Active Phase

-Stage 1-4 to 7 cm dilation-Cervical changes: dilates more rapidly-Discomfort increases-Woman's focus increasingly inward-Contractions 2-5 mins apart, last 40-60 sec, moderateintensity-Once active, minimum progress expected is: 1.2 cm/hrfor nullipara, 1.5cm/hr for multipara

Admission to Labor and Delivery

-1st: Focused assessment of mother (vital signs) and fetus (FHR) todetermine their condition and whether birth is imminent-2nd: Broader assessment-Obtain essential info from mother, e.g.: History: Age, G, P, EDC,LMP, # wks, ROM, bleeding, present OB hx, past OB hx, etc.-Fetal assessment: Leopold maneuvers, Assessment of FHR andpattern-Labor status: Assessment of uterine contractions, Vaginalexamination, CBC, Bld type, RH, midstream urine for protein,glucose-Physical examination

Aortocaval Compression

-aka Supine hypotension syndrome, vena cava syndrome-The supine position allows the heavy uterus to compressher inferior vena cava, reducing the amount of bloodreturned to the heart and can reduce placental perfusion-Frequent cause of low maternal blood pressure-If mother is in bed, lay her on side. LEFT side is optimalbut right side can be used

Attitude: Extension

Attitude: Flexion

Body Changes During Labor

-Cardiovascular: BP during contractions, Supinehypotension (Aorto-caval syndrome)-Respiratory: Increased rate and depth: Increasedchance of Hyperventilation-GI: Thirst, dry mouth; NPO, ice chips, popsicles-Urinary: Encourage emptying for comfort and betterfetal descent, postpartum diuresis-Blood: Increase of blood volume , WBC and clottingfactors (check for signs of DVT)

Bradley Method of Childbirth

-Similar to Lamaze-Originally called husband-coachedchildbirth, the first to include father as anintegral part of labor. -Slow abd. breathing, relaxationtechniques-Seeks to avoid medical interventions

Brow Presentation

-Least common of all presentation-When the forehead of the fetus becomes the presenting part.

-The fetal head is slightly extended instead of flexed, with the result that the fetal head enters the birth canal with the widestdiameter of the head (occipitomental) foremost.

-C-section birth is preferred.*If vaginal birth is attempted the woman will probably have an episiotomy and may require an extension at birth.

*Fetal mortality is increased b/c of injuries received during birth including cerbral and neck compression and damage to thetrachea and larynx

Causes of Labor

-Cervical ripening: complex cascade ofevents (change in E/P ratio, ↑ collagenaseactivity, ↑PGE2-Myometrial activation (sensitive tooxytocin release)

Cephalopelvic Disproportion

Condition preventing normal deliverythrough the birth canal; either the baby'shead is too large or the birth canal is toosmall

Comfort Measures during Labor

a. Lightingb. Keep temperature comfortable c. Attend to personal hygiened. Provide mouth care e. Assess for bladder distentionf. Assist woman to position of comfort g. Ice Chips

Contractions

-Comes from the upper 2/3 of the uterus-Frequency-Duration

-Intensity (mild, moderate, severe)

Dilatation

The extent to which the cervix has openedin preparation as a result of uterine

contractions-Full dilatation is 10cm.

Doulas

Non-medical, non-midwives who providecontinous physical, emotional &educational support to the mother before,during & after birth...not required to becertified in the U.S.

Effacement

Shortening of the uterine cervix and thinningof its walls as it is dilated during labor

Episiotomy

a surgical incision made through the perineum to enlargethe vaginal origice to prevent tearing of the tissues as the

infant moves out of the birth canal

Face Presentation

-The face of the fetus is the presenting part. -The fetal head is hyperextended even more than in the brow presentation.

-Occurs frequently in multiparous women or women with a pendulous abdomen.* The risks of CPD and prolonged labor are increased which increases the risk for infection

* The fetus may develop edema, the neck and internal structures may swell as a result of trauma received during descent.Petechiae swelling and facial bruising are seen int the superficial layers of the facial skin

*Results in C-Section delivery

False Labor

-Irregular contractions-Interval same-Intensity same or less-Felt in abdomen-Sedation relieves pain-No show-No cervical change with contractions

Fetal Head

The fetal head is designed to work with the pelvis, in that the cranial plates canoverride each other when necessary as when there is a tight squeeze. Also theshortest diameter of the fetal head is when the baby's head is fully flexed—the

suboccipitobregmatic diameter 9.5cm vs. 11 or 13.5 cm

Fetal Position

The location of a fixed reference point of the baby's presenting partin relation to the four quadrants of the mother's pelvis: the right

and left anterior or the right and left posterior,occiput/mentum/sacrum

Footling Breech

One or both feet come first, with , Baby's bottom is at a higher positionand either one or both feet come out first during delivery. This breech

condition is common in premature deliveries. This position is extremelyrare in full-term pregnancies.

Forceps assisted birth

A birth in which a set of instruments, known as forceps, are applied to thepresenting part of the fetus to provide traction or to enable the fetal head to be

rotated to an occiput-anterior position. Forceps-assisted birth is also knownas instrumental delivery, operative delivery, or operative vaginal delivery.

Four P's

1. Passenger (fetus)2. Passage (pelvis, vagina)

3. Powers (physiology of labor)4. Psyche (psychosocial considerations)

Fourth Stage of Labor

-Till mom stabilizes (usually about 1-4 hours after birth )-Vital signs q 15 mins first hour, assessing fundus andamount of lochia-Important for fundus to remain firm! (Pt canhemorrhage in minutes)-Physiologic changes may cause chill-Encourage parent-infant contact-Initiate breastfeeding-Ice pack to perineum

Frank Breech

Position of a fetus in which the buttocksare present at the maternal pelvic outlet

Friedman Curve

-Duration of labor usually between 7-13hours-A graphic representation of the hours oflabor plotted against cervical dilation incentimeters.

Full Breech

The reversal of the usual cephalic position: everythingflexed inward but butt presenting first.

Grantly Dick-Read Method of Childbirth

-Believed fear of childbirth producedtension which made the pain worse whichcreated a fear-tension-pain cycle-Introduced relaxation methods tomothers

Intrapartum Complications

-Meconium-Inadequate uterine relaxation betweencontractions-Inadequate uterine contractions-CPD: cephalo- pelvic disproportion-Prolapsed cord-Shoulder dystocia

Lamaze Method of Childbirth

-Birthing method focusing on partner-coached breathing techniques andrelaxation with the woman panting andusing outside focal points during labor-Postpones the use of pain medications

Latent Phase

-Stage 1-0 to 3 cm dilation-Cervical changes: primarily effacement-Contractions gradually increase, mildintensity, 5-30 minutes apart and last for30-40 seconds

Left Occiput Anterior

The most common and least troublesomebirth position

Leopold Maneuvers

-Can determine fatal position, presentation, and attitude by performing leopold's maneuvers. have the patient empty herbladder, assist her to a supine position, and expose her abdomen

1. Identify what occupies the fundus2. Identify where the baby's back is, the other side being the hands and feet

3. Attempt to grasp presenting part gently between thumb and fingers to see if the presenting part moves upward. Ifengaged, it will not move up

4. Face mothers feet, slide hands downward on either side of uterus. One side will be "obstructed" with cephalic prominence,if this is a flexed head, it will be on opposite side as the fetal back; extended head will be on same side as the back

Lightening

The process or time during late pregnancywhen the fetal head begins to descend intothe mother's pelvis, resulting in alessening of pressure on the diaphragm

Lithotomy

The client is lying on back, w/ knees bent,thighs apart, and feet resting in stirrups.The position is used for pelvic exams infemales,rectal exams& some operations.

LochiaDischarge of blood, mucous and tissue

from the uterous following delivery lasting4-6 weeks after delivery

Longitudinal Lie

When the long axis of the fetus is parallelto the long axis of the mother the fetus

Maternal Positions in Labor

-Preferred position in labor is UPRIGHT because it takes advantage of the force of gravity, improves the contraction, helpswith maternal cardiac output and utero-placental flow, and increases flow to the maternal kidneys

-"All Fours": good for shoulder dystocia-Lithotomy

-Sitting: excellent to facilitate the progress, abdominal muscles work together in greater synchrony with uterus contractions-Squatting/Kneeling: moves the uterus forward and aligns the fetus with the pelvic inlet which increases the pelvic outlet

-Lateral: goot to slow down the speed of precipitous birth and helps rotate the fetus in a posterior position

Maternal Response to Labor

-Cardiovascular:*Cardiac output increases*Increase pulse rate*Blood pressure changes: increases during contractions, hypotension my occur from vena caval syndrome*White blood cell count increases

-Respiratory system:*Increase in oxygen demand*Exhalation of more CO2

-Renal:*Tendency to concentrate urine*Full bladder increases discomfort*Proteinuria-increased metabolic activity and may be a sign of development of pre-eclampsia

-GI:-Decreased motility, absorption, and gastric emptying time-Nausea and vomiting is common-Dry lips and mouth

Military Presentation

-A type of cephalic presentation where the fetal head isneither flexed nor extended.

-The presenting part is the top of the head.

MultiparousWoman who has given birth two or more

times

Nulliparous Woman who has never given birth

Nurses Role in Labor

1. Comfort Measures2. Teaching3. Providing Encouragement4. Caring Presence (giving of self)5. Offering Pain Medication6. Care for the Birth Partner

Nursing Care during Active Phase of Labor

-Maternal response: labor-oriented, more inwardly focused and alert, moredemanding-Duration: averages 1.2cm/ hour nullip and 1.5 cm/hr multip, range is from 8-10 hours nullip and 6-7 hours multip (6-10 hrs) -Comfort measures, coping techniques-Encourage voiding q 2 hours-Assist with hygiene-Provide pharmacologic pain relief as requested and ordered: anesthesia,analgesia-Assess maternal BP, HR, RR q 30 min-Rupture of membranes, meconium?-Assess temp every 4 hours until ruptured then q 1-2 hoursAssess uterine activity and FHR q 15 - 30 min

Nursing Care during Fourth Stage of Labor

-Maternal response: tired yet difficult to rest, eager to becomeacquainted with newborn-Observe and be aware that the mother is vulnerable for a hemorrhage-Nursing care:*Vs. q 15 mins for first hour*Firm uterine fundus, massage if not firm (boggy)*Lochia: only saturates one standard pad in an hour*Bladder: watch for distention especially if boggy uterus*Ice pack to perineum: reduces edema and limits hematoma*Warm blanket*Promote early family attachment*Initiate breastfeeding

Nursing Care during Latent Phase of Labor

-Maternal response: Happy, excited, sociable, mild anxiety, cooperative-Duration: nullip-7-8 hrs and 4-5 hrs multip-Coping techniques: *Relaxation techniques*Breathing*Effleurage*Ambulation*Position change*Diversion-Education-Review of birth plan-Encourage voiding q2 hours-Basic hygiene-Assess maternal BP, HR, RR; uterine activity, FHR q 30 - 60 min-Assess maternal temperature q4 hours until ruptured membranes then q 1-2 hours

Nursing Care during Second Stage ofLabor

-20 mins to 3 hours-Maternal response: *Before baby is born: Intense concentration with pushing,dozing in between ctx, often oblivious to surroundings*After the birth: excited and relieved, very tired, may cry-Nurse responsible for:*Helping the mother bear down, positioning*Preparing delivery equipment, personnel*Cleansing of the perineum*Initial care and assessment of the newborn

Nursing Care during Third Stage of Labor

-Separation and birth of the placenta-Uterus continues to contract after the birth of the baby,causing the placenta to separate from the uterine wall-Lasts from 5 to 30 mins-Uterus must remain contracted to compress blood vessels(prevent hemorrhage)-Nurse responsible to administer pitocin and continuingcare of infant

Nursing Care during Transition Phase ofLabor

-Maternal response: irritable, intense concentration, may lose control,n/v-Duration: 30 mins to 3.5 hrs-Comfort measures, coping techniques-Encourage voiding q 2 hours-Assist with hygiene-Provide pharmacologic pain relief as requested and ordered-Avoid systemic analgesia, may use pudendal nerve block-Prepare for birth-Assess maternal BP, HR, RR and FHR q 15 to 30 min-Assess uterine activity q 10 - 15 min-Assist with amniotomy if membranes not ruptured

Oblique LieDiagonally across the uterus; between

transverse and longitudinal

Pain in Labor Caused by:

-hypoxia of compressed muscle cells-compression of nerves in cervix -stretching of cervix-stretching of perineum-bladder distension-intensified w/tension/anxiety/fear-oxytocin [Pitocin]-gives stronger contractions

Passenger

-Size and number-Lie of baby-Presentation of baby (Fetal structure thatenters the pelvis first) (caput swelling andmolding of the head)-Fetal attitude (flexion [easier] orextension)

Pelvis

-False vs. True Pelvis-We are more concerned with the true pelvis during

childbirth

Premonitory Signs of Labor

-Lightening-Braxton Hicks contractions

-Cervical changes-Bloody show

-Rupture of membranes-Sudden burst of energy

PrimiparousPertaining to a woman who has given birth

to her first child.

Prolapsed Cord

When the umbilical cord of the baby isexpelled first during delivery and issqueezed between the baby's head and thevaginal wall. This presents an emergencysituation since the baby's circulation iscompromised.

Relaxin

A hormone produced by the placenta thatcauses softening in the collagenconnective tissue of the symphysis pubisand sacroiliac joint

Rupture of Membranes

-Essential to assess FHR after rupture of membranes-Assess characteristics of amniotic fluida. Colorb. Odorc. Presence of meconiumd. Amount- Assess maternal temperature hourly thereafter

Second Stage of Labor

-The pushing stage-Woman may regain self-control-It begins with complete cervical dilatation -Contractions1.5 -3 minutes apart, lasting 40-90 sec (ctx may diminishslightly or pause)-Stages lasts 1-3 hours-Stage ends with the birth of the baby-Positional changes of the fetus (the baby twists and turnsas it is coming down the birth canal)(PATH OF LEASTRESISTANCE) referred to as the Cardinal Movements

Shape of the True Pelvis

1. Gynecoid: circular, 50%, vaginal birth2. Android: heart shaped, 23%, Cesarean ordifficult vaginal delivery3. Anthropoid: oval shaped, 24%, vaginalbirth, forceps used4. Platypoid: spherical, 3%, vaginal birth

Shoulder Dystocia

This occurs after the fetal head is deliveredand the broad anterior shoulder becomeswedged behind the mother's pubis, fetuscannot expand lungs because is trapped.This difficult delivery could result inmaternal lacerations & a fractured claviclein the infant.

Stages of Labor

-First stage (beginning of labor to 10 cm)*Latent*Active*Transition-Second Stage (from 10 cm to birth of baby)-Third Stage (from birth of baby to birth of placenta)-Fourth Stage (till mother stabilizes, 1-4 hrs)

Station

-Relationship of the presenting fetal part to an imaginary line drawnbetween the ischial spines of the pelvis.

- (-)5 to (+)5- (+)5 would be at the birth of the baby

The Cardinal Movements of Labor (part 1)

The Cardinal Movements of Labor (part 2)

The Support Person

1. Assess support person for signs of anxiety and/orfatigue2. Respect couple's values with regard to involvement offather3. Include support person in the plan of care4. Maternity care is FAMILY-CENTERED, every memberof their family is your patient too

Third Stage of Labor

-Shortest stage-Placenta separates and is expelled -May take up to 30 mins-Signs of placental separation:*Gush of blood*Lengthening of cord*Change in shape of uterus from flat to round, globular -Clamp and cut cord -Skin to skin

Transition Phase

-Stage 1-8 to 10 cm dilation-Strongest contractions-Woman may lose control-Contractions 1.5 - 2 mins apart, lasting60-90 seconds, strong/severe intensity

Transverse Lie

If the long axis of the fetus is at a rightangle to the long axis of the mother

True Labor

-Regular contractions-Interval shortens-Increasing intensity-Back to abdomen-No effect from mild sedation-Bloody show-Progressive dilatation of the cervix

Vacuum Assisted Birth

Monitor FHR throughout. Assist with pushing. Assess forcomplications. Look for lacerations. New Born- look for

scalp lacerations/hematoma

Vertex Presentation

-Fetal head fully flexed-The most favorable cephalic variation because the smallest possible

diameter of the head enters the pelvis. -This occurs in about 96% of births.