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Chapter 12--Processes & Stages of Labor and Birth

Chapter 12--Processes & Stages of Labor and Birth. Critical Factors In Labor. The Four P’s: passage, passenger, powers & psyche Passage : adequate pelvis? cephalopelvic disproportion (CPD) Suspect if presenting part does not engage in pelvis (0 station). Passenger.

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Chapter 12--Processes & Stages of Labor and Birth

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  1. Chapter 12--Processes & Stages of Labor and Birth

  2. Critical Factors In Labor • The Four P’s: passage, passenger, powers & psyche • Passage: • adequate pelvis? • cephalopelvic disproportion (CPD) • Suspect if presenting part does not engage in pelvis (0 station)

  3. Passenger • The fetus: head is largest diameter • Fetal head: 4 bones with 3 membranous interspaces (sutures) that allow bones to move & overlap to diminish size of skull • Molding: head becomes narrower, longer, sutures can overlap--normal--resolves 1-2 days after birth • Fontanelles: at junctures of skull bones

  4. Passenger • Fetus and fetal membranes • Molding of head • Fetal lie • Longitudinal • Transverse • Oblique

  5. Fetal Lie and Presentation • Leopold's maneuvers/US • Longitudinal lie: Vertical • Presenting part: • cephalic (head), • vertex (occiput), chin (mentum) • breech (buttocks or feet) (c-section) • sacrum • Transverse lie: Horizontal (c-section) • Presenting part: shoulder (acromion)

  6. Passenger (cont.) • Fetal attitude—flexion • Fetal presentation • Cephalic • Vertex • Military • Brow • Face

  7. FetalAttitude

  8. Advantages of Cephalic Presentations • Head usually largest part of infant • Molding • Optimal shape—smooth and round

  9. Breech presentation Assessment: FHT heard high on the abdomen, Leopold’s, vaginal exam & US. • Higher risk of anoxia from prolapsed cord, traumatic injury to the after coming head, fracture of spine or arm, dysfunctional labor • Usually delivered by C-section

  10. Disadvantages of Breech Presentation • Risk of cord prolapse • Presenting part less effective in cervical dilation • Risk of cord compression • Risk of prolonged labor

  11. Shoulder Presentation • Occurs when fetus in transverse lie • Cannot be delivered vaginally unless rotation occurs

  12. IMPORTANT TERMS • Effacement: shortening and thinning of cervix • Expressed as a percentage (0% to 100%) • Dilation: opening and enlargement of cervix • Expressed in centimeters (1 to 10 cm)

  13. Station Descent of fetal head (in cm) Effacement Thinning of cervix (in %)

  14. Descent of fetal head: Station Floating Engaged At outlet/crowning

  15. Passageway +Passenger Relationship • Engagement • Station • Ischial spines—0 station • Above ischial spines—(–) minus station • Below ischial spines—(+) plus station • +4 cm means that ...

  16. Powers • Uterine contractions—primary force • Maternal pushing efforts—secondary force • Characteristics of uterine contractions • Increment • Acme • Decrement

  17. Powers Maternal Pushing Efforts • “Bearing down” sensation • Urge to push • No urge to push

  18. Assessment of Uterine Contractions • Characteristics • Frequency • Duration • Intensity • Palpation • Electronic fetal monitoring

  19. Onset of labor • Usually begins between 38 & 42 weeks • Mechanism is unknown • Upper uterus contracts downward pushing presenting part on cervix causing effacement and dilatation • Premonitory signs of labor: • Lightening, Braxton-Hicks contractions (false labor), • cervical changes (ripening), • bloody show (mucous plug), • rupture of membranes (ROM), • sudden burst of energy

  20. False Labor Benign and irregular contractions Felt first abdominally and remain confined to the abdomen and groin Often disappear with ambulation and sleep. Do not increase in duration, frequency or intensity True Labor: Begin irregularly but become regular and predictable Felt first in lower back and sweep around to the abdomen in a wave Continue no matter what the women’s level of activity Increase in duration, frequency, and intensity False vs True Labor:Contractions

  21. False Labor No significant change in dilation or effacement No significant bloody show Fetus- presenting part is not engaged in pelvis True Labor Progressive change in dilation and effacement Bloody show Presenting part engages in pelvis False vs True Labor:Cervix

  22. Critical Thinking • A primigravida client has just arrived in the birthing unit. What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus? A. Check for ruptured membranes, and apply a fetal scalp electrode B. Auscultate the fetal heart rate between and during contractions C. Palpate contractions and resting uterine tone D. Perform a vaginal exam for cervical dilation, and perform Leopold's maneuvers E. Determine gestational age of fetus

  23. First Stage of Labor: • 0 to 10 cm: dilatation--opening of cervix) • Latent: slowest part of the process--slow dilation, mild contractions • from onset of regular UCs to rapid dilatation (about 3-4 cms) • Active: labor “picks up steam”--period of more rapid dilation • from 4 cm to full dilatation: stronger UCs • Transition: 7-10 cm--intense, N/V, shaking

  24. Landmarks • Abbreviations are used • First and last letter—maternal pelvis • Middle letter—fetus presenting part • Examples • ROA (right occiput anterior) • ROP • LSP

  25. Psychosocial Influences • Other critical factors • Readiness, educational preparedness, etc. • Cultural views of childbirth • Role transition facilitated by positive childbirth experience • Negative experience interferes with bonding and maternal role attainment

  26. Childbirth Settings and Labor Support

  27. Admission Procedures • Establish positive relationship • Collect admission data • Initial admission assessments • Focused • Psychosocial assessment • Cultural assessment • Laboratory tests

  28. Nursing Care • Ongoing assessment • Facilitate a positive birth experience • Manage discomfort • Advocate for patient’s needs • Provide anticipatory guidance

  29. Initial physical assessment & history Admission--rapport Fetal & UC monitoring Vaginal exams, q 2 hours Vital signs Temperature q 4 hours-intact or q 2 hours ROM Educate regarding labor Encourage comfort, position changes, bladder emptying Assess pain, pain tolerance, preferred type of labor/delivery Reassure regarding what is normal, reduceanxiety • Couple excited, talkative, pain is manageable Care of Laboring Patient Early Labor

  30. Couple quieter, discouraged, pain increasing Care of Laboring PatientActive Labor • Transition (7-10 cm): Yikes! “out of control”, shaking, nausea/vomiting, sweating, pain is intense • Prepare for delivery • Second stage (Pushing): • Educate/instruct regarding pushing • Assess urge to push and fetal descent • Encourage/motivate patient, assess fatigue • Monitor fetal/maternal response to pushing bulge, crowning • Signs of imminent birth: perineal bulging

  31. Labor Support • Presence • Promote comfort • Environment • Personal hygiene • Elimination • Supportive relaxation techniques

  32. Critical Thinking A client is admitted to the labor unit with contractions 2 to 3 minutes apart and lasting 60 to 90 seconds. The client is apprehensive and vomiting. This nurse understands this information to indicate that the client is most likely in what phase of labor? • A) Active • B) Transition • C) Latent • D) Second

  33. Fetal Assessment • Position • Fetal heart sounds • Baseline FHR • Presence of • Variability • Accelerations • Decelerations

  34. Interpretation of FHR Tracings • Consider contraction frequency and intensity, stage of labor, and earlier FHR pattern • Reassuring • Non-reassuring

  35. Nursing Care • FHR decelerations • Early: no action • Variable and late • Lateral position changes • Oxygen per face mask • Palpation for hyperstimulation • Discontinue oxytocin • Increase IVF rate

  36. Second Stage of Labor • Full dilation through birth of infant • Urge to push • Promote effective pushing • Closed-glottis • Open-glottis • Position of comfort

  37. Preparation for Birth • Bulging of the perineum and rectum • Flattening and thinning of the perineum • Increased bloody show • Labia begin to separate

  38. Dilatation & Effacement

  39. Imminent Birth • Crowning • Burning sensation • Intense pressure in rectum

  40. Mechanisms of labor. A, Descent. B, Flexion. C, Internal rotation. D, Extension. E, External rotation. Cardinal Movements of Birth

  41. Head Rotation during Descent

  42. Crowning Crowning In the hospital Alternative settings

  43. Nursing Diagnoses for Intrapartal Patient • Pain • Knowledge deficit • Anxiety • Fatigue • Risk for infection • Impaired fetal gas exchange

  44. Third Stage • Birth of baby to complete delivery of placenta • Smaller, spherical uterus • Elevation of uterus in abdomen • Lengthening and protrusion of cord • Gush of blood from vagina

  45. Fourth Stage • Delivery of placenta through 1 to 2 hours after birth • Monitor position and firmness of uterus • “Boggy,” soft uterus • Report immediately • Initiate fundal massage • Assess lochia • Vital signs and urine output • Shivering—offer blankets

  46. Fourth Stage—Risk Signs • Hypotension • Tachycardia • Excessive bleeding • Noncontracting uterus

  47. Chapter 13 Promoting Patient Comfort During Labor and Birth

  48. Pain During Labor and Birth • Shaped by past experiences • Assessing pain • Physiological, psychological indicators • Patient responses • May be intensified by fear, anxiety, fatigue

  49. Physical Causes of Pain Labor and Birth

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