent may be aided by abdominal muscle contraction. 

Flexion. A descent occurs; pressure from the pelvic floor causes the fetal head to bend forward onto the chest. The smallest anteroposterior diameter (suboccitobregmatic diameter) is the one presented to the birth canal in the flexed position. Flexion is aided by abdominal muscle contraction during pushing. 

Internal Rotation. During descent, the head enters the pelvis with the fetal anteroposterior head diameter (suboccipitobregmatic, occipitomental, or occipitofrontal, depending on the amount of flexion) in a diagonal transverse position. The head flexes as it touches the pelvic floor. And the occiput rotates until it is superior or just below the symphysis pubis, bringing the head into the best diameter for the outlet of the pelvis (the anteroposterior diameter is now in the anteroposterior plane of the pelvis). This movement brings the shoulder, coming next, into the optimum position to enter the inlet or puts the widest diameter of the shoulders (transverse one) in line with the wide transverse diameter of the inlet. 

Extension. As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. Head must extend and the foremost parts of the head, the face and chin are born. 

External Rotation. Almost immediately after the head of the infant is born, the head rotates back to the diagonal or transverse position of the early part of labor. The after coming shoulders are thus brought into an anteroposterior position which is best for entering the outlet. The anterior shoulder is delivered first, assisted perhaps by downward flexion of the infants head.   

Expulsion. Once the shoulders are delivered, the rest of the baby is delivered easily and smoothly because of its smaller size. This is expulsion and is the end of the pelvic division of labor. 

IV. POWERS OF LABOR 

The powers of labor, supplied by the fundus of the uterus are implemented by the uterine contractions, a process that causes cervical dilation and then expulsion of the fetus from the uterus. After full dilation of the cervix, the primary power is supplemented by the use of the abdominal muscle. It is important for women to understand they should not bear down with their abdominal muscles until the cervix is fully dilated. Doing so will impede the primary force or could cause fetal and cervical damage. 

UTERINE CONTRACTION 

Origins. Labor contractions begin at a pacemaker points located in the myometrium near one of the uterotubal junctions. Each contraction begins at a point and then sweeps down over the uterus as a wave. After a short rest period, another contraction is initiated and the downward sweep begins again. 

In early labor, the uterotubal pacemaker may not be working in a synchronous manner. This makes contraction sometimes strong, sometimes weak, and irregular. In some women, contractions appear to originate in the lower uterine segment rather than in the fundus. These are reverse, ineffective contractions, and actually cause tightening rather than dilation of the cervix. Contractions are being initiated in a reverse pattern which is different to tell by palpation. It can be suspected if a woman tells you that she feels pain in her lower abdomen before the contraction is readily palpated at the fundus. It is truly revealed only when cervical dilation does not occur. Some women seem to have additional pacemaker sites in other than portion of the uterus.

Phases. A contraction consist of three phases: the increment, when the intensity of the contraction increases: the acme, when the contraction is at its strongest; and the decrement, when the intensity decreases. Between contractions the uterus relaxes. As labor progresses, the relaxation interval decrease from 10 minutes early in labor 2 to 3 minutes. The duration of contractions also changes, increasing from 20 to 30 seconds to a range of 60 to 90 seconds. 

In early labor, the uterotubal pacemaker may not be working in a synchronous manner. This makes contraction sometimes strong, sometimes weak, and irregular. In some women, contractions appear to originate in the lower uterine segment rather than in the fundus. These are reverse, ineffective contractions, and actually cause tightening rather than dilation of the cervix. Contractions that are being initiated in a reverse pattern is different to tell by palpation. It can be suspected if a woman tells you that she feels pain in her lower abdomen before the contraction is readily palpated at the fundus. It is truly revealed only when cervical dilation does not occur. Some women seem to have additional pacemaker sites in other than portion of the uterus.

Contour changes. As labor contractions progress and become regular and strong, the uterus gradually differentiates itself into two distinct functioning areas. The upper portion becomes thicker and active, preparing it to exert the strength necessary to expel the fetus when the expulsion phase of labor is reached. The lower segment becomes thin walled, supple, and passive so the fetus can be pushed out of the fetus easily. As these events occur, the boundary between the two portions becomes marked by a ridge on the inner uterine surface, the physiologic retraction ring. Elongations of the uterus exert pressure against the diaphragm and cause the often expressed sensation that a uterus is taking control of the woman’s body. Pathologic retraction ring or Bandl’s ring is a danger sign that signifies impending rupture of the lower uterine segment if the obstruction to labor is not relieved. 

CERVICAL CHANGES      

Effacement. Is a shortening and thinning of the cervical canal. Normally, this canal is approximately 1 to 2 cm long. With effacement, this canal virtually disappears. This occurs because of longitudinal traction from the contracting uterine fundus. 

In primiparas, the effacement is accomplished before dilation begins. Be sure to inform the woman about this. In multiparas, dilation may proceed before effacement is complete. Effacement must occur at the end of dilation. 

Dilation. It refers to the enlargement of the cervical canal from the opening few millimeters wide to one enlarge enough (approx. 10 cm) to permit passage of the fetus. Dilation occurs for two reasons. First, uterine contraction occurs gradually increase the diameter of the cervical canal lumen by pulling the cervix up over the presenting part of the fetus. Second, the fluid filled membranes press against the cervix. If the membranes are intact, they push ahead of the fetus and serve as an opening wedge. If they are ruptured, the presenting parts serve same function. 

As dilation begins, there is an increase in the amount of vaginal secretion (termed show), because the last of the operculum or the mucus plug in the cervix are dislodged and minute capillaries in the cervix rupture. 

V. PYCHE 

The fourth “P” or psyche refers to the psychological state feelings that women brings in to labor with them. For many women, this is a feeling of apprehension or fright. For almost everyone, it includes as sense of excitement or awe. Women who manage, best in labor typically are those who have a strong sense of self esteem and a meaningful support person. This allows women to feel in control of sensation and circumstances they have not experienced previously. 

STATION. It refers to the relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis.  In a normal pelvis the ischial spines mark the narrowest diameter through which the fetus must pass. These spines are not sharp protrusions that harm the fetus but rather blunted prominences at the mid-pelvis. The ischial spines are landmark have been designated as zero station. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. Station -5 is at the inlet, and station +4 is at the outlet. If the presenting part can be seen at the woman’s perineum, birth will occur momentarily. During labor the presenting part should move progressively from the negative stations to the mid-pelvis at zero station and into the positive stations. Failure of the presenting part to descend in the presence of strong contractions may be due to disproportion between the maternal pelvis and fetal presenting part or to a short and/or entangled umbilical cord. (Ladewig)   

Differentiation between True & False Labor  

STAGES OF LABOR 

I. FIRST STAGE OF LABOR 

           Begins with true labor pains and ends with complete dilatation of the cervix, Power/Forces:  Involuntary Uterine Contractions, Primi = 12 ½ hours, Multis = 7 hours & 20 minutes. In these stage of labor, there are three phases namely;

 Latent, early time in labor, cervix dilates 3 – 4 cm. only, contractions occur regularly 5 – 10 minutes apart and period averages ranges from  6 to 8 hours.  A woman who enters labor with a nonripe cervix will have a longer than usual latent phase. The latent phase may be prolonged if a cephalopelvic disproportion (disproportion between the fetal head and the pelvis) 

In a woman who is psychologically prepared for labor and who does not tense at each tightening sensation in her abdomen, latent phase contraction cause only minimal discomfort. The woman can continue to walk about and make preparations for birth, such as doing minute packing for her stay at the hospital or birthing center, preparing for older children for her departure and upcoming birth, or giving instructions to the person who will take care of   while she is a way. 

 Active / Accelerated, cervical dilatation reaches 4- 8cm, rapid increase in duration, frequency and intensity of contractions (40-60 sec.) 2 to 5 minutes apart. Fetal descent is progressive. Contractions are stronger. This phase last approximately vaginal secretion.

Transition Phase, cervical dilatation from 8-10 cm. contractions are strongest, longest (50-90 sec) lasting for 2 minutes and 1-3 minutes apart. Nursing Care: involves hospital admission and general Physical Examination (Effacement & dilatation, Station) Station, relationship of the fetal presenting part to the level of ischial spine, station 0- at the level of the ischial spines. ( -1  - above the level of the ischial spines;+1 – below the level of ischial spines; +3, +4 – synonymous with crowning (encirclement of the largest diameter of the fetal head by the vulvar ring)  

General Physical Examination: VS (esp. BP); Note:  BP should not be taken during contraction because it tends to increase, BP reading should be taken every 30minutes during ACTIVE LABOR & monitor FHR (120 –160/min); Note: Should not be taken during contraction –it tends to decrease (compression of the fetal head when the uterus contracts stimulates the VAGAL REFLEX- Bradycardia); Note:  FHR should be taken: Latent – every hour, Active- every 30 minutes, Transition- every 15 minutes. 

When the woman enters the early active phase, her anxiety tends to increase as she sense the fairly constant intensifications of contraction and pain. She begins to fear a loss of control and may use coping mechanism to maintain control. Some woman exhibits decreased ability to cope and a sense of helplessness. Woman who have support person available, particularly the baby’s father, experience greater satisfaction and less anxiety throughout the birth process than those without support. S

When the woman enters the transition phase she may demonstrate significant anxiety. she become acutely aware of the increasing force and intensity of the contractions. She may become restless, frequently changing position. She may feel being left alone, and it is crucial that the nurse available as backup and relief for the support person. 

The woman in this phase is anxious to get it over with. She may be amnesic and sleep between her now frequent contractions. As dilation approaches 10 cm there may be increased rectal pressure, an uncontrollable desire to bear down, increased amount of bloody show, and ruptures of membranes.   

The peak of the transition phase can be identifies by a slight slowing in the rate of cervical dilation when 9 cm is reached termed deceleration. As the woman reaches the end of this stage at 10 cm of dilation, a new sensation begins to occur. 

Signs of Fetal Distress:

 Bradycardia, less than 100/min: Tachycardia, more than 180/min; Meconium, stained amniotic fluid: Hyperactivity of the Fetus. Encourage taking a bath if BOW is not yet ruptured and if contractions are tolerable; encouraging ambulation: NPO: Enema, Note: during enema, clamp rectal tube during contraction, check FHR after enema administration. Contraindications of Enema are: vaginal bleeding, premature labor, abnormal fetal presentation/position, ruptured membranes, crowning. Encourage to void every  2-3 hours 

• Perineal prep 

• Perineal shaving

• Encourage Sim’s position

• Advise not to bear down unnecessarily

II. SECOND STAGE OF LABOR 

           Second stage of labor is the period of dilation and cervical effacement to birth of the infant.  Contraction change from the characteristics crescendo-decrescendo pattern to an overwhelming, uncontrollable urge to push or bear down with contraction as if she where moving her bowels. 

Begins with complete dilatation of the cervix and ends with delivery of the baby.

Signs:

• (+) urge to push and to defecate from pressure of the presenting part on the rectum.

• Increase bloody show and rectal pressure

• Primi = 80 minutes

• Multi = 30 minutes

Nursing Care:

• Place on lithotomy position

• (+) crowning

• instruct mother not to push

• Assist in episiotomy

EPISIOTOMY

• Incision made in the perineum

PURPOSES:

1.  To prevent laceration 

2. Prevent prolonged and severe stretching of muscles

      supporting bladder or rectum

3. Reduce duration of second stage

Types:

1. Median - from middle portion of the lower vaginal border 

    directed  towards the anus.

2. Medio-lateral -beginning at the midline but directed 

    laterally away from the anus.

Nursing Care:

• Apply the modified RITGEN’S MANEUVER.

• To support perineum, to prevent laceration

• To favor flexion

• Ease the head out and immediately wipe the nose

• Insert 2 fingers into the vagina to feel for the presence of a cord loop around the neck (nuchal cord)

• Take note of the exact time of the baby’s delivery

• Wrap the baby in a sterile drapes to keep him warm

• Place baby on the mother’s abdomen

• Cut the cord
  Note:  Cutting of the cord is postponed until the pulsation has stopped

• ( 50-100ml of blood is flowing from the placenta to the baby.)

• Show the baby to the mother; inform her of the gender & time of delivery.

Third Stage

Placental  Separation 

It begins with the birth of the infant to the birth of the placenta. Two separate phases are involved, 1) placental separation, 2) placental expulsion. 

Placental separation occurs automatically as the uterus resumes contractions down on an almost empty interior, there is such as disproportion between the placenta and the contracting wall of the uterus that folding and separation of the placenta occur. Active bleeding on the maternal surface of the placenta begins with separation: the bleeding helps to separate the placenta still further by pushing it away from its attachment site. As separation is completed, the placenta sinks to the lower uterine segment or the upper vagina. 

The following signs indicate that the placenta has loosened and is ready to deliver: 

• Lengthening of umbilical cord 

• Sudden gush of vaginal blood 

• Change in the shape of the uterus 

If the placenta separates first as its center and last at its edges, it tends to fold on itself like an umbrella and will present at the vaginal opening with the fetal surface evident.  

Types:

•  SCHULTZ Mechanism

  • Placenta separates first at its center and last at its edge

  • Fetal surface comes first.

  •  80% of placenta separate in this manner.

  • Schultze’s placenta, shiny and glistening from the fetal membranes 

• DUNCAN Mechanism

  • Placenta separates first at its edge and slides along the uterine surface.

  • Maternal surface is the presenting part

  • Raw, red, beefy, irregular, & dirty

  • 20% 

Bleeding occurs as part of the normal consequence of placental separation, before the uterus contracts sufficiently to seal maternal sinuses. The normal blood loss is 300- 500 mL. 

Nursing Care:

• Watch for signs & symptoms of placental separation.

Separation:

• Uterus becoming round, firm, rising high to the level of umbilicus (CALKIN’S SIGN)

• Sudden gush of blood

• Lengthening of the cord

• Note:

           Do not hurry the expulsion of the placenta. 

• Tract the cord slowly, winding it around the clamp until placenta spontaneously  comes out, rotating slowly so that no membranes are left (BRANDT-ANDREW’S  MANEUVER)

• Take note of the time of placental delivery.

• Check for completeness of cotyledons.

• Palpate the uterus to determine degree of contraction.

• Administration of methergine.

  Note: Not to be given before placental delivery. 

• Inspect perineum for lacerations.

Categories of Lacerations:

• 1st degree – vaginal mucous membrane and skin

•  2nd degree – (+) muscles

•  3rd degree –(+) external sphincter of the rectum

•  4th degree – (+) mucous membrane of the rectum

• Assist the doctor in doing episiorrhapy (repair of episiotomy or lacerations)

•  Note:

      In vaginal episiorrhapy, packing is done to maintain pressure on the suture line to prevent further bleeding.

• Packing has to be removed after 24 - 48 hrs

• Make mother comfortable by doing perineal care & applying clean sanitary napkin snugly to prevent it from moving forward from the anus to the vagina. 

• Soiled napkins should be removed  from front to back

• Position  flat on bed with pillows to prevent dizziness due to decrease in intra abdominal pressure 

• May complain of chills due to rapid decrease of pressure, fatigue or cold temperature. Provide additional blanket to keep her warm. 

• Give initial nourishment e.g. milk

•  Allow patient to sleep in order to regain lost of energy. 

Placental Expulsion 

The placenta is delivered either by the natural bearing down effort of the mother or by gentle pressure on the contracted uterine fundus by the physician or nurse midwives (Credes Maneuver). Pressure must never be applied to the uterus in a contracted state or the uterus may evert and hemorrhage. This is a grave complication of birth, because the maternal blood sinuses are open and gross hemorrhage occurs.

If the placenta does not deliver spontaneously, it can remove manually. With deliver of the placenta, the third stage of labor is over. 

Fourth Stage - first 1 - 2 hours after delivery is the MOST CRITICAL stage:  UNSTABLE VITAL SIGNS

Management:

Assessment

a.  Fundus

• Should be checked every 15 minutes for 1 hour then every 30 minutes for the next 4 hours.

• Should be firm in the midline

• Should be a little above the umbilicus during the first 2   hours post partum.  

     b. Lochia

• Should be moderate in amount

• Perineal pad can be completely saturated after 30 minutes.

    c. Bladder

• Full bladder pushes the fundus to the right.

• Dark-red bleeding with some clots.

d. Perineum

• Normally tender, discolored & edematous

• Should be clean with intact sutures.

   e. BP & PR

• Slightly high due to excitement & effort of delivery, but normalize within one hour

Unang Yakap

• -mother & baby are together while in the hospital

• provides opportunity to develop a positive relationship between parents & newborn.

• eye-to-eye contact is immediately established releasing maternal caretaking responses.

PHYSICAL PREPARATIONS FOR DELIVERY 

POSITIONING FOR BIRTH. At one time lithotomy position was major position for birth. Alternative birth position include the lateral or Sim’s position, dorsal recumbent, semisitting and squatting. It is important that both legs in the stirrup are secured snugly but not too tightly that is causes constriction. Pushing becomes less effective in lithotomy position; top portion of the table can be raised to a 30 – 60 degree angle so the woman can continue to push. Lying for longer than 1 hour in a lithotomy position lead to intensive pelvic congestion. If the woman is in the lithotomy position, table lower half is folded downward (‘broken’) so the physician can be in close proximity to the birth outlet. Make sure there is always someone at the foot of the broken delivery room table. 

PERINEAL CLEANING. Perineum is cleaned with a warmed antiseptic (cold causes cramping) and then rinsed with a designated solution before birth by the physician, nurse-midwives or nurse according to agency policy. Cleaning should be done from the vagina outward (microorganism are moved away from the vagina), using a clean compress for each stroke. A wide area including vulva, upper inner thighs, pubis and anus are included. After cleaning sterile drapes are placed around the perineum. Pressure of the fetal head may cause fecal material to be expelled from the rectum. This is sponged away as it occurs to prevent contamination of the birth canal.  

POSTPARTUM CARE 

• Reproductive Changes

   Pain in perineal region may be relieved by:

• Sim’s Position – minimizes strain on the suture line

• Perineal heat lamp or warm sitz baths twice a day

• Application of topical analgesics or administration of mild oral analgesics, as ordered

• Sexual Activity

  • Maybe resumed by the third or fourth week postpartum if bleeding has stopped and episiorrhaphy has healed.  

  • Decreased physiologic reactions to sexual stimulation are expected for the first 3 months postpartum because of hormonal changes and emotional factors.

• Menstruation

  • If not breastfeeding, return of menstrual flow is expected within 8 weeks after delivery.  

  • If breastfeeding, menstrual return is expected in 3 – 4 months;  in some women, no menstruation occurs during the entire lactation period.

• Postpartum Check up

  • Should be done after the 6th week postpartum to assess involution.

• Urinary Changes

  • There is marked diuresis within 12 hours postpartum to eliminate excess tissue fluid accumulation 

  • Some newly-delivered mothers may complain of frequent urination in small amounts

• Explain that it is due to urinary retention with overflow.  

• Difficulty voiding 

1. decreased abdominal pressure or trauma to the trigone of the bladder. 

2. Voiding maybe initiated by pouring warm and cold water alternately over the vulva

3. encouraging patient to go to the comfort room and let her listen to the sound of running water. 

4. If these measures fail, catheterization, done gently and aseptically, is the last resort on doctor’s order.

•  Gastrointestinal Changes

• Delayed bowel evacuation postpartally due to:

  • Decreased muscle tone

  • Lack of food + enema during labor

  • Dehydration

  • Fear of pain from perineal tenderness due to episiotomy, lacerations, or hemorrhoids.

•  Vital Signs

A. Temperature may increase because of the dehydrating effects of labor.

• Bradycardia is common for 6 – 8 days postpartum

• No change in respiratory rate.

2. Weight

   1. There is an immediate weight loss of 10 – 12 lbs. Representing the weights of the fetus, placenta, amniotic fluid and blood

2.  Further weight loss will occur during the next days due to diaphoresis.

PHASES OF PUERPERIUM 

1. Taking-in Phase

Talking in phase is a time of reflection for a woman. During this period, she is largely passive. She prefers having a nurse minister to her, to get her a bath towel or a clean nightgown, and make decision for her. This dependence is due partly to her physical discomfort from possible perineal stitches, afterpains or hemorrhoids: partly to her uncertainty in caring for a newborn: and partly from extreme exhaustion that allows childbirth.   

2. Taking-hold Phase

Begins to initiate action and make decisions.  Postpartum Blues (an overwhelming feeling of sadness that cannot be accounted for) may be observed.  Could be due to hormonal changes, fatigue or feelings of inadequacy in taking care of a new baby.

Management:

Explain that it is normal and that crying is therapeutic.

C.  Letting-Go Phase

The woman redefines her new role. She gives up the fantasized image of her child and accepts the real one.  Give up his old role of being childless or the mother of only one or two.