THE LABOR PROCESS

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THE LABOR PROCESS

• DEBBIE AMASON RN,MS
• SPRING 2001

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Theory

• factors that influence
• uterine stretching
• pressure on cervix
• oxytocin stimulation
• prostaglandin
• placental age

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Signs of Labor

• preliminary
• lightening
• sudden burst of energy
• Braxton-Hicks contractions
• cervical ripening
• true signs
• regular contractions
• show
• ROM

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Components of Labor

• The 4 Ps
• passage
• passenger
• powers
• psyche

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Passage

• refers to pelvis
• 2 pelvic measurements
• diagonal conjugate
• transverse diameter
• if disproportion occurs usually the pelvis

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Passenger

• whether fetal head can pass through pelvis
  depends on both the structure and the alignment.
• Fetal skull composed of 8 bones
• bones meet at the suture lines
• smallest diameter
• engagement
• molding

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Definitions

• fetal attitude
• station
• crowning
• fetal lie

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presentations

• cephalic- 95
• 4 types
• breech - 3
• 3 types
• transverse

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positions

• relation of presenting part to a specific
  quadrant of the maternal pelvis
• 4 parts of fetus used as landmarks
• vertex- occiput (O)
• breech- sacrum ( SA)
• face- mentum (M)
• shouldar- scalula (A)

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methods used to determine

• abdominal inspection and palpation
• vaginal exam
• auscultation of FHTs
• ultrasound

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• labor is longer if not vertex r/t ineffective
  descent of the fetus, ineffective dilation, and
  irregular weak contractions
• mother fatigued
• increased risk of c/section
• increased risk of lacerations
• decreased bonding

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• also places fetus at risk for
• CPD
• PROMgt increased infection
• anoxia

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mechanisms of labor

• cardinal movements
• descent
• flexion
• internal rotation
• extension
• external rotation
• expulsion

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Powers of Labor

• uterine contractions
• abdominal muscles
• 3 phases of a contraction
• increment
• acme
• decrement

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Contour changes

• uterus gradually differentiates itself into 2
  distinct functioning areas
• fundus
• lower uterine segment
• boundary between 2 areas is marked by
  physiologic retraction ring
• consequences

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If labor becomes difficult this ring becomes a
prominent and observable abdominal indention
called Bandls ring This is a danger sign
indicative of impending uterine rupture
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Cervical changes

• effacement
• dilation

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Psyche

• psychological state or feelings the woman brings
  into labor with them
• fright
• apprehension
• excitement
• those who manage best are
• strong self esteem
• good support

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Stages of Labor

• 4 stages
• preparatory and dilation
• expulsion
• placental
• first 4 hours after delivery is called the 4th
  stage to emphasize the need for close observation.

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Stage 1

• divided into 3 phases
• latent
• active
• transition

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Latent phase

• Characteristics
• onset of regular contractions
• dilation to 3 cms
• contractions are mild, lasting 20-40 seconds
• time frame
• analgesia given now will slow labor

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Active phase

• Characteristics
• dilation 4-7 cms
• contractions every 3-5 minutes, lasting 40-60
  seconds
• increased amount of show
• time frame
• analgesia given now will have no effect on length
  of labor

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Transition

• Characteristics
• dilation 8-10 cms
• contractions are every 2-3 minutes lasting 60-90
  seconds
• intense discomfort
• very focused inward
• DO NOT LEAVE

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Second stage

• Definition
• full dilation to delivery of infant
• Characteristics
• contractions create intense urge to push
• perineum bulges, anus everted
• crowning occurs
• time frame

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Third Stage

• Definition
• from delivery of fetus to delivery of placenta
• placenta separation
• placenta expulsion
• signs of placental separation

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Placenta

• Duncan
• Schultz
• normal blood loss is 300-500 ml.

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Physiological Responses

• CV SYSTEM
• contractions decrease blood flow to uterusgt
  increased amount blood in circulationgt
• increases peripheral resistance gt increased blood
  pressure
• with pushing cardiac output increases 40-50
• BP systolic increases average 15mmHg with
  contraction

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CV system

• fetal- usually able to adjust without difficulty
• decrease oxygen with contraction causes state of
  hypoxia but with adequate reserves causes minimal
  problems

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Hemopoietic

• major change
• leukocytosis
• WBCs

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Respiratory

• responds to changes in CV system
• Oxygen consumption increases
• fetus- labor speeds maturation of surfactant
• pressure to chest during delivery clears lungs of
  excess fluid

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Temperature regulation

• increased muscular activity results in slight
  temperature elevation
• fluid balance- water loss increased r/t increased
  rate and depth of respiration as well as fluid
  restrictions

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Urinary

• Changes
• kidneys concentrate urine
• specific gravity increases
• trace protein excreted
• pressure of fetal head causes decreased tone of
  bladder

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Musculoskeletal

• hormone relaxin has acted to soften cartilage
  between bones
• increased pubic flexibility . Backache
• fetus- force of contraction pushes fetus into a
  position of full flexion

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GI tract

• fairly inactive during labor
• digestion and emptying stomach is prolonged

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Neuro system

• responses that occur r/t pain
• early- contraction of uterus and cervical
  dilation
• delivery- pain centered on perineum
• fetal- contraction exerts pressure fetal head
• FHR decreases

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Integumentary

• pressure of delivery can result in petechia or
  bruising
• may also have edema fetal head where the
  presenting part was pushing against the cervix

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Psychological Responses

• lead to emotional distress
• pain reduces ability to copegt quick tempered
• fatigue
• fear

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Culture

• every woman in labor responds to cultural cues
• response to pain
• choice of nourishment
• position
• proximity of support person
• customs r/t PP period
• differences must be addressed

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Danger signs- Fetal

• tachycardia
• bradycardia
• decelerations
• meconium staining
• hyperactivity
• acidosis

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Danger signs- maternal

• change in BP
• abnormal HR
• abnormal contractions
• pathological retraction ring
• abnormal lower abdominal contour
• increased apprehension

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Assessments- Stage 1

• initial interview
• EDC
• frequency, duration of contractions
• any show
• ROM?
• Vital signs
• last oral intake
• allergies

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History

• Review physical and psychological events of this
  pregnancy
• Current pregnancy
• Past pregnancy
• Past health
• Family history

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Physical Exam

• review of systems
• abdominal assessment
• assess for ROM
• vaginal exam
• sonogram
• vital signs
• lab

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Contractions

• frequency- measure from beginning to beginning
• duration- measure from beginning to end
• intensity- rated as mild, moderate and strong

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Fetal Heart rate

• assess fetal status upon admission
• auscultate through uterine wall and fetal back
• every 30 minutes early labor
• every 15 minutes active labor
• every 5 minutes Stage 2
• auscultate with stethoscope, fetoscope, or monitor

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Electronic monitoring

• Purpose
• provides a technique for assess of uteroplacental
  physiology and serves as an indicator to
  determine fetal oxygenation.
• 2 modes
• introduced in the mid 1970s.

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Monitoring

• Controversy
• early identification of fetal distress .
• studies have not supported
• affect nursing staffing pattern
• natural childbirth advocates oppose
• medical profession admits use leads to increased
  c/section

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Advantages of EFM

• easier to monitor FHR
• nurses grown to rely on them and feel insecure
  without them
• identify potential problems earlier

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External

• tocotransducer
• ultrasonic sensor
• advantages
• disadvantages

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Internal

• most precise method
• used only if membranes ruptured
• contractions- pressure sensing catheter
• fetal- placement of fetal scalp electrode gt
  elicits fetal EKG

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Tracings

• recorded paper with FHT noted on top and
  contractions on bottom
• patterns are assessed and interpreted by
  evaluating 3 parameters
• baseline
• variability
• periodic changes

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Baseline FHR

• assessed between contractions with no fetal
  movement noted
• normal rate 120- 160
• measure over 1 minute
• bradycardia- lt120 per minute for 10 minutes
• tachycardia- gt 160 per minute for 10 minutes

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Baseline

• Definitions
• bradycardia- rate less than 100
• marked tachycardia- rategt180

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Variability

• Definition
• beat to beat changes in the FHR
• The MOST important indicator of fetal well being
• 2 components
• long term
• short term

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Causes of altered variability

• Decreased
• extreme prematurity
• fetal cardiac arrhythmias

• Increased
• mild hypoxia
• fetal stimulation
• Decreased
• hypoxia
• acidosis
• drugs
• fetal sleep

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Periodic changes

• accelerations
• decelerations
• early
• late
• variable

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Early decelerations

• cause
• shape
• onset
• considered benign

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Late decelerations

• Cause
• Shape
• Onset.
• Tx
• change position
• d/c pitocin
• increase IVFs
• oxygen

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Variable decelerations

• cause
• shape
• onset
• Tx
• change position
• IVFs
• oxygen
• possible amnioinfusion

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Amnioinfusion

• addition of sterile fluid into the uterus to
  supplement amniotic fluid
• used warm NS, RL
• approximately 500 ml
• maintain aseptic technique
• record vital signs to monitor for temperature
• change pads frequently

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Additional assessment techniques

• scalp pH
• used to determine hypoxia
• pH less than 7.2 acidic
• procedre
• cervix dilated 3 cms
• amnioscope, scalp nicked and capillary blood
  obtained
• used to verify a fetal heart rate pattern

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Scalp stimulation

• sterile glove to apply pressure to fetal headgt
  increases variability
• assessment of acid- base balance if fetus hypoxia
  gt FHR will not increase
• acoustic stimulation- placing loud or sharp sound
  next to abdomen
• used with NST to increase fetal movement

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Care during Stage 1

• respect contraction time
• promote position changes
• promote voiding
• offer support
• respect and promote support persons activities
• support pain management efforts
• amniotomy

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Care during Stage 2

• urge to push is so strong some women try to
  resist gt greater discomfort
• as contractions increase in intensity gt women
  become argumentative and angry
• need good support
• stay with client
• FHR assessed throughout pushing efforts

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Prepare setting
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Positioning

• lithotomy, lateral, dorsal recumbant, semi
  sitting, squatting
• if use lithotomy position make sure you raise
  legs at same times to decrease strain back
• do not put up in stirrups until the last minute

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Pushing

• push with contraction to be effective
• best position is semi fowlers
• not to hold breath but breathe out while pushing
• to prevent pushing have patient pant

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perineal cleansing
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Episiotomy

• surgical incision of the perineum to prevent
  tearing of the perineum and release pressure on
  fetal head.
• Types
• Midline
• mediolateral
• lacerations
• classifications

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Birth

• fetal head is delivered and nose and mouth are
  suctioned
• check for nuchal cord
• delivery time is recorded when entire body is
  delivered
• cord clamped
• cord blood obtained

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Apgar score
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Apgar

• developed by Dr. Virginia Apgar in 1952 to
  evaluate physiologic adaptations of the newborn
• done at 1 and 5 minutes
• assess hr, color, reflexes, cry, muscle tone
• score of 0-2 for each item

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Assessment

• apgar
• cord
• physical defects
• identification
• attachment

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Stage 3

• usually delivers spontaneously
• if not removed manually
• must be inspected for intactness
• Oxytocin added to IVFs to increase contractions
  only after placenta delivered
• perineal repair

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Stage 4

• immediate postpartum time
• 1-4 hours after delivery
• assess vital signs, lochia, fundus, perineum
  every 15 miutes for first hour
• clean perineum
• offer clean gown
• shaking- normal response

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Report immediately

• decrease in BP
• tachycardia
• uterine atony
• excessive bleeding
• temperature above 100.4

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