Chapter 27: Comprehensive Study Guide to Labor and Delivery

Birth Planning and Setting Choices

• Ideally Begins Early: Birth planning should ideally commence early in the pregnancy to allow for full consideration of all available options.
• Outline of Options: The process begins as an outline that covers three major phases:
  • Labor
  • Delivery
  • Postpartum care
• Setting Choices: Parents can choose from various settings for the birth process, including:
  • Hospitals: Traditional clinical settings with full medical resources.
  • Birthing Centers: Often provide a more home-like environment while maintaining medical oversight.
  • Home: Birth occurring in the resident's private home, typically with a midwife.
• Personal Experiences: Clinical study can be supplemented by viewing personal accounts (e.g., RegisteredNurseRN) comparing Vaginal Birth vs. C-Section delivery experiences.

Signs and Symptoms of Impending Labor

• Lightening: Also referred to as being "dropped." This occurs when the fetus descends into the pelvic cavity to prepare for birth.
  • Physiological Impact: Prior to lightening, there is significant pressure on the abdominal cavity, diaphragm, and lungs, which can make breathing more uncomfortable. After lightening, this pressure shifts downward onto the bladder and cervix.
• Bloody Show: This refers to the loss of the mucus plug from the cervix, which may appear as bloody or pink-tinged mucus.
• Effacement: The process of the cervix thinning and shortening.
• Seepage: The leakage of amniotic fluid. This is often assessed using Nitrazine paper to confirm if the membranes have ruptured.
• Contractions:
  • Braxton Hicks: These are "false" contractions and do not signify the start of true labor.
• Slight Weight Loss: A mother may experience a weight loss of approximately $1-3\,lbs$ shortly before labor begins.
• Burst of Energy: A sudden increase in energy levels (sometimes called "nesting") often precedes the onset of labor.

Distinguishing True Labor vs. False Labor

• False Labor:
  • Contraction Pattern: Contractions rarely follow a consistent pattern; they vary significantly in length and intensity.
  • Location: Sensations are most noticeable in the fundus are (the top of the uterus).
  • Response to Intervention: Contractions typically stop when the woman utilizes relaxation interventions (e.g., rest, hydration).
  • Cervical Change: No effacement or dilation occurs.
  • Fetal Activity: There is no change in fetal position.
• True Labor:
  • Contraction Pattern: Contractions are regular and follow a rhythmic pattern. They gradually become closer together, stronger in intensity, and last longer.
  • Effect of Activity: Contractions get stronger with walking.
  • Location: Sensation usually begins in the lower back and travels around to the lower abdomen.
  • Response to Intervention: Contractions do not stop with relaxation techniques.
  • Fetal Progress: The fetus continues its descent into the pelvis.

The Five Factors (5 "P"s) Affecting Labor and Delivery

1. Passageway: Consists of the pelvis and soft tissues.
   • Pelvic Shapes: Round, Heart, Oval, and Flat.
   • Assessment Methods: Ultrasound, Palpation, and Pelvimetry.
   • Pelvic Landmarks: The Pelvic brim (Inlet, Linea terminalis, or Iliopectineal line) and the Pelvic outlet.
   • Soft Tissues: Includes Uterine tissues, Cervical tissues, the Vagina, and the Perineum.
2. Passengers: Consists of the fetus and the placenta.
   • Fetus Factors:
     • Molding: The shaping of the fetal head to fit through the birth canal.
     • Fetal Attitude: The relationship of one body part to another.
     • Fetal Presentation: The part of the fetus that enters the pelvis first.
     • Fetal Position: The relationship of the presenting part to a specific quadrant of the mother's pelvis.
     • Fetal Head Anatomy: Comprised of bones, fontanelles, and sutures.
   • Placenta: Its primary factor during this stage is its separation from the uterine wall.
3. Powers: The forces required to expel the fetus.
   • Primary Powers (Involuntary): Responsible for the dilation and effacement of the cervix and the descent of the fetus.
   • Secondary Powers (Voluntary): The "bearing-down" efforts or active pushing by the mother.
4. Position of the Mother: The physical stance or placement of the mother during labor (e.g., standing, walking, side-lying, squatting, or hands and knees).
5. Psyche: The mother's psychological response and emotional state during the labor process.

Cephalopelvic Disproportion (CPD)

• Definition: A condition where the head of the fetus is larger than the mother's pelvic outlet, making a vaginal delivery difficult or impossible.
• Clinical Significance: CPD is a major indication for a cesarean delivery (C-Section).

Mechanisms of Labor (Cardinal Movements)

• The Cardinal Mechanisms of Labor can be remembered with the mnemonic: "Every Darn Fool In Egypt Eats Raw Eggs."

1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External Rotation
7. Restitution
8. Expulsion

The Four Stages of Labor and Delivery

First Stage: Dilation

• Duration: This is the longest stage of labor. It begins with the onset of regular contractions and ends with complete cervical dilation ($10\,cm$).
• Mnemonic for Phases (F.L.A.T.): First Labor Actively Transitions.
• Latent Phase:
  • $0-3\,cm$ dilated.
  • Mom is typically still at home with mild discomfort.
  • Water generally has not broken yet.
  • Contractions: Every $5-8\,minutes$, lasting $20-35\,seconds$.\n* Active Phase:
  • $4-7\,cm$ dilation.
  • Water generally breaks in this stage; if the mother is at home, she must proceed to the hospital.
  • Contractions: Every $3-5\,minutes$, lasting $40-60\,seconds$.
• Transitional Phase:
  • $8-10\,cm$ dilation.
  • Characterized by more severe pain; nausea is considered normal.
  • Contractions: Every $2-3\,minute$ intervals, lasting up to $90\,seconds$.

Second Stage: Delivery of Fetus

• Begins with complete dilation ($10\,cm$) and ends with the birth of the baby.
• The mother experiences a strong urge to push.
• Contractions: $80-90\,seconds$ long.
• Episiotomy: An incision made to minimize tearing, reduce bleeding, and prevent further complications.

Third Stage: Delivery of the Placenta

• Begins after the delivery of the infant and ends with the delivery of the placenta.
• Timeframe: Usually takes between $5-20\,minutes$.
• Interventions: Any episiotomy is repaired during this phase.
• Blood Loss: Typical loss is $200-300\,ml$. Loss exceeding $500\,ml$ is considered excessive.
• Medications: Oxytocin (Pitocin) or methylergonovine (Methergine) are administered to stimulate contractions, reduce blood loss, and prevent postpartum hemorrhage.

Fourth Stage: Stabilization

• Begins immediately post-delivery.
• Monitoring Period: The mother is monitored closely for $2-4\,hours$.
  • Assessments occur every $15\,minutes$ for the first hour.
  • Assessments then occur every $30\,minutes$.
• Assessment Criteria: Vital signs, uterine tone, vaginal drainage (lochia), and the condition of the perineal tissues.

Monitoring Fetal Status

• Normal Fetal Heart Rate (FHR): $120-160\,bpm$.
• Indicator of Distress: An increase or decrease of $30\,bpm$ from the baseline indicates fetal distress.
• Monitoring Methods: Electronic Fetal Monitoring (EFM) can be applied via internal or external sensors.
• Fetal Heart Rate Decelerations:
  • Early Deceleration: Caused by Head Compression (Normal/Expected).
  • Late Deceleration: Caused by Uteroplacental insufficiency (Non-reassuring).
  • Variable Deceleration: Caused by Umbilical cord compression (Non-reassuring).
• Signs of Distress: Hypoxia, presence of Meconium (fetal stool) in amniotic fluid, tachycardia, bradycardia, or other non-reassuring FHR patterns.

Response of the Newborn to Birth

• Apgar Score:
  • Taken at $1$ and $5\,minutes$ of age.
  • Score Range: $0$ to $10$.
  • Criteria: Appearance (Color), Pulse (Heart Rate), Grimace (Reflex Irritability), Activity (Muscle Tone), and Respiration (Respiratory Effort).
  • Score Interpretations:
    • $7-10$: Excellent condition.
    • $4-6$: Moderately depressed.
    • $0-3$: Severely depressed (may require resuscitation).
• Initial Interventions:
  1. Clearing Airway: Necessary for immediate breathing.
  2. Umbilical Cord: Clamped immediately.
  3. Surfactant: This substance decreases surface tension within alveoli and permits inflation of the lungs.
  4. Warmth: Newborns are at high risk for Hypothermia; nursing interventions must focus on maintaining body temperature.

Clinical Assessments and Procedures during Labor

• Leopold’s Maneuvers: A system of four palpations used to determine the position and presentation of the fetus.
• Amniotic Fluid Assessment: Visual and chemical check of the fluid status.
• Vaginal Exams: Performed periodically to check for dilation, effacement, and station.
• Standard Care Patterns: Monitoring Nutrition, Metabolic patterns, Elimination, and Activity/Exercise.
• Precipitous Labor: Labor that lasts no more than $3\,hours$ from the start of regular contractions to the time of birth.
• Anesthesia and Pain Control:
  • General Anesthesia: Used for C-sections; carries risks of aspiration, respiratory distress, and uterine relaxation.
  • Epidural Block: Suitable for all stages of labor and repair of lacerations.
  • Pudendal Block: Suitable for second and third stages, and for episiotomy/laceration repair.
  • Other Options: Spinal Block, IV pain medications, and Local anesthetics.

Medical Interventions

• Induction: Using Oxytocin (Pitocin) to start labor; requires close FHR monitoring.
• Amniotomy: Artificial rupture of the membranes (breaking the water).
• Prostaglandin Gel: Applied to the cervix to promote softening and dilation.
• Assisted Delivery: Use of Forceps or Vacuum extraction to help the baby through the birth canal.
• Cesarean Delivery: Surgical birth.
• VBAC: Vaginal Birth After Cesarean; an option for some women who have previously delivered via C-section.

Questions & Discussion

• Question (Slide 11): What do you think about Standard Precautions during Childbirth?
• Question (Slide 30): What should vaginal drainage look like at [the Fourth Stage]?
• Question (Slide 34): Normal Fetal HR is $120-160$, increase of _________bpm may indicate fetal distress and needs to be reported immediately. (Answer: $30\,bpm$).
• Question (Slide 38): High risk for Hypothermia – Nursing Interventions: [Mother-infant skin-to-skin contact, drying the infant thoroughly, warming blankets].
• Question (Slide 39): Precipitous Labor lasts no more than _____________ hours. (Answer: $3\,hours$).
• Question (Slide 43): Which is which? (Matching Decelerations to causes: Early = Head Compression, Late = Uteroplacental insufficiency, Variable = Umbilical cord compression).