The Nursing Role in Caring for the Family During Labor

and Birth

LABOR

• Series of events by which uterine contractions and abdominal pressure expel the fetus and placenta from the woman's body.

NURSING PROCESS OVERVIEW

Assessment • Assessment of a woman in labor must be

done quickly yet thoroughly and gently.• Assess how much discomfort a woman in

labor • facial tenseness • paleness of the face • hands clenched in a fist • rapid breathing o rapid pulse rate

Nursing Diagnosis • Common nursing diagnoses used during,

labor include:• Pain related to labor contractions • Anxiety related to process of labor and birth • Health-seeking behaviors related to

management of discomfort of labor • Situational low self-esteem related to

inability to use prepared childbirth method

THEORIES OF LABOR ONSET

• Uterine muscle stretching: prostaglandin release

• Pressure on the cervix: release of oxytocin

• Oxytocin stimulation: together with prostaglandin to initiate contractions

• Change in the ratio of estrogen to progesterone

• Placental age• Rising fetal cortisol levels, which reduce

progesterone formation and increase prostaglandin formation

• Fetal membrane production of prostaglandin,which stimulates contractions

• Seasonal and time influences

THEORIES OF LABOR ONSET

SIGNS OF LABOR

• Preliminary Signs of labor Lightening

· Descent of the fetal presenting part into the pelvis · occurs approximately 10 – 14 days before labor begins. relief from the diaphragmatic pressure . . abdominal pressure increases . shooting leg pains . increased amounts of vaginal discharge . urinary frequency from pressure on the bladder.

Preliminary Signs of labor

• Increase in Level of Activity · increase in activity is due to an increase in epinephrine

• Braxton Hicks Contractions · last week or days before labor begins, extremely strong Braxton Hicks contractions which may be interpret as true labor contractions.

• Ripening of the Cervix

· Ripening of the cervix is an internal sign seen only on pelvic examination.

· At term, cervix is described as "butter-soft," and it tips forward.

Signs of True Labor

• Uterine Contractions · the initiation of effective, productive, involuntary uterine contractions.

• Show· As the cervix softens and ripens, the mucus plug that filled the cervical canal during pregnancy is expelled.· The blood, mixed with mucus, takes on a pink tinge and is referred to as "show" or "bloody show."

Signs of True Labor

• Rupture of the Membranes

· a sudden gush or scanty, slow seeping of clear fluid from the vagina, .

• Two risks associated with ruptured membranes

o intrauterine infection

o prolapse of the umbilical cord

COMPONENTS OF LABOR

Four integrated concepts: (1) Woman's pelvis (the passage)

- adequate size and contour (2) Passenger (the fetus)

- appropriate size and in an advantageous position and presentation

(3) Powers of labor (uterine factors) are adequate

(4) Woman's psyche

• Passage ·refers to the route the fetus must travel from the uterus cervix vagina external perineum.· Because these organs are contained inside the pelvis, the fetus must also pass through the pelvic ring.· the pelvis must be of adequate size.

• Two pelvic measurements are important to determine the adequacy of the pelvic size:o the diagonal conjugate (the anterior-posterior diameter of the inlet) o the transverse diameter of the outlet

• At the pelvic inlet, the anteroposterior diameter is the narrowest diameter

• · At the outlet, the transverse diameter is the narrowest diameter

• Passenger

· The passenger is the fetus.

· The body part of a fetus that has the widest diameter is the head,

· Whether a fetal skull can pass depends on both its structure

• FONTANELLE · Significant membrane-covered spaces called the fontanelles

o The anterior fontanelle - bregma- lies at the junction of the coronal and sagittal

suture- fontanelle diamond-shaped.

o The posterior fontanelle - lies at the junction of the lambdoidal and

sagittal sutures - parietal bones and the occipital bone >

triangular- approximately 2 cm across its widest part.

• Attitude.

· Attitude describes the degree of flexion the fetus assumes during labor or the relation of the fetal parts to each other.

• · A fetus in good attitude is in complete flexion:o the spinal column is bowed forwardo head is flexed forward so much that the chin touches the sternum o arms are flexed and folded on the chest o thighs are flexed onto the abdomen o calves are pressed against the posterior aspect of the thighs

Fetal Presentation and Position

Fetal Presentation and Position

• MODERATE FLEXION • chin is not touching the

chest but is in an alert • "military position" • This position causes

the next-widest anteroposterior diameter, the occipital frontal diameter, to present to the birth canal.

• PARTIAL EXTENSION presents the "brow" of the head to the birth canal

• POOR FLEXION• back is arched • neck is extended

• complete extension - presenting the occipitomental diameter of the head to the birth canal

Engagement.

• Engagement.• refers to the

settling of the presenting part of the fetus far enough into the pelvis to be at the level of the ischial spines, a midpoint of the pelvis.

Engagement.

• A presenting part that is not engaged is said to be "floating." ·

• One that is descending but has not yet reached the iliac spines can be said to be "dipping."

• The degree of engagement is assessed by vaginal and cervical examination.

Station.• Refers to the relationship of the

presenting part of the fetus to the level of the ischial spines

• Presenting part is at the level of the ischial spines, it is at a o station (synonymous with engagement).

• If the presenting part is above the spines• the distance is measured and described

as minus stations• range from 1 cm to 4 cm.

• If the presenting part is below the ischial spines• the distance is stated as plus stations• 1 cm to 4 cm• At 3 or 4 station, the presenting part

is at the perineum and can be seen if the vulva is separated (synonymous with crowning).

Station.

Fetal Lie.

• Relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal) axis of the woman's body

• Whether the fetus is lying in a horizontal (transverse) or a vertical (longitudinal) position.

• Approximately 99% of fetuses assume a longitudinal lie (with their long axis parallel with the long axis of the woman).

• Longitudinal lies are further classifiedo cephalic - with the head as the first part to contact

the cervix o breech

Types of Fetal Presentation

• Cephalic Presentation.- head is the body part that first contacts the cervix.- It is the most frequent type of presentation- 95% of the time.

o The four types of cephalic presentation • Vertex • Brow • Face • Mentum

Types of Fetal Presentation

• Breech Presentation.• either the buttocks or feet are the first body parts to

contact the cervix.• approximately 3% of births • usually are difficult births, with the presenting point

influencing the degree of difficultyo Three types of breech presentation • Complete • Frank • Footling

Types of Fetal Presentation

• Shoulder Presentation.• In a transverse lie, the fetus is lying

horizontally in the pelvis so that its long axis is perpendicular to that of the mother.

• one of the shoulders (acromion process), an iliac crest, a hand, or an elbow

• Fewer than 1 % of fetuses lie transversely.

• Shoulder Presentation• Relaxed abdominal walls from grand multiparity• Another cause is pelvic contraction, in which the

horizontal space is greater than the vertical space.

• Placenta previa (the placenta is located low in the uterus, obscuring some of the vertical space) may also limit the fetus' ability to turn, resulting in a transverse lie.

• Infant is preterm and smaller than usual

Position

• Relationship of the presenting part to a specific quadrant of the woman's pelvis.

• Maternal pelvis is divided into four quadrants according to the mother's right and left:

(1) right anterior

(2) left anterior

(3) right posterior

(4) left posterior.

Position

• Four parts of the fetus have been chosen as landmarks.

• Position is marked by an abbreviation of three letters.

• The middle letter denotes the fetal landmark• 0 for occiput • M for mentum or chin • S for sacrum• A for acromion process

Position

• The first letter denotes whether the landmark is pointing to the mother's right (R) or left (L).

• The last letter denotes whether the landmark points anteriorly (A), posteriorly (P), or transversely (T).

• LOA is the most common fetal position and right occipitoanterior (ROA) the second most frequent position

Mechanisms (Cardinal Movements) of Labor

• Descent• Flexion• internal rotation• Extension• External rotation• Expulsion

Descent.

• Downward movement of the fetal head to within the pelvic inlet.

• Full descent: fetal head extrudes beyond the dilated cervix and touches the posterior vaginal floor.

• Descent occurs because of pressure on the fetus by the uterine fundus.

• Full descent may be aided by abdominal muscle contraction.

Flexion

• As descent occurs, pressure from the pelvic floor causes the fetal head to bend forward onto the chest.

• The smallest anteroposterior diameter (the suboccipitobregmatic diameter) is the one presented to the birth canal in this flexed position.

Internal Rotation.

• The head flexes as it touches the pelvic floor, and the occiput rotates until it is superior, or just below the symphysis pubis, bringing the head into the best diameter for the outlet of the pelvis (the anteroposterior diameter is now in the anteroposterior plane of the pelvis).

• Movement brings the shoulders, coming next, into the optimal position to enter the inlet or puts the widest diameter of the shoulders (a transverse one) in line with the wide transverse diameter of the inlet.

Extension

• As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head.

• The head thus extends, and the foremost parts of the head, the face and chin, are born.

External Rotation.

• almost immediately after the head of the infant is born, the head rotates back to the diagonal or transverse position of the early part of labor.

• The aftercoming shoulders are thus brought into an anteroposterior position, which is best for entering the outlet.

• The anterior shoulder is delivered first, assisted perhaps by downward flexion of the infant's head.

Expulsion

• Once the shoulders are delivered, the rest of the baby is delivered easily and smoothly because of its smatter size.

• This is expulsion and is the end of the pelvic division of labor.

Powers of Labor

• Uterine contractions• a process that causes cervical dilatation

and then expulsion of the fetus from the uterus.

• It is important for women to understand they should not bear down with their abdominal muscles until the cervix is fully dilated. Doing so will impede the primary force or could cause fetal and cervical damage.

Cervical Changes

• Two changes that occur in the cervix: • effacement (thinning) • dilatation (enlargement)

• Effacement• is shortening and thinning of the cervical canal.• Normally : 1 to 2 cm long.• In primiparas, effacement is accomplished before

dilatation begins.• In multiparas, dilatation may proceed before

effacement is complete.• Effacement must occur at the end of dilatation,

however, before the fetus can be safely pushed through the cervical canal or cervical tearing may result.

Cervical Changes

• Dilatation • enlargement of the cervical canal from an opening

a few millimeters wide to one large enough (approximately 10 cm) to permit passage of the fetus

• Dilatation occurs for two reasons.o uterine contractions gradually increase the

diameter of the cervical canal lumen by pulling the cervix up over the presenting part of the fetus.

o fluid-filled membranes press against the cervix. If the membranes are intact, they push ahead of the fetus and serve as an opening wedge.