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CHAPTER 15 – LABOR AND BIRTH

Labor Prostaglandin Synthesis
- Uterine contractions and abdominal - Vaginal application of prostaglandin
pressure “ripens” cervix for induction of labor
- Progressive dilatation - Amnion and decidua possible sources of
- Baby to be pushed from the birth canal prostaglandin
- Time of change
Placental Aging Theory
COMMON NURSING DIAGNOSIS PERTINENT TO - The physical aging of the placenta may
LABOR INCLUDE cause insufficient nutrients to reach the
- Pain related to labor contractions fetus
- Anxiety related to process of labor and - The placenta reaches a set age, which
birth triggers contractions.
- Health-seeking behaviors related to
management of discomfort of labor • Rising fetal cortisol levels reduce
- Situational low self-esteem related to progesterone formation and increase
inability to use prepared childbirth method prostaglandin formation.
• Semen does contain prostaglandins, which can
THEORIES OF LABOR ONSET be helpful in softening, also known as
Labor normally begins between 37 and 42 weeks of “ripening,” of the cervix
pregnancy, when a fetus is sufficiently mature to adapt • if a cervix is ready to ripen, semen
to extrauterine life, yet not too large to cause prostaglandins could possibly stimulate the
mechanical difficulty with birth. beginning of contractions.
• Rhythmical contractions brought on by a
Progesterone Withdrawal woman’s orgasm can conceivably help as well
- Biochemical changes towards end of
pregnancy Premonitory Signs of Labor
- Changes in the ratio of estrogen to ➢ Lightening
progesterone occurs, increasing estrogen in - Fetus descends into pelvic inlet
relation to progesterone, which is interpreted - Occurs about 2 weeks before onset of
as progesterone withdrawal. labor; after the start of regular
- Decreased availability of progesterone to contractions in multis
myometrium - Woman breathes more easily after
• Antiprogestin at term inhibits relaxant lightening, but urinary frequency returns
effect and enables estrogen to stimulate - There is no cervical effacement or
contractions dilatation

Uterine Stretch Theory ➢ Braxton Hicks contractions

- The uterus reaches a crucial point of - Irregular, intermittent contractions that
distention, which may cause tension on occur during pregnancy
muscle fibers and stimulate their activity - Cause more discomfort closer to onset of
- Which results in release of prostaglandins. labor

Oxytocin Theory ➢ Cervical changes

- Nerve impulses from the uterus to the - Cervix begins to soften and weaken
posterior pituitary gland (when there is (ripening)
pressure in the cervix) may bring about • Effacement
release of oxytocin ¬ shortening and thinning of the
cervical canal
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¬ the longitudinal traction from the Electrolyte shift – water loss
contracting uterus shortens the ➢ Flu-like symptoms – diarrhea, nausea,
cervix so much that the cervix indigestion
virtually disappear
• Dilatation Onset of Labor
¬ refers to the enlargement or - Expulsion of mucus plug; pink/brown-
widening of the cervical canal tinged discharge (bloody show)
from an opening a few millimeters - Regular contractions increasing in
wide to one large enough frequency, duration, and intensity
(approximately 10 cm) to permit - Spontaneous rupture of membranes (SROM)
passage of a fetus may occur before or during labor
¬ increase in the amount of vaginal - Check FHR by auscultation for 1 minute and
secretions (show) because minute with next contraction
capillaries in the cervix rupture ➢ May be a gush or trickle
and the last of the mucus plug ➢ Report strong / foul odor (infection)
that has sealed the cervix since ➢ Meconium-stained (fetal distress /
early pregnancy is released. fetal anoxia)
§ Show – vaginal secretions ➢ Wine-colored (indicative of
premature

There is no cervical effacement or Questionable leakage of amniotic fluids should be

dilation. The fetal head is cushioned tested for alkalinity to differentiate from urine:
by amniotic fluid. a) Nitrazine tapen turns blue/gray/green
(alkaline); urine(acidic) does not change the
yellow color
b) A mixture if cervical mucus and amniotic
Beginning cervical effacement.
fluid dried on a slide looks like crystallized
As the cervix begins to efface, more
ferns by microscopic examination
amniotic fluid collects below the head

TRUE AND FALSE LABOR CONTRACTIONS

Cervix is about one half (50%) effaced
and slightly dilated. True Labor False Labor
The increasing amount of amniotic Regular; intervals Irregular;
fluid below the fetal head ejects. gradually shorten intervals remain
Lower back; sweep long
In the fundus, lower
around the abdomen abdomen, groin
Complete effacement and dilation
Increase in intensity Intensity the same or
and duration variable
Often relieved by
➢ Bloody show Intensified by walking
walking
- loss of cervical mucous plug (may
happen even before labor)
SHOW
- blood-tinged discharge
Usually present; Pink- Usually absent; if
tinged present, brownish
➢ Sudden burst of energy
- From 24 to 48 hours prior to labor onset
CERVIX
(Nesting)
Becomes effaced and No change
dilated
➢ Weight loss of 1 to 3 lbs
Changes in estrogen and progesterone levels
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SEDATION
Does not stop Tends to decrease - Uterine contractions cause dilation and
contractions contractions effacement
- Uterine contractions begin in the fundus
and spread downward
COMPONENTS OF LABOR - They are involuntary
1. THE PASSAGE - They are intermittent allowing for the
¬ a woman’s pelvis uterus (incomplete)
¬ adequate size and contour.
2. THE PASSENGER Origin
¬ the fetus - Like cardiac contractions, labor
¬ appropriate size and in an contractions begin at a “pacemaker”
advantageous position and point in the uterine myometrium near
presentation. one of the uterotubal junctions
3. THE POWERS OF LABOR - Each contraction begins at that point and
¬ uterine factors are adequate. then sweeps down over the uterus as a
4. THE PSYCHE wave. After a short rest period, another
¬ woman’s psychological state which may contraction is initiated and the downward
either encourage or inhibit labor sweep begins again.
¬ can be based on her past life - In early labor, the uterotubal pacemaker
experiences as well as her present may not operate in a synchronous manner.
psychological state. - This makes contractions sometimes strong,
sometimes weak, and somewhat irregular.
IN DEPTH EXPLANATION FOR COMPONENTS OF - This mild incoordination of early labor
LABOR OR THE 4 Ps of LABOR improves after a few hours as the
pacemaker becomes more attuned to
calcium concentrations in the myometrium
1. POWERS and begins to function effectively.
- Refers to uterine contractions
- During a uterine contraction the muscle Contour changes
shortens then returns to normal while ➢ Physiologic retraction ring Upper uterine
ultimately the shortening remains fixed segment (thick and active), Lower uterine
segment (thin walled, suppled, andpassive)
➢ Pathologic retraction ring (Bandl’s ring):
prominent abdominal indentation, signifies
impending uterine rupture if obstruction to
labor is not relieved.
Phases:
Primary power = contractions
o Increment
Secondary power = to the bearing down efforts
o Acme (peak)
o Decrement
• Frequency – uterine contraction is the time
from the beginning of one u/c to the
beginning of the next; from start to next
• As labor progresses, the relaxation intervals
contraction
decrease from 10 minutes early in
• Duration - time from the onset to end of u/c
• labor to only 2 to 3 minutes. The duration of
• Interval - time in between u/c; just the rest
contractions also changes, increasing from
period
• 20 to 30 seconds at the beginning to a range
• Intensity- mild, moderate, strong palpation
of 60 to 70 seconds by the end of the first
• Stage

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Baseline
Normal FHR ranges from 120-160 bpm
-
➢ Above 160 bpm is tachycardia
2. PASSAGEWAY
➢ Below 120 bpm is termed radychardia - a woman’s pelvis
- adequate size and contour.
Fetal Tachycardia - Bony pelvis
- Sustained rate of 161 bpm or above - Soft tissues
- If rate is 180 bpm of above, is marked - Maternal hormones Relaxin in later pregnancy
tachycardia soften the cartilage
- Causes of fetal tachycardia - True pelvis / False pelvis
➢ Early fetal hypoxia
➢ Maternal fever
➢ Maternal dehydration
➢ Amnionitis
➢ Maternal hyperthyroidism
➢ Beta-sympathomimetic drugs
➢ Fetal anemia
- Ominous sign if tachycardia is
accompanied by:
➢ Late decelerations
➢ Severe variable decelerations
➢ Decreased variability

Fetal Bradycardia
- Beat less than 110 bpm during a 10-
minute period or longer
- Causes include:
➢ Profound hypoxia in fetus
➢ Maternal hypotension
➢ Prolonged umbilical cord • inlet – transverse (larger)
compression • outlet – AP (larger)
➢ Fetal arrhythmias • diagonal conjugate (usually 12.5cm)–
➢ Uterine hyperstimulation can be measured by IE, while the other
➢ Abruptio placentae conjugate cannot
➢ Uterine rupture ¬ if less than 12.5 cm, can be CS
➢ Vaginal stimulation in second stage of 3. PASSANGER
labor
¬ the fetus
¬ appropriate size and in an
Hypotonic Uterine Hypertonic
advantageous position and
Contractions Uterine Contractions
presentation.
- Decrease in - Usually occur before
• Molding - overlapping of skull bones along
frequency and 4cm
the suture lines, which causes a change in
intensity - Increased muscle
the shape of the fetal skull to one long and
- Uterine muscle tonus
narrow, a shape that facilitates passage
weakness - Pain out of proportion
through the rigid pelvis. Molding is caused
- Tension not with cervical dilation
by the force of uterine contractions as the
synchronous - Increasing frequency
vertex of the head is pressed against the
- Over - Uterus remains
passageway
distension contracted between
uterine contraction

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• Fetal position - the relationship of the fetal
presenting part to a specific quadrant of the
woman’s pelvis
• Fetal lie - relationship between the long
(cephalocaudal) axis of the fetal body and
the long (cephalocaudal) axis of a woman’s
body—in other words, whether the fetus is
lying in a horizontal (transverse) or a vertical
(longitudinal) position.
Þ Vertex – well-flexion
Þ Sinciput or Military – chin not
touching the chest; causes the
next-widest AP diameter, the
occipital frontal diameter, to • Fetal presentation - the fetal body part that
present to the birth canal will initially contact the cervix; denotes the
Þ Brow – Frontum – some body part that will first contact the cervix or
extension of the forehead be born first and is determined by the
Þ Face – Mentum – combination of fetal lie and the degree of
hyperextension of the chin fetal flexion(attitude).
➢ 95 % are cephalic (head) also vertex
➢ Breech – 3%
TYPES OF BREECH PRESENTATIONS
Frank
- Attitude is moderate
because the hips are
flexed, but the knees are
extended to rest on the
chest.
- The buttocks alone
present to the cervix.
Complete
Brow or Face
- The fetus has the thighs
- may occur if there is less than the normal
tightly flexed on the
amount amniotic fluid present
abdomen
(oligohydramnios)
- both the buttocks and the
- may reflect a neurologic abnormality in the
tightly flexed feet present
fetus causing spasticity
to the cervix.
Know the measurements (even the pelvis) Footling
Suboccipitobregmatic - 9.5 cm - one or both legs
Occipito frontal - 12 cm extended
Occipito mental - 13 cm - Neither the thighs nor
lower legs are flexed
- If one foot presents, it is a
single-footling breech;
- if both present, it is a
doublefootling breech.

• Station – fetal presenting part in

relation to ischial spines
- (-): above
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- (+): below presentations) always presenting to the smallest
- floating: not engaged in pelvis diameter of the pelvis.
- engagement: widest diameter of fetal head
has passed into the inlet, usually “0” station
- When the presenting fetal part is at the level of
the ischial spines, it is at a 0
- station (synonymous with engagement).
§ If the presenting part is above the
1. ENGAGEMENT
spines, the distance is measured and
o settling of the presenting part of a
described as minus stations, which
fetus far enough into the pelvis that it
range from −1 to −4 cm.
rests at the level of the ischial spines,
§ If the presenting part is below the ischial
the midpoint of the pelvis.
spines, the distance is stated as plus
stations (+1 to +4 cm).
2. DESCENT
§ At a +3 or +4 station, the presenting
Forces that cause descent
part is at the perineum and can be seen
o Pressure of the amniotic fluid
if the vulva is separated (i.e., it is
o Contraction of the uterine fundus
crowning).
o Contraction of the mother’s
diaphragm and abdominal
• Position – fetal presenting part in
muscles
relation to the maternal pelvis
o Extension of the fetal body
st
» 1 letter – Right or Left of mother’s o Measured by station
spine o Accelerates in the active phase
nd (cervical dilatation of 5-7 cm)
» 2 letter – depends on attitude
and presentation Occiput/ Mentum/ o Rapid after rupture of
Sacrum/ Acromion/ Dorsal membranes
o Assessed in Leopold’s maneuver
» 3rd letter – Anterior, Posterior, or
o downward movement of the biparietal
Transverse of pelvis diameter of the fetal head within the
pelvic inlet.
LOA, and ROA, OA – most common and favorable
for delivery 3. FLEXION
o Happens when the head meets
4. PSYCHE resistance from the cervix and
pelvic floor
- woman’s psychological state which may either
o Allows the
encourage or inhibit labor
suboccipitobregmatic diameter
- can be based on her past life experiences as
to present
well as her present psychological state.
o the fetal head touches the pelvic
- Physical preparation for childbirth
floor, the head bends forward
- Cultural heritage
onto the chest, causing the
- Previous experience
smallest anteroposterior
- Support system
diameter to present to the birth
- Self-esteem
canal
- Psyche disorders

4. INTERNAL ROTATION
MECHANISMS OR CARDINAL MOVEMENTS OF
o Fetal head enters the pelvis with
LABOR
the biparietal diameter parallel to
the pelvic AP diameter
are different position changes in order to keep the
o Internal rotation
smallest diameter of the fetal head (in cephalic
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o Fetal head passes through the o anterior shoulder rotates to the
pelvic outlet with the biparietal midline (external rotation)
diameter perpendicular to the o anterior shoulder delivered from
pelvic AP diameter under the public arch
o Begins at the level of the ischial o Posterior shoulder is guided over
spine the perineum
o Brought about by the bony o the head rotates a final time (from the
pelvis and levator ani anteroposterior position it assumed to
o As the head flexes at the end of enter the outlet) back to the diagonal
descent, the occiput rotates so the or transverse position of the early part
head is brought into the best of labor. This brings the after coming
relationship to the outlet of the pelvis, shoulders into an anteroposterior
or the anteroposterior diameter is now position, which is best for entering the
in the anteroposterior plane of the outlet. The anterior shoulder is born
pelvis. This movement brings the first, assisted perhaps by downward
shoulders, coming next, into the flexion of the infant’s head.
optimal position to enter the inlet

7. EXPULSION
5. EXTENSION o head and shoulders are lifted up
o The perineum deflects the fetal towards the mother’s pubic bone
head anteriorly ➢ trunk is born by flexing it
➢ occiput passes under the laterally in the direction of the
lower border of the symphysis pubis
symphysis pubis ➢ delivery is completed!
➢ head emerges by extension o Once the shoulders are born, the rest of
(occiput – face – chin) the baby is born easily and smoothly
o As the occiput of the fetal head is because of its smaller size. This
born, the back of the neck stops movement, called expulsion, is the end of
beneath the pubic arch and acts as a the pelvic division of labor.
pivot for the rest of the head. The head
extends, and the foremost parts of the
head, the face and chin, are born.

STAGES OF LABOR
Labor is traditionally divided into 3 stages:
6. RESTITUTION / EXTERNAL ROTATION st
1 stage– begins with the initiation of true labor
o Head rotates to its position during
contractions and ends when the cervix is fully
engagement at the inlet (restitution)
dilated
o Fetal heal realigns with the back and
shoulders 2nd stage – extending from the time of full

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dilatation until the infant is born - Effacement: 50-75%
rd
- Dilation: 4-7 cm
3 stage– lasting from the infant is born until after
the delivery of the placenta. - Contraction:
➢ F: every 3-5 mins
4th stage - The first 1-4 hrs after birth of placenta, to
emphasize the importance of the close maternal ➢ I: Moderate
observation ➢ D: 40-60 sec
- Station: - 1 – 0
- Primiparas: 3 hr
FIRST STAGE - Multiparas: 2 hr
CERVICAL DILATION - Division: Acceleration (4-5 cm), Max
- from onset of regular contractions to full Slope (5-9 cm)
dilation
- averages 13-18 hrs for nulliparas
- 8-9 hrs for multiparas
TRANSITION PHASE
PHASE DURATION CERVICAL INTENSITY - contractions reach their peak of intensity a
DILATION woman may experience intense discomfort
LATENT 20-40 0-3 cm Mild that is so strong, it might be accompanied by
Seconds nausea and vomiting.
ACTIVE 40-60 4-7 cm Moderate - She may also experience a feeling of loss of
Seconds control, anxiety, panic, and/or irritability
TRANSITION 60-90 8-10 cm Strong - 8- 10 cm – contractions may be every 1.5 to
Seconds 2 min and last 60-90s
- Effacement: 70-100%
LATENT PHASE - Dilation: 8-10 cm
- The latent or early phase begins at the onset - Contraction:
of regularly perceived uterine contractions ➢ F: every 2 mins
and ends when rapid cervical dilatation ➢ I: Strong
begins. ➢ D: 60-90 sec
- the cervix begins effacing and dilating and - Station: 0- +1
contractions become increasingly stronger - Nulliparas: should not be more than 3
and more frequent - Multiparas: 0.5 – 1 hr
- Effacement: 0-50%
- Dilation: 0-3 cm May be accompanied by:
- Contraction: - irritability and restlessness
➢ F: 5-10 mins - hyperventilation
➢ I: Mild - dark heavy show
➢ D: 20-40 sec - leg cramps
- Station: - 2 – 0 - nausea/vomiting, hiccups, belching
- Nulliparas: 6 hr - possible rectal pressure creating a
- Multiparas: 4.5 hr desire to push
- may cause maternal exhaustion and
ACTIVE PHASE cervical and fetal trauma
- More rapid dilation of cervix and descent of - extreme back pain
presenting part
- During the active phase of labor, cervical Nursing Care for First Stage of Labor
dilatation occurs more rapidly. PSYCHOLOGICAL PREPARATION
- Show (increased vaginal secretions) and - orientation to the process of labor and
perhaps spontaneous rupture of the general environment
membranes may occur during this time - establishment of nurse-patient
relationship
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- providing assurance her perineum begins to bulge and
appear tense.
PHYSICAL PREPARATION - The anus may become everted, and
- nutrient and fluid intake stool may be expelled.
- management of discomfort • CROWNING - As the fetal head
(pharmacologic and non-pharmacologic) pushes against the vaginal
- vulvar and perineal preparation introitus, this opens and the
- Enema (contraindications) fetal scalp appears at the
» unengaged vertex opening to the vagina and
» nonvertex life enlarges from the size of a
» abnormal amount of vaginal bleeding dime, to a quarter, then a half-
» placenta previa and abruptio placenta dollar.
» advanced labor - Contractions are now severe, lasting 60-
90s at 1.5-3 min intervals
- Nulliparas: averages 2hr for
- Multiparas: 20 mins
- Bearing down/ pushing increases intra-
abdominal pressure (pushes the
presenting part against the pelvic floor)
- Causing a stretching, burning sensation,
and bulging of the perineum
- “crowning” – occurs when the presenting
part appears at the vaginal orifice,
distending the vulva

TIMING OF TRANSFER TO DELIVERY ROOM

nd stage when
1. NULLIPARAS – during 2
the presenting part begins to distend the
perineum
MULTIPARAS – at the end of the 1st stage
SECOND STAGE 2.
when the cervix is dilated 8-9 cm
FETAL EXPULSION
- from complete dilation of cervix to NORMAL SPONTANEOUS VAGINAL DELIVERY
delivery of the baby a. The mother is encouraged not to push as
- A woman typically feels contractions the head is delivered;The infant cries (or
change from the characteristic is encouraged to do so to expand the
crescendo–decrescendo pattern to an lungs); If the cord is encircling the neck
uncontrollable urge to push or bear (nuchal cord), it is gently slipped over the
down with each contraction as if to head
move her bowels. b. Episiotomy (a surgical incision of the
- She may experience momentary perineum) may be done at the end of the
nausea or vomiting because pressure is second stage of labor to facilitate delivery
no longer exerted on her stomach as and to avoid laceration of the perineum
the fetus descends into the pelvis.
- She pushes with such force that she SYMPTOMS OF THE 2ND STAGE OF LABOR
perspires and the blood vessels in her - Woman’s involuntary bearing down –
neck become distended. Ferguson reflex due to pressure of the
- The fetus begins descent and, as the presenting part on stretch receptors of the
fetal head touches the internal pelvic floor
perineum to begin internal rotation, - Woman’s increasing apprehension
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- Sudden increase in show
- Woman’s feeling of wanting to defecate
- Rupture of membranes
- Bulging of the perineum

Nursing Care for Second Stage of Labor

- Asepsis and antisepsis
- Preparation of birth area and instruments
- Positioning the woman
- Coaching the woman on bearing down THIRD STAGE
efforts PLACENTAL STAGE
- Providing psychological support - From the delivery of the baby to delivery
- Pain management of the placenta
• Amniotomy – artificial rupturing of - Two separate phases are involved:
amniotic sac placental separation and placental
expulsion.
• Episiotomy – latter part of 2nd stage
- After the birth of the infant, the uterus can be
• 4th degree laceration – till anus palpated as a firm, round mass just below the
» Midline incision level of the umbilicus.
» Mediolateral incision - After a few minutes of rest, uterine
contractions begin again, and the organ
DELIVERY OF THE BABY assumes a discoid shape.
- Remove fecal material with sponges PRN - It retains this new shape until the placenta has
- As soon as crowning occurs, place a towel separated, approximately 5 minutes after the
over the rectum while exertingforward birth of the infant.
pressure on the baby’s chin with one hand. - If more than 30 mins, placenta is
At the same time, exert downward considered retained
pressure on the occiput using the other
hand (Ritgen’s maneuver) – prevents SIGNS OF PLACENTAL SEPARATION (CULS)
perineal lacerations - Calkin’s sign (globular-shaped uterus)
- Immediately after the birth of the head, - Uterine fundus rises in abdomen
wipe the baby’s face with a towel and - Lengthening of the cord
suction the mouth the nose (do not wipe - Small gush of blood from vagina
hands unless it contains feces)
- Pass a finger along the occiput to the MECHANISM OF PLACENTAL SEPARATION
baby’s neck to feel for umbilical loops If the placenta separates first at its center and lastly at
➢ LOOSE NUCHAL CORD – slip its edges, it tends to fold on itself like an umbrella and
over the baby’s head presents at the vaginal opening with the fetal surface
➢ TIGHT NUCHAL LOOP – clamp evident. Approximately 80% of placentas separate and
and cut present in this way.
- The anterior shoulder is delivered first, 1. Shultze Mechanism of Placental
then the posterior shoulder, followed by Separation
the rest of the baby’s body - Shiny Schultz; Fetal side
- Take note of the time of delivery - Appearing shiny and glistening from the fetal
- Clamp the umbilical cord with 2 clamps. membrane
Cut between the clamps. (Surgeon - Retroplacental clot
will clamp and cut UC) - Placenta/ membranes dragged
downwards
- Membranes peel from periphery
- Placental delivered by inversion

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2. Duncan Mechanism of Placental Separation she has competent people with her to offer
- Dirty Duncan; Maternal side support, reassurance, and comfort.
- Separation at periphery of placenta
- Placenta descends to vagina sideways 2. Fear
- Maternal surface of placenta appears first • They appreciate a review of the labor process
- separates first at its edges, it slides along early in labor as a reminder that childbirth is
the uterine surface and presents at the not a strange, bewildering event but a
vagina with the maternal surface evident predictable and well-documented one.
- looks raw, red, and irregular, with the • Being taken by surprise—labor moving faster or
ridges or cotyledons that separate blood slower than the woman thought it would or
collection spaces evident; contractions harder and longer than she
remembers from last time—can lead a woman
Nursing Care for Third Stage of Labor to feel out of control and increase the level of
- Do controlled cord traction pain she experiences.
- Deliver the placenta slowly • Explain and repeat as necessary that labor is
- Massage fundus until it is hard / predictable but also variable.
contracted • Contractions last a certain length and reach a
- Administer methergine / oxytocin as certain intensity but always have a rest period
ordered in between so she can have a break from pain.
- Check if placenta is complete • Fear of labor this way releases adrenaline, and
- Inspect perineum for laceration adrenaline interferes with oxytocin release and
so can limit the effectiveness of uterine

FOURTH STAGE contractions

- Immediate recovery period from delivery of 3. Cultural Influences

placenta to stabilization of maternal - Cultural factors can strongly influence a
systemic responses and contraction of the woman’s experience and satisfaction with
uterus; from 1 to 4 hr labor.
a. Mother begins to readjust to - women are encouraged to help plan their
nonpregnant state care. In addition, every woman responds to
b. Areas of concern include discomfort due to cultural cues in some way. This makes her
contraction of uterus (afterpain) and/ or response to pain, her choice of nourishment,
episiotomy fatigue or exhaustion, hunger her preferred birthing position, the proximity
thirst, excessive bleeding, bladder and involvement of a support person, and
distention customs related to the immediate postpartal
period highly individualized.
PSYCHOLOGICAL RESPONSE - . If a woman has traditions that run counter to
1. Fatigue hospital protocols, address these differences
• By the time the date of birth approaches, a and make arrangements to accommodate her
woman is generally tired from the normal desires, beliefs, or customs, if possible, such
• discomforts of pregnancy and has not slept as advocating for special foods to eat,
well for the past month ballroom dancing in order to remain upright,
• Sleep hunger from this type of discomfort can or saving the placenta for the mother to take
make it difficult for a woman to perceive home.
situations clearly or to adjust rapidly to new
situations. FOURTH STAGE PHYSIOLOGIC CHANGES
• It can make a small deficiency such as a - Increased pulse
wrinkled sheet appear as a major threatening - Decreased BP
discrepancy in her care. - Uterus remains contracted and located
• It can make the process of labor loom as an between umbilicus and symphysis pubis
overwhelming, unendurable experience unless - Urine may be retained due to decreased
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bladder tone and possible trauma to the - Fundal massage
bladder - If bleeding – Trendelenburg
• BP, pulse return to normal within 1 hr, BV
MATERNAL SYSTEMIC RESPONSE TO LABOR reabsorbed within 5 mins
CARDIOVASCULAR SYSTEM CHANGES • Watch out for vaginal bleeding
- Cardiac output increases 40%–50% from • Keep bladder empty
prelabor levels. • Provide nourishing liquids or foods
- Blood loss at birth is 300–500 ml on average. • Encourage rest and sleep
- Blood pressure may rise with pain response • Prevent infection by handwashing
and, due to work of the system during prior caring for the mother
contractions, by an average systolic rise of 15 • Discuss importance of
mmHg per contraction. breastfeeding, immunization
- Epidural anesthesia may cause hypotension. • Motivate use of family planning
- BP Rises with each contraction
- May rise further with pushing CAUSES OF PAIN DURING LABOR
st st
➢ 1 stage: systolic pressure increasesby 1 stage:
about 35 mmHg and diastolic pressure • Dilatation of cervix
by 25 mmHg • Stretching of the lower uterine
segment
RESPIRATORY SYSTEM CHANGES • Pressure on the adjacent structures
- Increase in oxygen demand and • Hypoxia of the uterine muscle cells
consumption (100%) during contraction
- Mild respiratory acidosis usually occurs 2nd stage
by the time of birth
• Hypoxia of the contracting uterine
- Hyperventilation muscles
RENAL CHANGES • Distention of the vagina and
- Increase in renin, plasma renin activity, perineum
angiotensinogen
• Pressure on the adjacent structures
- Edema may occur at base of bladder due to rd
pressure of fetal head 3 stage
• Uterine contractions and cervical
GI AND IMMUNE SYSTEM dilatation as the placenta is expelled
- Gastric motility decreased - Blood shunts to
life sustaining organs causing the GI system to FACTORS AFFECTING RESPONSE TO PAIN
become fairly inactive during labor. » Childbirth preparation classes
- Gastric emptying is prolonged » Culture
- Digestive and emptying time of the stomach » Fatigue and sleep deprivation
becomes lengthened. » Previous experience with pain and anxiety
- Some women experience a loose bowel » Attention and distraction
movement as contractions grow strong.
- Gastric volume remains increased FETAL RESPONSES TO LABOR
- WBC count increases to 25,000 to Fetal Response to Labor
30,000/mm 3 1. Heart Rate Changes
- Blood glucose decreases ➢ Early fetal heart rate decelerations
➢ decreases by as much as 5 beats/min
Nursing Care for Fourth Stage of Labor during a contraction, as soon as
- Perineal care contraction strength reaches 40 mmHg
- Feel for the fundus ➢ although not measurable, fetal blood
- Check q15 mins for 1 hr; q30 mins for 4 hrs pressure also rises.
st 2. Acid-Base Status in Labor
- Above the umbilicus 1 12 hr postpartum
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➢ A slow decrease in pH status • FETAL ACIDOSIS / LOW OXYGEN SATURATION
➢ Feta l oxygen saturation drops to - Oxygen saturation in a fetus is normally 40%
10% to 70%. A fetus can be assessed for this by a
3. Hemodynamic Changes catheter inserted next to the cheek (under
➢ Altered exchange of gas and 40% oxygenation needs further assessment).
nutrients - If fetal blood is obtained by scalp puncture,
4. Fetal Sensation the finding of acidosis (blood pH lower than
5. Intergumentary System 7.2) suggests fetal well-being is becoming
➢ The pressure involved in the birth process compromised and that further investigation is
is often reflected in minimal petechiae or also necessary.
ecchymotic areas on a fetus (particularly
the presenting part). There may also be MATERNAL DANGER SIGNS
edema 1. VITAL SIGNS ABNORMALITY
➢ of the presenting part (caput o High or Low Blood Pressure
succedaneum) from this pressure. ¬ blood pressure rises slightly in the
6. Respiratory System second (pelvic) stage of labor because
➢ The process of labor appears to aid in the of her pushing effort.
maturation of surfactant production by ¬ systolic pressure greater than 140
alveoli mmHg and a diastolic pressure
➢ in the fetal lung. Both the pressure applied greater than 90 mmHg, or an increase
to the chest from contractions and passage in the systolic pressure of more than
➢ through the birth canal help to clear the 30 mmHg or in the diastolic pressure
respiratory tract of lung fluid. For this of more than 15 mmHg
reason, ¬ falling blood à may be the first sign
➢ an infant born vaginally is usually able to of intrauterine hemorrhage, although
establish respirations more easily than a a falling blood pressure from
fetus hemorrhage is often associated with
➢ born by cesarean birth. other clinical signs of hypovolemic
shock, such as apprehension,
FETAL DANGER SIGNS increased pulse rate, and pallor.
• FETAL HEART RATE (ABNORMALITY) o Abnormal Pulse
- As a rule, an FHR of more than 160 beats/min ¬ Most women during pregnancy have a
(fetal tachycardia) or less than 110 beats/min pulse rate of 70 to 80 beats/min.
(fetal bradycardia) is a sign of possible fetal ¬ A maternal pulse rate greater than 100
distress. beats/min during labor is unusual
• MECONIUM STAINING
- This is not always a sign of fetal distress but is 2. INADEQUATE/ PROLONGED
highly correlated with its occurrence. CONTRACTION
- Meconium staining, a green color in the - Uterine contractions normally become more
amniotic fluid, reveals the fetus has had a loss frequent, intense, and longer as labor
of rectal sphincter control, allowing progresses. I
meconium to pass into the amniotic fluid. - f they become less frequent, less intense, or
- It may indicate a fetus has or is experiencing shorter in duration, this may indicate uterine
hypoxia, which stimulates the vagal reflex and exhaustion (inertia).
leads to increased bowel motility - This problem may be correctable but needs
• HYPERACTIVITY augmentation or other interventions to
- Fetal hyperactivity may be a subtle sign that accomplish this.
hypoxia is occurring because frantic motion is - Observe also if there is a period of relaxation
a common reaction to the need for oxygen. between contractions so the intervillous
spaces of the uterus can fill and maintain an

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adequate supply of oxygen and nutrients for - If there is an Rh blood incompatibility
the fetus. between the baby and the mother
- contractions lasting longer than 70 seconds - If the mother or baby has a medical
are becoming long enough to compromise problem that requires delivery of the
fetal well-being because this interferes with baby (premature rupture of the
adequate uterine artery filling. membranes)

3. PATHOGENIC RETRACTION RING Amniotomy

- (Bandl’s ring): prominent abdominal - Artificial rupture of membranes to induce
indentation, signifies impending uterine labor and for augmentation
rupture if obstruction to labor is not relieved. - Risks:
➢ Cord prolapse
4. ABNORMAL LOWER ABDOMINAL ➢ Infection
CONTOUR ➢ FHR decelerations
- If a woman has a full bladder during labor, a
round bulge appears on her lower anterior External Version
abdomen. - Abdominal maneuver that externally
- the bladder may be injured by the pressure of rotates the fetus from a breech
the fetal head pressing against it presentation to a vertex presentation
- the pressure of the full bladder may not allow - The fetus is manipulated by a forward roll
the fetal head to descend. or back flip

5. INCREASING APPREHENSION FACTORS MAY CAUSE A FETUS TO PRESENT

- Warnings of psychological danger during BREECH
labor are as important to consider in - Placenta previa
assessing maternal well-being as are physical - Multiple gestation
signs. - Uterine anomalies
- a woman who is becoming increasingly - Fetal anomalies
apprehensive despite clear explanations of - Poor uterine tone
unfolding events may not be “hearing” - Prematurity
because she has a concern that has not been - Majority of cases have no apparent
met. cause
- Increasing apprehension also needs to be
investigated for physical reasons because it EXPULSION CRITERIA
can be a sign of oxygen deprivation or - Multiple pregnancy
internal hemorrhage. - Evidence of uteroplacental insufficiency
- Significant third-trimester bleeding
INDUCTION OF LABOR - Suspected intrauterine growth restriction
- Involves using artificial means to assist - Amniotic fluid abnormalities
the mother in delivering her baby - Uterine malformation
➢ Amniotomy - Placenta previa
➢ Pitocin - Maternal cardiac disease
➢ Prostaglandin get suppository - Pregnancy-induced hypertension
➢ Misoprostal - Uncontrolled hypertension

Indications: Protocol in External Version

- Post term pregnancy • Ultrasound examination
- Mother shows no signs of going into • Empty the bladder
labor • Non-stress test
- Mother is suffering from diseases • CBC, blood type, and screen
(preeclampsia, chronic hypertension) • IV access
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• Tocolytic agent such as terbutaline (Brethine) disproportion (CPD)
• Supine or slight Trendelenburg position to
facilitate disengagement/mobility of the CESAREAN SECTION
breech Indications: Maternal and Fetal
• Nonstress test and ultrasound examination - Cephalopelvic disproportion
• Rhogam is administered after the procedure to - Failed induction or progression of labor
Rh negative in patients - Abnormal uterine contraction pattern

Benefits MATERNAL DISEASES:

- Speed up the birth ¬ Eclampsia or preeclampsia with non- inducible
- Prevent tearing cervix
- Protects against incontinence ¬ Diabetes mellitus
- Protects against pelvic floor relaxation ¬ Cardiac disease
- Heals easier than tears ¬ Cervical disease
¬ Active herpes genitalis
Complications
- Infection PREVIOUS UTERINE SURGERY
- Increased pain ¬ Classic cesarean section
¬ Previous uterine rapture
- Increase in 3rd and 4th degree vaginal
¬ Full-thickness myomectomy
lacerations
- Longer healing times
OBSTRUCTION TO THE BIRTH CANAL
- Increased discomfort when intercourse is
¬ Fibroids
resumed
¬ Ovarian tumors
LACERATIONS
FETAL
1ST Perineal skin and vaginal
¬ Fetal distress
DEGREE mucosa, may need repair or not
¬ Cord prolapse
2ND
Skin, mucous membrane and
¬ Fetal malpresentations
DEGREE fascia,usually repaired
3RD
Skin, mucous membrane, and
PLACENTAL
DEGREE extends torectal sphincter
¬ Placenta previa (unless marginal)
4TH
As above but into rectal lumen
¬ Abruptio placentae
DEGREE
MATERNAL RISKS
VACUUM EXTRACTION
¬ Infection
- delivery with use of a suction device that is
¬ Hemorrhage
applied to the fetal scalp for traction
¬ Injury to urinary tract
- Used in prolonged second stage
¬ Adverse reactions to anesthesia
- Contraindicated in CPD and face/breech
¬ Prolonged recovery
presentation
ANTIBIOTIC PROPHYLAXIS
FORCEPS ASSISTED
¬ Reduced incidence of endometritis
a) Forceps
¬ Wound infection
- Two double-curved, spoon-like,
¬ Urinary tract infection and fever
articulated blades used to extract the
fetal head
b) Indicated if mother cannot push fetus out
or compromised maternal/fetal status in
late second stage
c) Contraindicated in cephalopelvic

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