LABOR AND DELIVERY by Princess Lianne (engagement, attitude, position)

Aglibot finalized by Hero Daniel Fernandez Psychological Response

LABOR – when abdominal pressure and uterine 1) PASSENGER – size, presentation, position
contraction expels fetus and placenta outside the of the fetus, little attitude and fetal lie
body - FETAL HEAD – largest part of the baby;
- Process of “fetal expulsion” with products of bones of the skull are joined by membranous
conception secondary to regular progressive sutures that allow overlapping or molding of
and frequent uterine contraction cranial bones during birthing process
- Usually starts within 2 weeks (before/after)
the estimated date of delivery 2) FETAL LIE – relation after long axis of the
- Cause of labor to start: unknown fetus to that of the mother
- It lasts 12-18 hrs in 1st pregnancy - Longitudinal lie: ~99%
- Labor is Shorter in subsequent pregnancy (6-8 - Transverse lie: <1%
hrs) - OBLIQUE LIE – unstable; always become
- Every woman's labor is different longitudinal or transverse during the course of
- Achieved with changes in the biochemical labor
connective tissue and with gradual effacement
and dilation of the uterine cervix as a result of 3) FETAL PRESENTATION – presenting part
rhythmic uterine contractions of sufficient of fetus which enter the pelvis; either
frequency, intensity, duration (page 37) foremost within the birth canal or in closest
proximity to it
SIGNS OF LABOR
● Persistent lower back pain/abdominal pain Types of presentation:
with premenstrual feeling and cramps ● CEPHALIC – head in presenting part,
● Painful contractions that occur at regular and usually vertex (occiput), “Most favorable and
increasingly shorter intervals (becomes longer ideal”
and stronger in intensity) - Sinciput-brow-face presentation when the
● Broken waters fetal neck is sharply extended
● Membrane may rupture with a gush or a ● BREECH – buttock/lower extremities present
trickle of amniotic fluid first,most managed through Cesarian birth.
- Frank breech : buttocks
GOALS IN MANAGEMENT OF LABOR - Full breech: baby in squatting position
● Achieve normal delivery with healthy child - Footling breech: one/both feet presenting
(Malpractice cases!) ● SHOULDER – presenting part of the
● recognize and treat potential abnormal scapula, baby on horizontal or transverse
conditions before significant hazard develops position
for the mom and fetus
4) FETAL POSITION – Relationship of the
PRINCIPLES OF LABOR MANAGEMENT fetal presenting part to a specific quadrant of
● Diagnosis of labor (recognition of the start) the woman's maternal bony pelvis
● Monitoring of the progress of labor ● Maternal bony pelvis has four quadrants
● Ensuring maternal well-being ● Right and left anterior
● Ensuring fetal wellbeing ● Right and left posterior
● 3-letter abbreviation - maternal side (R or L),
CRITERIA FOR NORMAL LABOR the fetal presentation, maternal quadrant (Aor
● Spontaneous expulsion of a: single P)
mature fetus (37-42 weeks) ● RIGHT/LEFT OCCIPUT ANTERIOR –
● Presented by vertex fetal occiput on maternal right/left side toward
● Through the birth canal (vagina) front, face is down
● Within a reasonable time (more than 3 hrs,less ● “Favorable deliver position”
than 18 hrd)
● Without complications to the mother and fetus 5) ATTITUDE OR POSTURE
● In later months of pregnancy, fetus forms an
FIVE ESSENTIAL FACTORS IN LABOR avoid mass that corresponds roughly to the
Passageway : MATERNAL PELVIS shape of the uterine cavity
Passenger: FETUS (head) ● Fetus becomes folded upon itself
Power: UTERUS (myometrium) ● The back becomes markedly convex
Passageway passenger and their relationship ● Head is sharply flexed
 ● Thighs are flexed over abdomen ● Changes in levels of estrogen (increased)
● Legs are bent at the knees ● Progesterone (dropped)
● prostaglandins (increased)
6) PASSAGEWAY – shape and measurement ● Increasing myometrial irritability
of the maternal pelvis and the Distensibility of
birth canal FIVE THEORIES OF LABOR ONSET
● UTERINE STRETCH THEORY – hollow
7) ENGAGEMENT – Settling of the fetal organ stretched to its maximum potential
presenting part for enough into the pelvis to always expels its contents
the level of the ischial spines ● PROSTAGLANDIN THEORY –
- Occurs 2 weeks before labor (primipara) arachidonic acid stimulates
- Occurs at beginning of labor (multipara) ● PROGESTERONE DEPRIVATION
THEORY – sudden drop in progesterone
8) STATION – Relationship of the fetal levels will initiate contractions
presenting part to the level of ischial spines ● THEORY OF AGING PLACENTA –
- Measurement of how far the presenting part placenta degenerate at 36 weeks (body
has descended into the pelvis perceives it as foreign object)
- ENGAGED (STATION O): when ● OXYTOCIN STIMULATION THEORY –
presenting part is at the ischial spines pituitary gland produce a substance that cause
- If above ischial spine: station expressed as uterine contractions
negative numbers (fetus is floating)

9) POWERS - forces of labor, acting in concert, PRELIMINARY SIGNS OF LABOR

to expel fetus and placenta ● LIGHTENING – descent of the fetal
● UTERINE CONTRACTION – involuntary presenting part into the pelvic brim 2 weeks
● FREQUENCY – Timed from beginning of before delivery (primigravida)
one contraction to the beginning of the next ● INCREASED LEVEL OF ACTIVITY - an
contraction increase in epinephrine release initiated by the
● INTENSITY – strength of contraction decrease in progesterone by placenta
● DURATION – length of contraction (lasts ● BRAXTON HICKS CONTRACTION –
more than 90 seconds without subsequent May be interpreted as true labor contractions
relaxation must be reported) ● EFFACEMENT/RIPENING OF THE
● VOLUNTARY BEARING – down effort CERVIX – Integral and sure sign seen only
- After full dilation of cervix, mother can use in pelvic examination
abdominal muscles to help expel fetus ● BLOODY SHOW – mucus flag of cervical
- Similar to defecation, but the mother is canal during pregnancy is expelled
pushing out the feet is from birth canal ● RUPTURE OF MEMBRANES –
- Contraction of levator ani muscles experienced as sudden gush for scanty, slow
seeping of clear fluid from vagina
10) PASSAGEWAY AND PASSENGER – ● UTERINE CONTRACTION – surest sign
identified as two of the factors that affect that labor has began with the initiation of
labor effective, productive, involuntary uterine
- The next P is the relationship between contraction
passageway (maternal pelvis) and the _________________________________________
passenger (fetus and membranes) DIFFERENCE BETWEEN FALSE LABOR AND
TRUE LABOR
11) PHYCHOLOGICAL RESPONSE
- The woman relaxed, aware and participating FALSE LABOR
in a birth process usually has shorter, less Contraction : Irregular, no increase in frequency and
intense labor intensity
- A woman who is fearful has high levels of Intervals of contraction: Longer between
adrenaline and norepinephrine which slows contractions
uterine contraction Pain/discomfort: Lower abdomen, walking has no
effect or decreases
THE LABOR PROCESS Bloody show: None
CAUSES Dilation and effacement: None
● Progressive uterine distension
● Increase in intrauterine pressure TRUE LABOR
● Aging of the placenta Contraction : regular, increase in frequency and
intensity and duration
Intervals of contraction: shorter between WHO – defines normal birth as spontaneous in
contractions onset, low risk at the start of labor and remaining so
Pain/discomfort: back then radiates to the abdomen, throughout labor and delivery
not relieved by walking - Infant born spontaneously in the vertex
Bloody show: Present position (37-42 competed weeks of
With Effacement and Dilatation; fetal descent pregnancy)
progress
_________________________________________ STAGES OF LABOR
FIRST STAGE OF LABOR – begins with regular
MECHANISMS OF LABOR uterine contractions and ends with complete cervical
● ENGAGEMENT – biparietal diameter Of dilation at 10 cm
the head passes the pelvic inlet (head fixed in
the pelvis) •3 PHASES:
● DESCENT - downward movement of 1. LATENT PHASE – mild, irregular uterine
biparietal diameter off the fetal head to within contractions (30-45 sec. long) that shorten and
the pelvic inlet; progress of the presenting soften the cervix until 4 cm dilated
part through the pelvis
● FLEXION – as descent occurs, head bends NURSING CARE DURING LATENT PHASE
forward to the chest, chin flexed more firmly ● Establish relationship
to the chest by pressure on fetal head from ● Review record
maternal soft tissue (cervix, vaginal walls, ● Review birth plan
pelvic floor) ● Labor assessment
● INTERNAL ROTATION – during descent, ● Laboratory studies
head enters the pelvis with the fetal antero ● Explain and provide guidance
posterior head diameter in a diagonal or ● Monitor vital signs, pain,FHT, uterine
transverse position activity, breathing
- Fetal skull rotates along axis from transverse
to anteroposterior at pelvic outlet 2. ACTIVE PHASE – begin about 3-4 cm to 7
- head passes the midpelvis cm cervical dilation, characterized by rapid
● EXTENSION – as occiput is born, the back cervical dilatation and descent of presenting
of the next stops beneath the pubic arch and fetal parts
acts as pivot for the rest of the head. Fetal - Contraction are stronger (40-60 secs. Every 3
head passes under the symphysis pubis and is to 5 minutes)
delivered, occiput first, followed by the chest - Show and rupture of membranes may occur
and chin - True discomfort
● EXTERNAL ROTATION – after the head, - Phase last from 3 hours (PRIMIPARA)
head rotates from anteroposterior position, - Last for 2 hours (MULTIPARA)
assumes to enter the outlet back to the
diagonal/transverse position of the early part NURSING CARE DURING ACTIVE PHASE
of labor ● Supportive care
- The head rotates full alignment with back and ● Maternal vital signs hourly
shoulders for shoulder delivery mechanisms ● FHT monitoring every 15 to 30 minutes
- To accommodate the shoulder, the head goes ● Hydration- IV fluid?
back to its original position ● Membranes
● EXPULSION – once shoulders are born, the ● Comfort measures
rest of body is born spontaneously because of ● Pain control
its smaller size. When entire body of the baby ● Labor assessment
has emerged, the birthdays complete. This
time is recorded as the time of birth 3. TRANSITION PHASE – shortest part of
labor but definitely the hardest and most
DEFINITION OF NORMAL LABOR painful
● onset of labor is defined as regular, painful - Contractions 2 to 3 minutes apart and last for
uterine contractions resulting in progressive a minute and a half
cervical effacement - Pushing down further through the cervix
● cervical dilation in the absence of uterine allowing the head to enter the vagina
contraction suggest cervical insufficiency - Can last 10 minutes or an hour or two
● Uterine contraction without cervical change - Patners support is crucial
does not meet the definition of labor - At the end of the phase you will be
 completely dilated (10 cm) - Reestablishing muscle tone

NURSING CARE DURING TRANSITION PHASE MANAGEMENT: treat mother and baby as though
● Support they were HIV positive
● Comfort measures OBSERVE THE FOLLOWING:
● Labor assessment ● Note the time of the delivery of the placenta
● Maternal vital signs and FHT every 15 ● Check the uterus that this is well contracted
minutes and not bleeding
● Examine the placenta and membranes
SECOND STAGE OF LABOR – begins with
complete cervical dilatation and ends with the THE LENGTH OF LATENT PHASE (WALA SA PPT,
delivery of its NOTES ATA)
- 10 cm to birth of the baby PRIMIPARA – 8 hrs-24 hrs
- Contractions occur every 1½ to 2 minutes, MULTIPARA – 5 Hrs-14 hrs
(60-90 secs.) (Client is happy and talkative in latent phase)
- Bulging perineum
CROWNING: when you see the top of your baby's ASSESSMENT DURING LABOR
head through the opening in vagina The initial assessment of labor should include:
RING OF FIRE: the burning or stinging sensation
as baby's head crowns ● Frequency and time of onset of contractions
EFFACEMENT: means that the cervix stretches and ● Status of the amniotic membranes (whether
gets thinner spontaneous rupture of membranes occurred
DILATATION: cervix opens and whether the amniotic fluid is clear or
meconium stained)
-As labor nears, cervix may start to Thin or ● Fetal movement
stretch(efface) and open (dilate) which prepare the ● Presence or absence of vaginal bleeding
cervix for the baby to pass to birth canal
HISTORY TAKING
NURSING CARE DURING SECOND STAGE OF ● OB score
LABOR ● Description of pregnancy
● Presence of nurse, support, reassurance ● Plans of labor
● Monitor vital signs every 5 to 15 minutes and ● Future childcare
fht ● Post pregnancy
● Assist with pushing ● Health history
● Position changes
● Prepare for birth POINTS TO REMEMBER
● BRAXTON HICKS CONTRACTION must
THIRD STAGE OF LABOR – period between the be differentiated from true contraction .the
delivery of fetus to the delivery of the placenta and Features of braxton contraction are as follows:
fetal membranes - usually occur no more often than once or
- Delivery of placenta makes less than 10 twice per hour(a few times in a day)
minutes but this stage may last as long as 30 - Irregular and do not increase in frequency
minutes, considered prolonged after 30 with increasing intensity
minutes - Resolve with ambulation or change in activity
- EXPECTANT MANAGEMENT involves
spontaneous delivery of placenta ● Contractions that leads to LABOR have the
- ACTIVE MANAGEMENT: following characteristics:
- Involves Prophylactic administration of - May start as in frequently as every 10 to 15
oxytocin or other euterotonics(prostaglandins minutes, usually accelerate over time,
or ergot alkaloids) increasing to contractions that occur every 2-3
- Cord clamping or cutting and controlled mins.
traction of umbilical cord - Tend to last longer and are more intense than
- “commonly considered for prolonged third braxton hick contractions
stage of labor” - Leads to cervical change
-
FOURTH STAGE OF LABOR – “recovery” period PHYSICAL EXAMINATION
which begins during 2 to 3 hours after delivery ● Maternal vital signs
- Uterus contracts here and there, Pushing out ● Fetal presentation
what is left inside ● Assessment of fetal wellbeing
 ● Frequency, duration and intensity of uterine beginning of the next
contractions
● Abdominal examination with leopold AUSCULTATION – FHT auscultation atleast every
maneuver 15 to 30 minutes during the first stage of labor, every
● Pelvic examination with sterile gloves 5 to 10 minutes during second stage of labor
● Assess fundal height and pelvic adequacy - Normal range 120 to 160 beats per minute
● Percuss bladder best recorded during the 30 seconds immediately
● Inspect lower extremities for edema, skin following a contraction
turgor, and varicose veins
PALPATION – assess intensity of contraction by
● LEOPOLD'S MANEUVER manual palpation of uterine fundus
- Instruct worman to empty bladder MILD: tense condos but can be indented with
- Supine position with miss slightly flexed with fingertips
small pillow on right side MODERATE: firm pandas that is difficult to indent
- Wash hands using warm water with fingertips
STRONG: very firm fundus that cannot be indented
FIRST MANEUVER – Determine if head or with fingertips
buttocks in the fundus
SECOND MANEUVER – locates back of the fetus FETAL ASSESSMENT
THIRD MANEUVER – Determine part at the inlet ● ELECTRONIC FETAL MONITOR –
and its mobility placement of ultrasound transducer and
FOURTH MANEUVER – fetal attitude tocotransducer to record FHT And uterine
contractions and display them on special
● ASSESS RUPTURE OF MEMBRANES – graph paper for comparison and identification
Woman feels sudden gush of fluid from of normal and abnormal patterns
vagina - Can be applied externally to mother's
NITRAZINE PAPER- pH > 6.5 (blue abdomen or internally within the uterus
green,gray,deep blue)
FERN TEST- Ferning pattern ● PATTERN RECOGNITION - nurse is
COLOR – should be clear responsible for assessing FHR patterns,
yellow stained = blood incompatibility implementing appropriate interventions and
Green = meconium reporting suspicious patterns to physician
AMNIOTOMY – artificial rupturing of membranes BASELINE/NORMAL FHR: 120-160 when uterus
- Woman in dorsal recumbent is not contracting
- Measure FHT immediately to check for cord FHR variability is normal, indicative of intact fetal
prolapse nervous system or reliable fetal well-being

● VAGINAL EXAMINATION – do not VARIABILITY: the result of interaction of the

performance woman has placenta previa sympathetic and parasympathetic nervous systems
- Check dilatation and effacement SHORT TERM(beat to beat) – the difference
between successive heartbeats. Assessed as present or
VITAL SIGNS absent or decreased FHR: average 3 to 5 bpm
TEMPERATURE – obtain q2h if membranes are LONG TERM (rhythmic fluctuations) – the broad
ruptured view of the recording and from fluctuations in the
PULSE – persistent >100 means dehydration or FHR . Classified according to the number of cycles
hemorrhage per minute: average 6 to 10 bpm
RESPIRATION – don’t occur during contractions
BLOOD PRESSURE – Measure between TACHYCARDIA – FHR more than 160-180 bpm
contractions, check bp 15 minutes after giving lasting 10 mins
analgesic MARKED TACHYCARDIA – FHR is >180 bpm
that has multiple causes:
● ASSESS UTERINE CONTRACTIONS MATERNAL: fever, dehydration, severe anemia,
DURATION – From the moment the uterus first hyperthyroidism and medications like terbutaline,
tenses until it relaxes again bronchodilators, decongestants and stimulant drugs
INTENSITY – mild, moderate (firm), strong (hard FETAL: arrhythmia (oxygen may be administered)
as wooden board, can't indent the uterus with fingers)
FREQUENCY – beginning of one contraction to the
beginning of the next BRADYCARDIA – FHR less than 120 bpm lasting
INTERVAL – from the end of one contraction to the 10 minutes
MODERATE BRADYCARDIA – FHR is 100-119 infusion
bpm
Is not serious due to fetal head compression during RATIONALE: with each uterine contraction being
labor stimulated by oxytocin,blood flow from the mother to
MARKED BRADYCARDIA – FHR of <100 bpm baby initially ceases as the uterine myometrial veins
Is considered dangerous and maybe of multiple are compressed
causes: - Prepare client for vaginal at examination to
- Umbilical cord compression, fetal hypoxia, assess for prolapse cord
heart block - If chord not prolapse, relieve pressure on the
- Maternal seizure, epidural and spinal cord and do not attempt to replace it
anesthesia - Cesarean delivery is needed
- Oxygen may be administered - Severe variable deceleration indicate fetal
distress
EARLY DECELERATION – periodic decrease in
FHR from pressure on the fetal head brought by the CARE OF WOMAN IN LABOR
parasympathetic stimulation in response to vagal
nerve compression FIRST STAGE - NATURAL LABOR & BIRTH
- FHR between 120 to 160 bpm, a mirror image CONCEPTS
of contraction - Labor should begin on its own, not be
- Deceleration of FHR begins in early or with artificially induced
the peak of uterine contraction, may be within - Women should be able to move freely
normal range (reassuring pattern) and returns throughout labor, not be confined to bed
to baseline by the end of contraction - Women should receive continuous support
- Believed to be the result of compression of during labor
fetal head against cervix
- Not an ominous pattern, no nursing - No interventions such as IVF should be used
interventions required routinely
- Women should be allowed to assume a non
LATE DECELERATION - deceleration begins 30- supine position for birth
40 secs. After the onset of uterine contraction - Mother and baby should be housed together
- Depth varies within the strength of after birth, with unlimited opportunity for
contraction and does not return to baseline by breastfeeding
the end of contraction
- Lowest peak of FHR: 110-120 bpm INTERVENTIONS
- May be occasional or consistent - Give couple frequent progress reports Advise
- Gradual increase in numbers is always breathing exercises; use paper bag or cupped
suspicious and may be reported or charted hands if hyperventilating
- Believed to be the result of utero placental - Reassure the woman that she may move about
insufficiency as needed; if membranes ruptured, side lying
- Nurse should change maternal position, - Encourage woman to void
administer oxygen, discontinue any oxytocin - Suggest to suck on hard candy or ice chips
infusions, assess variability and prepare for
immediate delivery if patterns remain SECOND STAGE
uncorrected - Raise both woman's legs at the same time to
- An ominous pattern prevent strain on her back and lower
abdominal muscles
VARIABLE DECELERATION – onset of - Place in lithotomy position only at the last
deceleration not related to uterine contraction moment to prevent intense pelvic congestion
- Occurs at unpredictable times seen in U,V,W causing thrombophlebitis, excessive blood
shaped waves loss during birth and placental loosening
- Lowest FHR: 55-85 bpm - Advise mother to push only during
- Believed to be the result of compression of contractions and rest between them; urge her
the umbilical cord to breathe out during a pushing effort
- Although not an ominous pattern, continued
nursing assessment is required - For multipara, advise to pant with
- Nurse should change maternal position from contractions to keep labor from moving too
supine to trendelenburg to relieve pressure on fast
chord, if no improvement seen then - Immediately after birth of baby's head,
administer oxygen and discontinue oxytocin suction the infant's mouth with bulb syringe
 - Note and record time of birth when the whole
body is born - Fetal hyperactivity, a sign of hypoxia. Frantic
- Assess vessels in the cord motion is a common reaction for the need for
oxygen
EPISIOTOMY - Fetal acidosis (sign of compromised fetal well
- Surgical incision of the perineum to prevent being, blood pH lower than 7.2): scalp
tearing of the perineum, release pressure on capillary technique
the fetal head with birth, and shorten the last
portion of the 2nd stage of labor MATERNAL DANGER SIGNS
- Rising or falling of blood pressure - sign of
MIDLINE heals more easily, less blood loss, less intrauterine hemorrhage, shock, PIH
postpartal discomfort - Abnormal pulse - sign of hemorrhage
MEDIOLATERAL if tearing beyond incision - Inadequate prolonged contractions (less
occurs, it will be away from the rectum frequent and shorter duration indicates inertia)
- report contractions lasting more than 70
RITGEN MANEUVER seconds
- Sterile towel over the rectum and pressed - Pathologic Retraction Ring - indentation
forward on the fetal chin while the other hand across the woman's abdomen; sign of extreme
is pressed downward on the occiput uterine stress and impending uterine rupture
- Helps the fetus achieve extension, controls
rate at which the head is born DANGER SIGNS OF LABOR
- Abnormal lower abdominal contour indicates
THIRD & FOURTH STAGE full bladder or injured bladder or pressure of
- Check for completeness of placenta Maintain bladder may not allow fetal head to descend
uterus contracted: massage, initiate - Increasing apprehension (sign of oxygen
breastfeeding deprivation and internal hemorrhage) due to
- Administer oxytocin IV or IM after delivery psychological reasons
of placenta to increase uterine contractions;
obtain baseline BP before administration
- Simultaneously lower down the legs to
prevent back injury

- Obtain VS q15 mins for the first hour

- Palpate woman's fundus for size, consistency,
and position
- Observe amount & consistency of lochia
- Offer clean gown and warm blanket because a
woman often experiences chills and shaking
sensation due to cold temperature or sudden
release of pressure on pelvic nerves or excess
epinephrine during labor

ADOPTION
- A woman needs to be an active participant in
her labor and birth experience
- She should watch the baby being born and be
allowed to hold it as desired
- She needs support no matter what decision
she eventually makes
- Do not offer influencing advises

FETAL DANGER SIGNS

- High or Low Fetal Heart Rate: FHR> 160
bpm and < 110 bpm - both signs of possible
fetal distress as shown in the fetal monitor
with late or variable deceleration pattern
- Meconium Staining (green color in the
amniotic fluid results in the loss of sphincter
control); fetus is experiencing hypoxia