Normal Labor and Delivery

Normal Labor and Delivery

Factors That May Trigger Labor

  • Maternal Factors

    • Uterine muscle adjustments

    • Increased pressure on nerve plexus

    • Rise in estrogen and oxytocin levels

    • Decrease in progesterone levels

  • Fetal Factors

    • Deterioration of the placenta

    • Synthesis of prostaglandins

    • Increase in fetal cortisol levels

Labor Process

  • Premonitory Signs of Labor

    • Lightening: The descent of the fetus into the true pelvis.

    • Braxton-Hicks Contractions: Irregular uterine contractions (UC's) that do not result in cervical changes, associated with false labor.

    • Surge in Energy: Some women may experience a burst of energy or feel a need to organize (often referred to as "nesting").

    • Gastrointestinal Changes: 1-3 pound weight loss, diarrhea, nausea, or indigestion preceding labor.

    • Backache: Low backache and discomfort in the sacroiliac region, related to the relaxation of pelvic joints.

    • Bloody Show: Brownish or blood-tinged discharge from cervical mucus.

    • Spontaneous Rupture of Membranes: Typically occurs during the active phase of labor.

    • Cervical Changes: Cervix softens (ripens) and may become partially effaced and begin to dilate.

True Labor

  • True labor is indicated by a change in cervix.

Vaginal Exam

  • Cervical Dilation: Measurement of cervical opening by sweeping fingers across the cervical rim.

  • Cervical Effacement: Measurement from 2 cm to paper-thin using fingertip palpation, expressed in percentage.

    • 50% effaced equals a reduction of 1 cm.

    • 100% effaced means the cervix is completely thinned out.

  • Position of Cervix: Orientation of the cervical os to the vaginal canal (posterior, mid-position, anterior).

  • Station: The level of the presenting part in relation to the ischial spines of the mother’s pelvis (0 is when engaged).

  • Presentation: Determined by fetal position:

    • Cephalic (head-first)

    • Breech (pelvis-first)

    • Shoulder (shoulder-first)

  • Fetal Position: Identifying the location of the presenting part and its structures in relation to the maternal pelvis.

Factors Affecting Labor (5 Ps)

  1. Powers: The contractions themselves.

  2. Psyche: The psychological response of the woman giving birth.

  3. Position: Maternal physical positions to facilitate labor.

  4. Passage: The maternal pelvis through which the fetus travels.

  5. Passenger: The fetus being delivered.

Pelvic Types

  • Platypelloid

  • Anthropoid

  • Android

  • Gynecoid

  • Describes the shape of the pelvic inlet, midpelvis, and outlet.

Fetal Position Indicators

  • ROT (Right Occipito-Transverse)

  • ROP (Right Occipito-Posterior)

  • ROA (Right Occipito-Anterior)

  • Occiput Posterior

  • Occiput Anterior

  • LOP (Left Occipito-Posterior)

  • LOA (Left Occipito-Anterior)

  • LOT (Left Occipito-Transverse)

Fetal Structures

  • Bitemporal diameter: 8 cm.

  • Biparietal diameter: 9.25 cm.

  • Fetal head molding includes:

    • Anterior Fontanelle

    • Vertex

    • Frontal Bone

    • Parietal Bone

    • Sinciput (brow)

    • Mentum (chin)

    • Posterior Fontanelle

    • Occipital Bone

    • Occiput

Leopold's Maneuvers

  • Purpose: To assess fetal position, station, and size via abdominal palpation.

  • First Maneuver: Identify the part of the fetus in the fundus.

  • Second Maneuver: Determine the location of the fetal back.

  • Third Maneuver: Identify the presenting part.

  • Fourth Maneuver: Locate the cephalic prominence.

Mechanism of Labor

  • Stages Involved:

    1. Engagement

    2. Descent

    3. Flexion

    4. Internal rotation

    5. Extension

    6. External rotation

    7. Expulsion

Stages of Labor

  • Labor is the process of expelling the fetus, placenta, and membranes spontaneously.

  • Stage 1: Begins with labor onset and ends with complete cervical dilation.

  • Stage 2: Commences at full dilation, culminating in the delivery of the baby.

  • Stage 3: Starts after the baby’s delivery and concludes with placental delivery.

  • Stage 4: Begins post-delivery of the placenta and lasts approximately 4 hours.

First Stage of Labor

Latent Phase

  • Cervical dilation: 0-3 cm, effacement: 0-40%.

    • Primigravida: lasts up to 6 hours.

    • Multigravida: lasts up to 4 hours.

  • Contractions: Every 5-10 minutes, of mild intensity, lasting 30-45 seconds.

  • Maternal pain described as strong menstrual cramps.

Nursing Actions in Latent Phase

  • Medical Interventions:

    • Order lab tests (CBC, urinalysis, possible drug screening).

    • Implement IV or saline lock.

    • Initiate intermittent or continuous fetal monitoring.

  • Nursing Actions:

    • Admit to labor unit; orient woman and family.

    • Discuss childbirth plan and expectations during the admission process.

    • Obtain lab tests as ordered.

    • Initiate IV or saline lock.

    • Complete labor and delivery admission records.

Assessment Parameters

  • Record:

    • Maternal vital signs

    • Fetal heart rate (FHR)

    • Uterine contractions

    • Cervical dilation and effacement

    • Fetal presentation, position, and station

    • Status of membranes and amniotic fluid (color, amount, consistency, odor)

    • Vaginal bleeding or discharge characteristics

    • Deep tendon reflexes, signs of edema, and heart/lung sounds

    • Emotional status, pain, and discomfort.

Nursing Actions (Cont'd)

  • Review laboratory results, GBS status, and document allergies.

  • Encourage adequate fluid intake.

  • Provide comfort measures and facilitate ambulation.

  • Establish therapeutic relationships through active listening.

  • Assess cultural needs and incorporate into the care plan.

  • Review labor plan and address concerns of the woman and partner.

Induction of Labor

  • Purpose: To initiate contractions if patterns are absent or dysrhythmic.

  • Criteria: Must be term unless complications exist.

  • Methods:

    • Stripping of membranes

    • Homeopathic remedies

    • Medications

    • AROM (Artificial Rupture of Membranes)

Stripping Membranes

  • Conducted by a provider if dilation has begun and cervix is 90-100% effaced.

  • Creates space between the uterine wall and amniotic bag.

Homeopathic Remedies

  • Examples include:

    • Castor oil

    • Nipple stimulation

    • Sexual intercourse

    • Specific food (eggplant, licorice, pineapple, spicy foods)

    • Herbal remedies (Evening Primrose oil, Black/Blue cohosh, Red raspberry leaf)

    • Walking.

Medications for Induction

  • Cervical Ripening Agents:

    • Cervidil

    • Cytotec

    • Prostaglandin gel

  • Pitocin Administration:

    • Infusion**: Start at 2mU/min (6mL/hr), increase 1-2 mU/min every 20-30 minutes until contractions are appropriate.

Nursing Actions During Induction

  • Initiate Pitocin 6-12 hours post-prostaglandin administration.

  • Continuously monitor FHT and contraction patterns every 15 minutes after dose changes.

  • Observe maternal BP/pulse/respiration every 30 minutes; discontinue if contractions are more frequent than every 2 minutes.

AROM (Artificial Rupture of Membranes)

  • Conducted with Amnihook to release prostaglandins and stimulate contractions.

  • Assess if the presenting part is engaged and monitor FHR for potential prolapsed cord.

  • Document characteristics of the amniotic fluid (color, odor, consistency).

First Stage (Continuation)

Active Phase

  • Cervical dilation: 4-7 cm, effacement: 40-80%.

    • Average dilation speed: 1.2 cm/hr (primigravida may take 3 hours; multipara may take 2 hours).

  • Fetal descent.

  • Intense contractions: every 2-5 minutes, lasting 40-60 seconds.

Medical Interventions in Active Phase

  • Rupture membranes if indicated.

  • Monitor fetal status via continuous or intermittent methods.

  • Internal monitoring if necessary (internal fetal electrode/uterine transducer).

  • Order pain medication or epidural anesthesia based on pain assessment.

Nursing Actions in Active Phase

  • Monitor FHR and contractions every 15-30 minutes.

  • Monitor maternal vital signs hourly.

  • Perform vaginal exams as needed to assess progress.

  • Administer analgesia as per orders; evaluate pain management effectiveness.

  • Encourage oral intake of fluids.

  • Promote comfort measures and support relaxation techniques.

Active Phase Strategies

  • Provide clear updates and promote comfort.

  • Assist with bladder elimination; this support can aid fetal descent.

  • Apply direct communication with calm reassurance; utilize therapeutic touch if appropriate.

  • Engage the support person in care.

Management of Discomfort During Labor

  • Pain may arise from:

    • Decreased blood supply to the uterus

    • Increased pressure/stretching of pelvic structures

    • Cervical dilation and stretching.

Non-Pharmacological Management Techniques

  • Various methods to alleviate pain without medication.

Pharmacological Management

  • Care plan before, during, and after any anesthesia or pain relief method applied.

  • Various medications for pain management include:

    • Nubain: 10-20 mg IV/IM every 3-6 hours.

    • Phenergan: 25 mg IV/IM every 4-6 hours.

    • Sublimaze: 25-50 mg IV or 50-100 mg IM.

    • Stadol: 0.5-2 mg IV or 2-4 mg IM every 3-4 hours.

    • Nitronox: equal parts of oxygen and nitrous oxide for inhalation.

Transition Phase of First Stage

  • Cervical dilation: 8-10 cm, 100% effacement.

  • Intense contractions: every 1-2 minutes, lasting 60-90 seconds.

  • Symptoms: Exhaustion, difficulty focusing, nausea/vomiting, backache, diaphoresis, trembling.

  • Strong urge to bear down is common.

Medical Interventions in Transition Phase

  • Perform amniotomy (AROM) if not done.

  • Assess fetal position and cervical state.

  • Prepare for delivery.

Nursing Actions in Transition Phase

  • Monitor FHR and UC's every 15 minutes.

  • Provide calming support, speaking in soothing tones, and directing with clarity.

  • Encourage breathing techniques and promote comfort measures.

  • Maintain attention to maternal hygiene.

  • Familiarize room and couple with delivery processes to reduce anxiety.

  • Prepare equipment like delivery tray and infant warmer.

  • Keep support persons updated on labor progress.

Second Stage of Labor

Overview

  • Stage begins at complete dilation and is marked by improved focus and energy.

  • Generally shorter for multiparous women compared to primiparous.

  • Contractions: every 2 minutes lasting 60-90 seconds.

  • Increased bloody show and flattening of the perineum.

Medical Interventions in Second Stage

  • Prepare for delivery while offering reassurance during pushing.

  • Perform episiotomy if necessary.

  • Assist with childbirth process.

Nursing Actions in Second Stage

  • Guide the woman in bearing down during contractions.

  • Monitor fetal response to the pushing effort.

  • Provide comfort measures; pay attention to perineal hygiene.

  • Encourage rest between contractions and offer praise for progress.

Third Stage of Labor

  • Involves separation and delivery of the placenta/membranes.

  • Duration: Typically 5-20 minutes.

Medical Interventions in Third Stage

  • Neonate placed skin-to-skin on the mother's abdomen post-delivery.

  • Wait for and inspect placenta after delivery.

  • Order medications as necessary, particularly for pain relief and uterotonics.

Nursing Actions in Third Stage

  • Monitor maternal vital signs every 15 minutes.

  • Facilitate breathing and relaxation during contractions.

  • Support immediate newborn interactions, if stable.

  • Complete documentation of procedures executed during delivery.

Fourth Stage of Labor

  • Initiates postpartum period, lasting until about 4 hours post-delivery.

  • Involves mechanisms for homeostasis.

Medical Interventions in Fourth Stage

  • Repair any episiotomy or laceration.

  • Inspect the placenta.

  • Assess uterine firmness and order uterotonics as needed.

Nursing Actions in Fourth Stage

  • Explain all processes to the mother.

  • Assess the uterus for position, tone, and intervene as necessary.

  • Monitor lochia characteristics and manage any perineal pain or swelling.

  • Help with bladder distension management and provide assistance to the bathroom.

  • Monitor baby's vital parameters every 30 minutes.