NCM 107 MCN THEORY THEORIES OF LABOR

3F: INTRANATAL CARE How does labor start?

LABOR – series of events by which uterine
DEFINITION OF TERMS contractions and abdominal pressure expel a fetus
Labor and placenta from uterus
A series of events by which uterine contraction Normally begins between 37 and 42 weeks of
and abdominal pressure expel a fetus and pregnancy
placenta from the uterus Many factors known to be responsible for the
Begins within 37–42 weeks initiation of spontaneous labor
Primipara: 14–16 hours 1. Uterine muscle stretching – resulting in
Multipara: 6–8 hours release of prostaglandins

Episiotomy 2. Cervical pressure

A surgical incision made at the opening of the Fetus pressing on the cervix stimulates
vagina during childbirth to aid a difficult delivery the release of oxytocin from the posterior
and prevent rupture of tissues pituitary gland
2 types Oxytocin stimulation + Prostaglandins
− Midline – less bleeding Oxytocin stimulation works together with
− Mediolateral – less risk of greater laceration prostaglandins to initiate contractions
3. Estrogen – Progesterone Ratio
Trial of Labor Progesterone withdrawal
An attempt labor to determine whether labor will Increasing estrogen in relation to
progress normally progesterone
For women post-cesarean section
4. Placental Degeneration
Augmentation of Labor Placenta has set age
Assisting labor that has spontaneously started but 5. Rising Fetal Cortisol Levels
is not effective or strong enough Reduction of progesterone and increase
Uses oxytocin or amniotomy to strengthen labor in prostaglandins
contractions
6. Fetal Membrane prostaglandin production
Duration – Length of a uterine contraction
PREPARATIONS FOR LABOR
Intensity – Strength of a uterine contraction
Preliminary Signs of Labor
Frequency – Beginning of one contraction to the − Subtle signs or symptoms days or hours before
beginning of the next labor begins

Increment – Building-up phase of the contraction 1. Lightening

Sinking of the fetal head unto the true pelvis
Acrement – Peak of the contraction Changes in abdominal contour (decreasing
fundal height)
Decrement – Letting down phase of the contraction Relief from diaphragmatic pressure
Primiparas: approx. 10-14 days before labor
Induction of Labor – Labor started artificially
Multiparas: on the day of labor or after
Dysfunctional Labor – Prolonged labor due to the beginning of true labor
sluggishness of contractions

Eutocia – Normal labor

Dystocia – Difficult labor

Amniotomy – Artificial rupture of membranes during

labor

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2. Slight weight loss 7. Show
1-3 lbs. Internal cervical mucus plug has been released
Progesterone level decreases “Bloody Show” – blood from cervical capillaries
Increases fluid excretion mixed with mucus plug
Increased urine production

8. Uterine Contractions
Braxton Hicks
− Last week or days before labor begins
3. Excess energy
− May be extremely strong (varying or no
Burst of adrenaline to provide energy for labor
change)
4. Backache − Localized in the abdomen
Intermittent − Due to decreasing progesterone levels
Stronger than usual − Primigravid mothers may not be able to
Labor contractions begin in the back distinguish between Braxton Hicks and true
contractions
5. Cervical Ripening
− Relieved by rest, activity, or repositioning
Cervix feels very soft upon palpation during
internal examination True Labor
“Butter soft” − Begin at the back and sweeps forward
Goodell’s sign – earlobe consistency of cervix across abdomen and possibly legs
throughout pregnancy − Gradually increases in frequency and
intensity
− Painful, wavelike, building and receding
− Not relieved by rest
− Uterus becomes hard on palpation,
indentation with fingers is not possible

COMPONENTS OF THE BIRTHING PROCESS

PASSAGE
6. Rupture of Membranes Mother’s pelvis
Sudden gush or scanty, slow seeping of clear Route a fetus must travel from the uterus through
fluid from the vagina the cervix
Early ROM helps fetal head descent and Fetopelvic disproportion – commonly caused by
engagement the insufficient pelvic structure
− Cervical dilation and labor progression Shape of Pelvis
Amniotic fluid continues to be produced until − Gynecoid
delivery of the membranes after the birth of the − Android
child − Anthropoid
Risks − Platypelloid
− Intrauterine Infection – labor does not
before spontaneously by 24h PASSENGER
− Umbilical Cord prolapse Refers to the fetus and its ability to move through
the passage
Affected by the following fetal features
− Fetal skull
− Fetal Presentation (Cephalic)
− Fetal Lie (Longitudinal)
− Fetal Attitude
− Fetal Position
− Fetal Station

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POWER Ends when rapid cervical dilatation
Uterine contractions begins
Phases Cervical dilation: 0-3 cm
− Increment – building up phase (longest) Mild and short contractions
− Acrement – peak of contraction − 20-40 seconds
− Decrement – letting down phase − May be irregular
Characteristics Longer for women with “nonripe” cervix
− Duration Primipara: around 6 hours
Beginning of increment to end of Multipara: 4 ½ hours
decrement Nursing Care
Early labor: 30 seconds − Pain Management
Late labor: 60-90 seconds Analgesia may be given but if
− Frequency given too early, it may prolong
Beginning of one contraction to the the stage
beginning of the next Assist mother to prepare
Early labor: 5-30 mins apart psychologically
Late labor: 2-3 mins apart Teach controlled and deep
− Intensity breathing exercises
Measured through palpation or Encourage activity, ambulation,
intrauterine catheter and other non –
pharmacotherapeutic measures
Offer clear liquids or ice chips
Involve partner, family, or support
person
Provide calm environment
Psychological Maternal Responses
− Anticipation
− Excitement
− Apprehension

2. Active Phase
More rapid cervical dilatation (4-7 cm)
Uncomfortable phase for the mother
Stronger contractions (40-60 seconds
PSYCHE every 3-5 minutes)
Maternal psychological state Bloody show and spontaneous rupture of
Feelings that the mother brings to the labor membranes may occur
Apprehension, fear, wonder, excitement Primipara: around 3 hours
Factors affecting psychological readiness Multipara: around 2 hours
− Presences of support system Nursing Care
− Degree of preparation Frequent perineal care
− Childbirth education classes Encourage mothers to keep active
− Past experiences and assume most comfortable
− Accomplishment of pregnancy tasks position except flat on back
− Feeling of control over situation Pain management
Anticipate mood swings and difficulty
STAGES OF LABOR in coping (offer support)
FIRST STAGE OF LABOR Continue to involve family and partner
From onset of true labor contractions until full Positioning
cervical dilation − Upright
Average – 12 hours − Left side lying
− Primipara: 6-18 hours
− Multipara: 2-10 hours 3. Transition Phase
Recent research suggests that normal labor can Cervical Dilatation (8-10 cm)
take longer Contractions reach peak of intensity
Three Phases Longer contractions (60-70 seconds
1. Latent Phase every 2-3 minutes)
Begins at onset of regularly perceived Full cervical dilatation and effacement
uterine contractions ROM may occur at full cervical dilation
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 Strong urge to push Cardinal Movements of Labor
Nursing Care 1. Fetal Engagement, Descent, and Flexions
Mothers may experience intense
2. Internal Rotation
discomfort, nausea and vomiting,
Of the fetal head at the internal perineum
feeling of loss of control, anxiety,
Aligns fetal head in the most optimum
panic, or irritability
position for descent (widest part at widest
Help direct maternal focus to birthing
inlet area)
of baby
Perineum may appear bulging and tense
Provide support
Anus may be everted; stool may be
Stay with the mother at all times
expelled
Crowning – fetal scalp visible at the
SECOND STAGE OF LABOR
opening of the vagina

3. Extension
Delivery of the head
Compression of presenting parts

4. External Rotation
Head rotates to being the anterior
shoulders into the best line with the pelvis
Slight upward flexion needed to deliver
posterior shoulder
Watch for: Shoulder dystocia in
macrosomic babies

5. Expulsion of the baby

The baby is considered born once the
entire body is already delivered and
exposed to the extrauterine life

THIRD STAGE OF LABOR

Begins with the birth of the infant and ends with
the delivery of the placenta (1-30 mins_
Two Phases
1. Placental Separation
Placenta detaches from the uterine wall
Signs
− Lengthening of the umbilical cord
− Sudden gush of vaginal blood
Complete cervical dilatation to delivery of the
− Placenta is visible at the vaginal
neonate
opening
Lasts 2-60 minutes
− Uterus contracts and feels firm
Primipara: 40 mins average
− Presentations: Schultze and Duncan
Multipara: 20 mins average
Psychological Maternal Responses
− Focus from discomfort to active pushing
− Exhaustion
Nursing Care
− Assist with second stage pushing
− Prepare birthing area
− Assist mother in birthing position 2. Placental Expulsion
− Be ready to assist in episiotomy Placenta is delivered through natural
− Prepare for and assist with delivery bearing down or gentle pressure on the
Mother may feel contracted uterine fundus (Crede’s
− Uncontrollable urge to push Maneuver)
− Nausea and vomiting (due to decrease in No pressure on noncontracted uterus –
abdominal pressure) can cause uterine eversion and massive
Fetus moved along the birth canal by the hemorrhage
mechanisms of labor
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 Excessive hemorrhage with poor FOURTH STAGE OF LABOR
contraction – administer Hemabate or Time immediately after placental delivery
Methergine (Check BP before First hour after delivery (recovery period)
administration) Beginning of the postpartum period
Note time of placental delivery Postpartum period: 6 weeks
Inspect intactness of placenta High risk for hemorrhage
Inspect for placental remains (leads to Psychological Maternal Responses
uncontracted uterus and bleeding) − Attention towards neonate
Psychological Maternal Responses − Adjusting to maternal role
Nursing Care
− Concern for neonate’s condition
− Primary activity is stabilizing the status of the
− Discomfort from uterine contractions before
neonate and helping neonate get acclimated
placental expulsion
to extrauterine life
Nursing Care
− Focus on maternal-neonatal bonding
− Assist with the delivery of the placenta
− Obtain vital signs every 15 mins for the first
− Assist with episiorrhaphy
hour
− Administer oxytocin as ordered (IV)
− Assess lochia, consistency and position of the
− Introduce neonate to the parents and allow
fundus, episiotomy site
breastfeeding
− Be prepared to initiate emergency procedures
Classification of Perineal Lacerations
if mother’s or child’s condition do not stabilize
Classification Description of involvement
Vaginal mucous membrane and
First degree skin of the perineum to the
fourchette
Vagina, perineal skin, fascia,
Second degree levator ani muscle, and perineal
body
Entire perineum, extending to
Third degree reach the external sphincter of
the rectum
Entire perineum, rectal sphincter,
Fourth degree and some of the mucous
membrane of the rectum

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