Download Components of Labor

The Labor Process
Labor is the series of events by which uterine
contractions and abdominal pressure expel
the fetus and placenta from the woman’s
body.
Regular contractions cause progressive
dilatation of the cervix and sufficient
muscular force to allow the baby to be
pushed to the outside.
A time of change, both ending and beginning
for the woman, fetus and family.
Woman uses all psychological and physical
coping methods.
Nursing Process
Assessment
Outcome Identification and Planning
Implementation
Outcome Evaluation
Theories of Labor Onset
Unknown
Factors:
• Uterine muscle stretching releases
prostaglandin's.
• Pressure on cervix stimulates release of
oxytocin from posterior pituitary.
• Oxytocin stimulation, works together with
prostaglandin to initiate contractions.
• Increasing estrogen in relation to
progesterone stimulates contractions.
• Placental age, triggers contractions at a set
point.
Theories of Labor Onset
• Rising fetal cortisol levels, reduce
progesterone formation and increase
prostaglandin formation.
• Fetal membrane production of
prostaglandin which stimulates contractions
• Seasonal and time influences.
Signs of Labor
Preliminary Signs of Labor:
Before labor, the woman experiences subtle
signs of labor. Teach how to recognize
these.
Lightening-descent of fetal presenting part
into the pelvis.
• Occurs 10 to 14 days before labor begins.
• Shooting leg pains, increased vaginal
discharge, urinary frequency.
Signs of Labor
Increase in Level of Activity:
• Feeling full of energy due to increase in
epinephrine release initiated by decreased
progesterone produced by placenta.
Braxton Hicks Contractions:
• Stronger 1 week to days before labor.
• Support if not true contractions.
Ripening of the Cervix:
• Internal sign seen with pelvic exam.
• Cervix is butter-soft and tips forward.
Signs of True Labor
Uterine and cervical changes.
Uterine Contractions:
• Surest sign that labor has begun.
• Effective, productive, involuntary uterine
contractions.
Show or Bloody Show:
• Blood mixed with mucus when the mucus
plug is expelled.
• Pink tinged.
Signs of True Labor
Rupture of the Membranes:
• Either sudden gush or scanty, slow
seeping of clear fluid from the vagina.
• Amniotic fluid continues to be produced
until delivery of the membranes.
• Early rupture is good, fetal head settles
snugly into the pelvis.
• Risks: infection and cord prolapse.
• Induce after 24 hours.
Components of Labor
Four integrated concepts:
1. Passage
2. Passenger
3. Power of labor
4. Psyche of the woman is preserved.
1. Passage:
• Route the fetus must travel from uterus
through cervix and vagina to external
perineum.
Components of Labor
• Diagonal conjugate-anterior-posterior
diameter of the inlet.
• Transverse diameter of the outlet.
• Pelvis structure at fault or fetal head is
presented to the birth canal at a less than its
narrowest diameter, not because the head is
to large. Avoid negative thoughts about the
baby.
Components of Labor
2. Passenger:
Fetus is the passenger and must pass through
the pelvic ring.
Depends on fetal skull and alignment with the
pelvis.
Structure of the Fetal Skull:
• Cranium-upper portion of skull
• 4 superior bones-fontal, 2 parietal, and
occipital are important in childbirth.
• 4 at base of cranium-sphenoid bone,
ethmoid bone and 2 temporal bones.
Components of Labor
• Chin-mentum can be a presenting part.
• Suture lines allow cranial bones to move
and overlap, thus molding or diminishing
the size of the skull so it can pass through
the birth canal.
• Fontanelles are membrane-covered spaces
found at junction of the main suture lines.
• Compress during birth to aid in molding of
the fetal head.
• Anterior fontanelle (bregma) lies a the
junction of the coronal and sagittal sutures.
Components of Labor
– Diamond shaped
– Anteroposterior diameter-3 to 4 cm.
– Transverse diameter-2 to 3 cm.
• Posterior fontanelle-lies at junction of
lambdoidal and sagittal sutures.
– Triangular shape
– 2 cm. across widest part.
• Vertex-space between the two fontanelles
Components of Labor
Diameters of the Fetal Skull:
• Shape is wider anteroposterior than its
transverse diameter.
• Fetus must present transverse diameter to
the smaller diameter of the maternal pelvis.
• Biparital diameter-9.25 cm.
• Outlet space-9.5 to 11.5 cm.
• Engagement – setting of fetal head into the
pelvis.
• Depends on degree of flexion of fetal head.
Components of Labor
• Inlet-12.4 to 13.5 cm.
Molding:
• Change in shape of the fetal skull produced
by the force of uterine contractions pressing
the vertex against the not yet dilated cervix.
• Overlap and cause head to become narrower
but longer.
• Lasts 1 to 2 days not permanent.
• No skull molding occurs when fetus is
breech; buttocks are first.
Components of Labor
Fetal Presentation and Position:
• Attitude-degree of flexion the fetus
assumes during labor or relation of the fetal
parts to each other (figure 18.3 and 18.4).
• Good attitude-complete flexion:
– Spinal column bowed forward
– Head flexed forward-chin touches the
sternum
– Arms flexed and folded on chest
– Thighs flexed onto abdomen and calves
pressed against posterior aspect of thighs
– Ovoid shape
Components of Labor
Moderate flexion-military position-chin not
touching the chest.
Partial extension-brow of head presents first.
Engagement – settling of presenting part of
fetus far enough into pelvis to be at level of
ischial spines, at midpoint of pelvis.
• Floating-a presenting part not engaged.
• Dipping-a presenting part that is descending
but not yet reached iliac spines
• Assessed by vaginal and cervical exam.
Components of Labor
Station:
• Relationship of presenting part of fetus to
level of ischial spines (figure 18.5).
• Station 0 - presenting part at level of ischial
spines (head is engaged).
• Minus station – presenting part above the
spines (-1cm to - 4cm) (floating).
• Plus station – presenting part is below the
spines (+1cm to +4cm) at +3 to +4 station
presenting part is at perineum and can be
seen if vulva is separated (crowning).
Components of Labor
Fetal Lie:
• Lie is relationship between long axis of
fetal body and long axis of woman’s body.
• 99% are longitudinal lie.
Types of Fetal Presentation:
Demotes the body part that will first contact
the cervix or deliver first. Determined by
fetal lie and degree of flexion (attitude).
• Cephalic presentation-head is the fetal part
that first contacts the cervix.
Components of Labor
• Four types:
– Vertex-best
– Brow
– Face
– Mentum
• Caput succedaneum-edematous area of fetal
skull that contacted the cervix during labor.
Breech Presentation:
• Buttocks or feet are the first body part to
contact the cervix.
• 3% of births
Components of Labor
• Affected by attitude
• Types:
– Complete
– Frank
– Footling
Shoulder Presentation:
• Transverse lie, fetus is lying horizontally in
the pelvis so long axis is perpendicular to
mother.
• Presenting part-shoulders, iliac crest, hand
or elbow.
Components of Labor
• Fewer than 1%
• Cesarean birth
Types of Fetal Position:
Relationship of presenting part to a specific
quadrant of the woman’s pelvis.
• Pelvis is divided into 4 quadrants according
to the mother’s right and left.
–
–
–
–
1. Right anterior
2. Left anterior
3. Right posterior
4. Left posterior
Components of Labor
• Abbreviations: (3 letters)
– Middle letter denotes fetal landmark: O
for occiput, M for mentum or chin, SA
for sacrum, A for acromion process.
– First letter defines whether the landmark
is pointing to the mother’s right R or left
L.
– Last letter defines whether the landmark
points anteriorly A, posteriorly P, or
transversely T.
• LOA-left occipitanterior- most common.
• ROP-right occipitoposterior-second
Components of Labor
• Six common positions
• Position influences the process and
efficiency of labor.
• Fastest-ROA or LOA
• Extended-ROP or LOP-more painful
Importance of Determining Fetal Presentation
and Presentation:
• Presentations other than vertex puts the
fetus at risk.
• Implies proportional differences between
fetus and pelvis.
Components of Labor
Methods to determine position, presentation
and lie:
• 1. Abdominal inspection and palpation
• 2. Vaginal exam
• 3. Auscultation of fetal heart tones
• 4. Sonography
Mechanisms of Labor (Cardinal Movements)
A number of different position changes to
keep the smallest diameter of fetal head
presenting to the smallest diameter of the
birth canal.
Components of Labor
Descent
• Downward movement of biparietal diameter
of fetal head to within pelvic inlet.
Flexion
• Fetal head bends forward onto chest.
• Suboccipitobregmatic diameter.
Internal Rotation
• Head flexes as it touches pelvic floor, and
occiput rotates until it is superior or just
below the symphysis pubis, bringing head
into best diameter for the outlet of pelvis.
Components of Labor
• Brings shoulders into position to enter the
inlet.
Extension
• As occiput is born, back of neck stops
beneath the pubic arch and acts as a pivot
for the rest of the head.
• Head extends and foremost parts of head,
face and chin are born.
External Rotation
• Immediately after head of infant is born
Components of Labor
• Head rotates from anteroposterior position
back to diagonal or transverse position of
the early part of labor.
• Anterior shoulder is born first, assisted by
downward flexion of infant’s head.
Expulsion
• Once shoulders are born, the rest of the
baby is born easily and smoothly.
• End of the pelvic division of labor.
Powers of Labor
Supplied by the fundus of the uterus.
Implemented by uterine contractions
A process that causes cervical dilatation
Then expulsion
After full dilatation of cervix power is
abdominal muscles.
Do not bear down with abdominal muscles
until cervix is fully dilated. Could cause
fetal and cervical damage.
Powers of Labor
Uterine Contractions:
Origin:
• Begin at a pacemaker point located in the
myometrium near one of the uterotubal
junctions.
• Each contraction begins at that point and
then sweeps down over the uterus as a wave
• After a short rest period another contraction
is initiated.
• In early labor, pacemaker is not
synchronous
Powers of Labor
• Pacemaker becomes more attuned to
calcium concentration in myometrium and
begins to function smoothly.
Phases
• 1. Increment-when intensity of contraction
increases.
• 2. Acme-when the contraction is at its
strongest.
• 3. Decrement-when intensity decreases.
• Between contractions the uterus rests 10
min.early labor, 2 to 3 min. later.
Powers of Labor
• Duration increasing from 20 to 30 seconds
to a range of 60 to 90 seconds.
Contour Changes
• Upper-becomes thicker and active,
preparing to exert strength to expel fetus.
• Lower segment-becomes thin-walled,
supple, and passive so it can be pushed out.
• Physiologic retraction ring-ridge on inner
uterine surface.
• Contour changes to elongated.
Powers of Labor
• Pathologic retraction ring (Bandl’s ring)abdominal indentation that is a danger sign
of impending rupture of lower uterine
segment.
Cervical Changes:
Effacement-shortening and thinning of the
cervical canal (normal 1 to 2 cm.)
Dilatation-enlargement of cervical canal from
a few millimeters to 10 cm.
• Increases diameter of cervical canal lumen
by pulling cervix up over presenting part.
Powers of Labor
• Fluid filled membranes press against cervix.
Psyche
• Psychological state or feelings that women
bring into labor with them.
• Fright, apprehension,excitement, awe.
• Debriefing time.
Stages of Labor
Divided into 3 stages:
1. First stage of dilatation-beginning with
true labor contractions and ending with
cervix fully dilated.
2. Second stage-from time of full dilatation
until the infant is born.
3. Third or placental stage-from the time the
infant is born until after delivery of the
placenta.
4. Fourth stage-first 1 to 4 hours after birth
of the placenta.
First Stage of Labor
Divided into 3 phases:
1. Latent
2. Active
3. Transition
1. Latent phase:
• Preparatory phase-begins at the onset of
regularly perceived uterine contractions
and ends when rapid cervical dilation
begins.
• Contractions-mild and short 20 to 40 sec.
First Stage of Labor
• Cervical effacement occurs
• Cervix dilates from 0 to 3 cm
• Phase lasts approx. 6 hours in nullipara and
4.5 hours in multipara.
• Analgesics given too early in labor will
prolong this phase.
• Walking, preparation for birth, packing,
care for siblings.
First Stage of Labor
Active phase:
• Cervical dilatation occurs more rapidly,
from 4 cm to 7 cm.
• Contractions are stronger, lasting from 40 to
60 sec., every 3 to 5 min.
• Phase lasts from 3 hours in nullipara to 2
hours in multipara.
• Show and rupture of membranes may occur.
• True discomfort.
• Dilatation 3.5 cm in nullipara per hour to 5
to 9 cm in multipara per hour.
First Stage of Labor
• Analgesics has little effect on progress of
labor.
Transition Phase:
• Dilatation 8 to 10 cm occur
• Contractions at peak of intensity every 2 to
3 min. with duration of 60 to 90 sec.
• If membranes not ruptured, will rupture at
10 cm.
• If not occurred-show will be present and
mucus plug is released.
First Stage of Labor
• Full dilatation and complete cervical
effacement occur.
• Intense discomfort and nausea/vomiting,
feeling of loss of control, anxiety, panic,
irritability.
• Her focus is inward on task of birthing.
• Peak is identified by slight slowing in rate
of dilatation when 9 cm is reached
(deceleration on graph).
• At 10 cm irresistible urge to push.
Second Stage of Labor
• Full dilatation and cervical effacement to
birth of infant.
• Contractions change from crescendodecrescendo pattern to uncontrollable urge
to push.
• N/V, she perspires, blood vessels in neck
become distended.
• Perineum begins to bulge and appear tense.
• Anus appears everted, stool expelled,
vaginal introitus opens, fetal head visible.
Second Stage of Labor
• Crowning – at first slitlike opening then
oval, then circular, from size of dime to that
of a quarter, then half-dollar.
• She can not stop pushing, all energy is
directed toward birth.
Third Stage:
Placental stage begins with the birth of the
infant and ends with delivery of the placenta
Two separate phases:
• Placental separation
• Placental expulsion
Third Stage of Labor
After birth the uterus can be palpated as a
firm, round mass, inferior to level of
umbilicus.
Uterine contractions begin again and organ
assumes a discoid shape until separated,
approx. 5 min.
Placental Separation:
• Occurs automatically as uterus resumes
contractions.
• Folding and separation of the placenta
occurs.
Third Stage of Labor
• Active bleeding on maternal surface of
placenta and this helps separate the placenta
by pushing it away from its attachment site.
Signs:
• Lengthening of the umbilical cord
• Sudden gush of vaginal blood
• Change in the shape of the uterus
Schultze-shiny and glistening side of placenta
fetal surface. (80%)
Duncan-looks raw, red irregular with ridges,
maternal surface.
Third Stage of Labor
• Normal blood loss-300 to 500 ml.
Placental Expulsion:
After separation, the placenta is delivered by
natural bearing down effort or gentle
pressure on fundus by physician.
Never apply pressure to uterus in uncontracted
state or uterus may evert and hemorrhage.
Placenta can be removed manually.
Saved for stem cell research.
Responses to Labor
Maternal Response:
Almost all body systems are affected.
• Cardiovascular
– Cardiac output
– Blood pressure
• Hemopoietic system
• Respiratory
• Temperature regulation
• Fluid balance
• Urinary
Responses to Labor
• Musculoskeletal
• Gastrointestinal
• Neurologic and sensory
Psychological Responses:
• Fatigue
• Fear
• Cultural influences
Responses to Labor
Fetal responses:
• Neurologic system
• Cardiovascular
• Integumentary
• Musculoskeletal
• Respiratory
Danger Signs of Labor
Fetal Danger Signs:
• High or low fetal heart rate
• Meconium
• Hyperactivity
• Fetal acidosis
Danger Signs of Labor
Maternal Danger Signs:
• Rising or falling blood pressure
• Abnormal pulse
• Inadequate or prolonged contractions
• Pathologic retraction ring
• Abnormal lower abdominal contour
• Increasing apprehension
Assessment During Labor
Once a woman arrives at a birthing facility:
Initial Interview and Physical Examination:
• Extent of woman’s labor
• General physical condition
• Preparedness for labor and birth
Ask:
• Expected date of birth
• Frequency, duration and intensity of
contractions
• Amount and character of show
Assessment During Labor
•
•
•
•
•
•
Rupture of membranes
Vital signs – assess between contractions
Time she last ate
Drug allergies
Past pregnancy history and outcomes
Her birth plans (analgesia, who cuts the
cord)
This establishes whether she is in active labor
and needs intense care or earlier stage of
labor and interventions can be paced.
Assessment During Labor
Detailed Assessment During the First Stage:
History:
• Current pregnancy history
• Past pregnancy history
• Past health history
• Family medical history
Physical Examination:
• Includes pelvic exam to confirm
presentation and position of fetus and stage
of dilatation.
Assessment During Labor
• Abdominal assessment
– Estimate fetal size by fundal height
(xiphoid)
– Presentation and position
– Palpate and percuss bladder
– Abdominal scars (adhesions)
– Skin turgor
Assessment During Labor
Leopold’s Maneuvers
Observation and palpation to determine fetal
presentation and position.
Assessing Rupture of Membranes:
• 1 of every 4 labors are spontaneous
• Sterile vaginal exam
• pH > 6.5 alkaline, nitrazine paper=blue or
fern pattern under microscope.
• Normal color clear, green is meconium,
yellow indicates blood incompatibility.
Assessment During Labor
Vaginal Examination:
• Extent of cervical effacement and dilatation
• Confirm presentation, position, and degree
of descent.
• Can be done during contractions but is more
painful
• Do not do exam if bleeding present.
Assessment of Pelvic Adequacy:
• Not routine unless no prenatal care
• Internal conjugate and ischial tuberosity
size
Assessment During Labor
Sonography:
• Determines diameter of fetal skull,
presentation, presenting part, position,
flexion, degree of descent.
Vital Signs:
• T – q 4 hours if membranes ruptured q2hrs
• P- q 4hours – 70 to 80 bpm
• R – q 4 hours – 18 to 20/min
• B/P – q 4 hours – rises 5 to 15 mm Hg with
contraction
Assessment During Labor
Laboratory Analysis:
• Blood-H&H, VDRL, Hep B antibodies,
blood type
• Urine-protein, glucose, UA
Assessment of Uterine Contractions:
• Length-duration-use monitor or palpate
• Intensity-strength-rated as mild, moderate,
strong (unable to indent uterus)
• Frequency-from beginning of one
contraction to the beginning of next one.
Assessment During Labor
Initial Fetal Assessment
Auscultation of Fetal Heart Sounds:
• Best heard through the fetal back
• Count every 30 min. at beginning labor
• Every 15 min. during active labor
• Every 5 min. during second stage of labor
Electronic Monitoring
External Electronic Monitoring:
Monitors both uterine contractions and FHR
continuously or intermittently
• Sensors are strapped to the woman’s
abdomen. Transducer placed over the
fundus and ultrasound sensor for the fetus at
the level of the fetal chest.
Internal Electronic Monitoring:
• Most precise method
• Pressure sensing catheter passed through the
vagina.
Electronic Monitoring
• Inserted after membranes have ruptured
and 3 cm dilated.
• Monitors frequency, duration, baseline
strength, peak strength
– Latent phase 5 mm Hg
– Active contractions 12 mm Hg
– Second stage 20 mm Hg
FHR recording from scalp electrode
• When fetal head is engaged, electrode is
inserted vaginally and attached to scalp.
Electronic Monitoring
• Invasive procedure, risk of uterine infection,
limits woman’s movement.
Telemetry
• Allows monitoring of both FHR and uterine
contractions; free of connecting wires.
• An internal pressure uterine lead is inserted
and fetal scalp electrode is attached, a
miniature radio transmitter is placed in the
vagina that signals to a monitor.
• Allows the woman to ambulate.
Electronic Monitoring
Fetal Heart Rate Tracing:
• Trace FHR and duration and interval of
uterine contractions onto paper rolls.
– Uterine contractions on bottom half
– FHR on top half
• Count number of bold vertical lines (space
between two bold lines represent 60 sec.
Electronic Monitoring
Fetal Heart Rate Patterns
Evaluates 3 parameters:
• Baseline rate
• Variabilities in the baseline rate (long term
and short term)
• Periodic changes in the rate (acceleration
and deceleration)
Electronic Monitoring
Baseline FHR:
• Determined by analyzing a range of fetal
heart beats recorded on a 10 min. tracing
obtained between contractions.
• Normal 120-160 bpm
• Bradycardia – below 120 bpm for 10 min.
– <100 bpm is sign of hypoxia
• Tachycardia – 160 or more for 10 min.
– >180 bpm
Electronic Monitoring
Variability:
Most reliable indicators of fetal well-being.
• Is variation or differing rhythmicity in heart
rate over time and is reflected on FHR
tracing as a slight irregularity or jitter to the
wave.
• Long term-LTV-fluctuations in FHR of 6 to
10 beats occurring 3 to 10 times / min.
• Short term-STV- difference between
successive heartbeats, 3 to 5 bpm
– Rated as present, decreased or absent
Electronic Monitoring
Periodic Changes:
• Acceleration-temporary normal increases
in FHR due to fetal movement or
compression of the umbilical vein during
contractions.
• Early Decelerations-are periodic decreases
in FHR resulting from pressure on fetal
head during contractions. Slowing of FHR.
– Follows pattern of contraction beginning
when contraction begins and ending
when contraction ends.
– Waveform is inverse to contraction
Electronic Monitoring
• Lowest point of deceleration occurs with
peak of contraction. (mirror image)
• Rate rarely falls below 100 bpm and returns
quickly to 120 and 160 bpm
• Normally occurs late in labor
• If early in labor cause for concern
Late Decelerations:
• Delayed until 30 to 40 sec after onset of
contraction and continue beyond end of
contraction.
Electronic Monitoring
• Suggests uteroplacental insufficiency or
decreased blood flow through intervillous
spaces during uterine contractions.
• Lowest point of deceleration occurs near the
end of the contraction instead of at the peak.
• Oxytocin-stop or slow rate, change
positions, administer IV or O2
• Prolonged deceleration last longer than 2 to
3 min but less than 10 min.
– Cord compression or maternal
hypotension
Electronic Monitoring
Variable Decelerations:
• Unpredictable times in relation to
contractions.
• Indicates compression of cord
• Change woman’s position from supine to
lateral or to trandelenburg
• Administer fluids and O2
• May need amnioinfusion
Electronic Monitoring
Amnioinfusion:
• The addition of fluid into the uterus to
supplement amniotic fluid.
• Prevents additional cord compression
• Sterile catheter is introduced through cervix
into uterus. Attached to IV tubing and
warmed NS or LR is infused rapidly. 500ml
initially then rate is adjusted to infuse the
least amount to maintain a monitor pattern
without variable decelerations.
• Keep woman in lateral recumbent position
Electronic Monitoring
• Maintain aseptic technique
• Monitor temp q 1 hr
• Change bed frequently due to continuous
flow of solution.
• If vaginal leakage stops means head is
engaged and fluid will remain in uterus
which may lead to hydramnios or uterine
rupture.
Sinusoidal FHR Pattern:
• CNS control of heart pacing so impaired
that pattern resembles a undulating wave
Electronic Monitoring
Nonperiodic Changes:
• Decelerations or accelerations changes that
occur at times other than when the uterus is
contracting.
• Due to fetal movement, change in maternal
position, or administration of analgesia.
Other Assessment Technique
Scalp Stimulation:
• Apply pressure with fingers to fetal scalp
• Tactile response increased FHR
Electronic Monitoring
• If fetus is in distress and becoming acidotic
FHR will not increase
• Assesses acid base balance in fetus
Fetal Blood Sampling:
• Composition determine hypoxia before
ECG (pH decreased < 7.20 = hypoxic
• Sample taken from scalp into capillary tube
Acoustic Stimulation:
• Sharp sound next to woman’s abdomen to
produce FHR acceleration.
Care During First Stage of Labor
Starts at beginning of contractions and ends
when cervix is fully dilated.
Helping the woman feel confident in pain
control, progress of labor and physiologic
stability.
Give frequent progress reports.
• Respect Contraction Time and do not
interrupt the woman during breathing
exercises.
• Promote Change of Positions walking,
kneeling, squatting
Care During First Stage of Labor
• Promote Voiding and Provide Bladder
Care. A full bladder impedes fetal descent.
Void q 2 to 4 hours, catheterize if needed.
Hyperventilation (resp. alkalosis) breath in
paper bag.
• Offer Support give a cool cloth, TLC
• Respect and Promote the Person’s
Activities, allow them to remain with the
woman throughout the birth.
• Support the Woman’s Pain Management
Efforts
Care During First Stage of Labor
• Amniotomy artificial rupturing of
membranes with amniohook or hemostat.
– Risk for cord prolapse
– Monitor FHR immediately
Care During Second Stage of Labor
Full cervical dilation to birth of the newborn.
Preparing the Place of Birth
• Birthing Room
• Positioning for Birth
– Lithotomy-raise both legs up at the same
time to prevent back and lower
abdominal strain.
– Lateral, Sim’s, dorsal recumbent,
semisitting and squatting.
Care During Second Stage of Labor
Promoting Effective Pushing:
• Must push with contractions and rest
between them.
• Allow her to push when she feels the urge,
use the position and technique she chooses.
• Semi fowlers, squatting, all fours.
• Do not hold breath when pushing always
breath out.
• Panting with contraction is used to prevent
her from pushing.
• Breath with her and take deep cleansing
breath.
Care During Second Stage of Labor
Perineal Cleaning:
• Clean from vagina outward
Episiotomy:
• Surgical incision of perineum made to
prevent tearing of the perineum with birth
and to release pressure on the fetal head
with birth.
• Mediolateral have an advantage over
midline cuts, tearing occurs away from the
rectum.
• Substitutes a clean cut for a ragged tear.
Care During Second Stage of Labor
• Minimizes pressure on fetal head
• Shortens last portion of labor
• Pressure of fetal presenting part against
perineum deadens nerve endings so an
episiotomy may be done without anesthesia.
• Pressure of the fetal presenting part also
seals the cut edges and minimizes bleeding.
Birth:
• As soon as the head of the fetus is
prominent (8 cm) the Dr. may place a sterile
Care During Second Stage of Labor
• Towel over rectum and press forward on
fetal chin while the other hand presses
downward on the occiput.
• This helps fetus achieve extension, so head
is born with the smallest diameter
presenting.
• Also controls the rate at which the head is
born.
• Never apply pressure to the fundus of the
uterus to effect birth, because uterine
rupture may occur.
Care During Second Stage of Labor
• Woman pushes until occiput of the fetal
head is firmly in the pubic arch.
• The head is born between contractions.
(panting)(flash of pain or burning sensation)
• Suction infant’s mouth and feel neck for
cord and gently remove it if present by
drawing over the fetal head. If tight it must
be clamped and cut before shoulders are
delivered.
• Push again without a contraction to deliver
the shoulders. Downward pressure on head.
Care During Second Stage of Labor
Delivers the anterior shoulder.
• External rotation occurs and upward
pressure on side of head delivers posterior
shoulder.
• The remainder of the body slides free and
when whole body is delivered this is the
time of birth recorded.
Cutting and Clamping the Cord:
• Hold infant in dependent position and
suction with bulb syringe.
• Lay infant on abdominal drape while cord
Care During Second Stage of Labor
is cut. Place 2 Kelly hemostates placed 8 to
10 inches from infant’s umbilicus, and is
cut between them. An umbilical clamp is
applied.
• Obtain a sample of cord blood and count the
vessels.
• Clamping the cord is part of the stimulus
that initiates a first breath.
Introducing the Infant:
• Use sterile blanket and hold firmly because
the baby is very slippery.
Care During Second Stage of Labor
• Lay infant on radiant heat warmer and dry
with warmed towel.
• Cover head with cap and wrap infant snugly
• Take to mother and father.
• May breast feed which stimulates the
release of endogenous oxytocin.
Care During Third Stage of Labor
From the time of the birth until the placenta is
delivered.
Fourth stage includes the first few hours after
birth.
Oxytocin:(Pitocin)
• Once placenta is delivered oxytocin is
administered IM or IV (8 hours)
• Increases uterine contractions and
minimizes uterine bleeding.
• Methergine last several hours.
• Check B/P for hypertension
Care During Third Stage of Labor
Placenta Delivery:
• Spontaneous or manual removal within 5
min.
• Inspect to be certain it is intact and normal
in appearance and weight.
• 1/6th weight of infant.
Perineal Repair:
• Long tedious process
Immediate Postpartal Assessment
• VS q 15 min for 1 hour
Care During Third Stage of Labor
• Palpate the fundus for size, consistency, and
position.
• Observe the amount and characteristics of
the lochia.
• Perform peri care and apply a pad.
• Clean gown and warm blanket
Aftercare:
• Fourth stage of labor
• High risk for hemorrhage
Concerns of Woman in Labor
Woman Without a Support Person:
Woman Who Will Be Placing Her Baby Up
For Adoption:
• Hold baby, has a number of days to decide.
• Support
Vaginal Birth After Cesarean Birth:
• Low transverse incision she may try.
• Risk for uterine rupture.
• Less painful afterwards.