Care of Mother, Child, TOPIC 13: LABOR & DELIVERY

Adolescent (Well Clients) LEC Management

NCM 107
LABOR - PHYSICAL & MECHANICAL PROCESS
from pages 179 -
IN WHICH THE BABY, THE PLACENTA & FETAL
MEMBRANES ARE PROPELLED THROUGH THE
TOPIC 12: CHILDBIRTH PELVIS & ARE EXPELLED FROM THE BIRTH
PREPARATION CLASSES CANAL.
- Nonpharmacologic pain reduction during DELIVERY - ACTUAL EVENT OF BIRTH
labor.
- To decrease fear & anxiety 5 P'S IN LABOR & DELIVERY
1. PASSENGER = THE FETUS
2. PASSAGEWAY = THE BIRTH CANAL
1 THE BRADLEY (PARTNER COACHED) 3. POWERS OF LABOR = FORCE OF
METHOD UTERINE CONTRACTIONS
- Pain is reduced by abdominal breathing 4. PLACENTAL IMPLANTATION
5. PSYCHOLOGICAL STATE OR
FEELINGS THAT WOMEN BRING TO
2 PSYCHOSEXUAL METHOD LABOR
- CONSCIENTIOUS RELAXATION &
LEVELS OF PROGRESSIVE BREATHING THAT THE FETAL SKULL
ENCOURAGES THE WOMAN TO "FLOW WITH" FROM AN OBSTETRICAL POINT OF VIEW, THE
RATHER THAN STRUGGLE WITH FETAL SKULL IS THE MOST IMPORTANT PART
CONTRACTIONS. OF THE FETUS BECAUSE:
A. IT IS THE LARGEST PART OF THE BODY

3 DICK-READ METHOD B. IT IS THE MOST FREQUENT

PRESENTING PART
- FEAR LEADS TO TENSION. WHICH C. IT IS THE LEAST COMPRESSIBLE OF ALL
LEADS TO PAIN PARTS
- RELAXATION TECHNIQUES
- AVOIDANCE OF MEDICINES CRANIAL BONES
1. SPHENOIDAL
4 LAMAZE METHOD 2. FRONTAL
3. ETHMOIDAL
- USE CONTROLLED BREATHING & 4. TEMPORAL
THEREFORE REDUCE PAIN DURING LABOR 5. PARIETAL
- PREVIOUSLY TERMED
PSYCHOPROPHYLACTIC METHOD MEANING MEMBRANE SPACES
PREVENTING PAIN IN LABOR (PROPHYLAXIS) SUTURE LINES ARE IMPORTANT BECAUSE
BY USE OF THE MIND (PSYCHE) THEY ALLOW THE BONES TO MOVE AND
- CONSCIOUS APPLICATION OF OVERLAP. CHANGING THE SHAPE OF THE
CONDITIONED RESPONSES TO STIMULI FETAL HEAD IN ORDER TO FIT THROUGH THE
- CHEST BREATHING IN EARLY LABOR BIRTH CANAL, A PROCESS CALLED MOLDING.
- INCREASE RATE AS LABOR 1. SAGITTAL SUTURE LINE = THE
PROGRESSES MEMBRANOUS INTERSPACE WHICH JOINS
THE 2 PARIETAL BONES.
2. CORONAL SUTURE LINE = THE
MEMBRANOUS INTERSPACE WHICH JOINS
THE FRONTAL BONE AND THE PARIETAL
BONES
LAMBDOIDAL SUTURE LINE
FONTANELLES
MEMBRANE COVERED SPACES AT THE
JUNCTION OF THE MAIN SUTURE LINES:
1. ANTERIOR FONTANEL = THE
LARGER, DIAMOND SHAPED FONTANEL
WHICH CLOSES BETWEEN 12 TO 18 MONTHS
IN AN INFANT
2. POSTERIOR FONTANEL = THE
SMALLER TRIANGULAR SHAPED FONTANEL
WHICH CLOSES BETWEEN 2-3 MONTHS IN
THE INFANT. THE SPACE BETWEEN THE TWO
FONTANELLES IS REFERRED TO AS THE
VERTEX
MEASUREMENTS - THE SHAPE OF THE
FETAL SKULL CAUSES IT TO BE WIDER IN ITS
ANTEROPOSTERIOR (AP) DIAMETER THAN
IN ITS TRANSVERSE DIAMETER.
1. TRANSVERSE DIAMETER OF THE FETAL
SKULL:
I. BIPARIETAL = 9.25CM TO 9.5CM
II. BITEMPORAL = 8CM.
III. BIMASTOID = 7CM.
2. ANTEROPOSTERIOR DIAMETERS
I. SUBOCCIPITOBREGMATIC = FROM
BELOW THE OCCIPUT TO THE
ANTERIOR FONTANELLE = 9.5 CM
(THE NARROWEST AP DIAMETER)
II. OCCIPITOFRONTAL = FROM THE
OCCIPITAL PROMINENCE TO THE
BRIDGE OF THE NOSE = 12 CM.
III. OCCIPITOMENTAL = FROM THE
POSTERIOR FONTANELLE TO THE CHIN
= 13.5 CM (THE WIDEST AP
DIAMETER)
WHICH ONE OF THESE DIAMETERS IS
PRESENTED AT THE BIRTH CANAL DEPENDS
ON THE DEGREE OF FLEXION (ATTITUDE)
THE FETAL HEAD ASSUMES PRIOR TO
DELIVERY. IN FULL FLEXION, (VERY GOOD
ATTITUDE WHEN THE CHIN IS FLEXED ON
THE CHEST), THE SMALLEST
SUBOCCIPITOBREGMATIC DIAMETER IS THE
ONE PRESENTED AT THE BIRTH CANAL. IF IN
POOR FLEXION, THE WIDEST
OCCIPITOMENTAL DIAMETER WILL BE THE
ONE PRESENTED & WILL GIVE MOTHER &
BABY MORE PROBLEMS.
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. DESCENT TO THIS
POINT MEANS THAT THE WIDEST PART OF
THE FETUS (THE BIPARIETAL DIAMETER IN A
CEPHALIC PRESENTATION. THE
INTERTROCHANTERIC DIAMETER IN A
BREECH PRESENTATION) HAS PASSED
THROUGH THE PELVIS OR THE PELVIC INLET
HAS BEEN PROVEN ADEQUATE FOR BIRTH. IN
A PRIMIPARA. NONENGAGEMENT OF THE
HEAD AT THE BEGINNING OF LABOR
INDICATES A POSSIBLE COMPLICATION SUCH
AS ABNORMAL PRESENTATION OR POSITION,
ABNORMALITY OF THE FETAL HEAD. OR
CEPHALOPELVIC DISPROPORTION (CPD).
IN PRIMIPARAS, ENGAGEMENT MAY OR MAY
NOT BE PRESENT AT THE BEGINNING OF
LABOR. A PRESENTING PART THAT IS NOT
ENGAGED IS SAID TO BE "FLOATING". ONE
THAT IS DESCENDING BUT HAS NOT YET
REACHED THE ISCHIAL SPINES CAN BE SAID
TO BE " DIPPING". THE DEGREE OF
ENGAGEMENT IS ASSESSED BY VAGINAL &
CERVICAL EXAMINATION.
STATION = REFERS TO THE RELATIONSHIP
OF THE PRESENTING PART OF THE FETUS TO
THE LEVEL OF THE ISCHIAL SPINES.
STATION 0 = PRESENTING PART IS AT
THE LEVEL OF THE ISCHIAL SPINES
(SYNONYMOUS TO ENGAGEMENT)
STATION -1 = PRESENTING PART IS
1CM ABOVE THE ISCHIAL SPINES
STATION +1 = PRESENTING PART IS
1CM BELOW THE ISCHIAL SPINES
STATION +3 OR +4 = THE
PRESENTING PART IS AT THE PERINEUM &
CAN BE SEEN IF THE VULVA IS SEPARATED;
SYNONYMOUS TO "CROWNING"
(ENCIRCLING OF THE LARGEST DIAMETER OF
THE FETAL HEAD BY THE VULVAR RING).
FETAL LIE/ PRESENTATION = IS THE
RELATIONSHIP BETWEEN THE LONG AXIS OF
THE FETUS TO THE LONG AXIS OF THE
MOTHER.
PRESENTING PART = REFERS TO THE FETAL
PART THAT FIRST ENTERS THE MATERNAL
PELVIS & COVER THE INTERNAL OS.
2 KINDS OF LIE
1. LONGITUDINAL LIE = LONG AXIS OF
THE FETUS IS PARALLEL TO THE LONG AXIS
OF THE MOTHER.
2. TRANSVERSE LIE = LONG AXIS OF
THE FETUS IS PERPENDICULAR TO THE LONG
AXIS OF THE MOTHER
CAUSES OF TRANSVERSE LIE:
1. MULTIPARITY
2. CONTRACTED PELVIS
3. PLACENTA PREVIA
TYPES OF FETAL PRESENTATION
A. VERTICAL/ LONGITUDINAL LIE:
1. CEPHALIC PRESENTATION (96%) =
MEANS THAT THE HEAD IS THE BODY PART
THAT FIRST CONTACTS THE CERVIX.
a. VERTEX/ OCCIPUT ( MOST
COMMON) = THE HEAD IS FULLY
FLEXED ON THE CHEST MAKING THE
PARIETAL BONES OR THE SPACE BETWEEN
THE FONTANELLES
POSITION = REFERS TO THE RELATIONSHIP
OF THE PRESENTING PART TO A SPECIFIC
QUADRANT OF THE WOMAN'S PELVIS.
4 QUADRANTS OF THE MATERNAL
PELVIS:
A. RIGHT ANTERIOR
B. LEFT ANTERIOR
C. RIGHT POSTERIOR
D. LEFT POSTERIOR
E. TRANSVERSE
4 PARTS OF THE FETUS CHOSEN AS
LANDMARKS:
1. OCCIPUT "O" - VERTEX PRESENTATION
2. MENTUM "M' (CHIN) -FACE
PRESENTATION
3. SACRUM "Sa"- IN BREECH
PRESENTATION
4. SCAPULA "SC” - IN SHOULDER
PRESENTATION
POSITION IS IMPORTANT BECAUSE IT
INFLUENCES THE PROCESS & EFFICIENCY OF
LABOR. TYPICALLY, A FETUS DELIVERS
FASTEST FROM AN
LOA - LEFT OCCIPITO ANTERIOR (MOST
COMMON) &
ROA - RIGHT OCCIPITO ANTERIOR (2ND MOST
COMMON).
POSTERIOR POSITIONS MAY BE MORE
PAINFUL FOR THE MOTHER BECAUSE THE
ROTATION OF THE FETAL HEAD PUTS
PRESSURE ON THE SACRAL NERVES,
CAUSING SHARP BACK PAINS. ("BACK
LABOR")
THE PASSAGEWAY/ THE BIRTH CANAL
A. THE PELVIS
TYPES OF PELVIS
1. GYNECOID = NORMAL FEMALE
PELVIS; THE INLET IS WELL ROUNDED
FORWARD & BACKWARD; THE PUBIC ARCH IS
WIDE; THIS PELVIS IS IDEAL FOR CHILDBIRTH
2. ANDROID = "MALE PELVIS": THE
PUBIC ARCH IN THIS PELVIS TYPE FORMS AN
ACUTE ANGLE MAKING THE LOWER
DIMENSIONS OF THE PELVIS NARROW. A
FETUS MAY HAVE DIFFICULTY EXITING FROM
THIS TYPE OF PELVIS. (LEAST FAVORABLE)
3. ANTHROPOID PELVIS = "APE-LIKE
PELVIS"; THE TRANSVERSE DIAMETER IS
NARROW & THE AP DIAMETER OF THE INLET
IS LARGER THAN NORMAL.
4. PLATYPELLOID = " FLATTENED
PELVIS" THE INLET IS AN OVAL SMOOTHLY
CURVED BUT THE AP DIAMETER IS SHALLOW.
A FETAL HEAD MIGHT NOT ABLE TO ROTATE
TO MATCH THE CURVES OF THE PELVIC
CAVITY.
DIVISIONS:
 1. FALSE PELVIS = "SUPERIOR HALF".
SUPPORTS THE UTERUS DURING THE LATE
MONTHS OF PREGNANCY & AIDS IN
DIRECTING THE FETUS INTO THE TRUE
PELVIS FOR BIRTH.
2. TRUE PELVIS = “INFERIOR HALF":
FORMED BY THE PUBES IN FRONT, THE ILIA &
THE ISCHIA ON THE SIDES & THE SACRUM &
COCCYX BEHIND.
** THE FALSE PELVIS IS DIVIDED FROM THE
TRUE PELVIS ONLY BY AN IMAGINARY LINE:
THE LINEA TERMINALIS DRAWN FROM THE
SACRAL PROMINENCE AT THE BACK TO THE
SUPERIOR ASPECT OF THE SYMPHYSIS PUBIS
AT THE FRONT OF THE PELVIS.
a. PELVIC INLET = ENTRANCE TO THE
TRUE PELVIS, OR THE UPPER RING OF BONE
THROUGH WHICH THE FETUS MUST FIRST
PASS TO BE BORN VAGINALLY. ITS
TRANSVERSE DIAMETER IS WIDER THAN ITS
AP DIAMETER. THUS:
** TRANSVERSE DIAMETER = 13.5 CM
** AP DIAMETER = 11 CM
b. MIDPELVIS/ PELVIC CAVITY = THE
SPACE BETWEEN THE INLET & THE OUTLET.
THIS IS NOT A STRAIGHT BUT A CURVED
PASSAGE
c. PELVIC OUTLET = THE INFERIOR
PORTION OF THE PELVIS. THE MOST
IMPORTANT DIAMETER OF THE OUTLET IS ITS
TRANSVERSE OR BI-ISCHIAL DIAMETER(
DISTANCE BET THE TWO ISCHIAL
TUBEROSITIES) WHICH IS ABOUT 11.5 CM
** AP DIAMETER = 9.5 TO 11.5 CM
MEASUREMENTS:
a. DIAGONAL CONJUGATE = DISTANCE
BETWEEN THE MIDPOINT OF THE SACRAL
PROMONTORY TO THE LOWER MARGIN OF
THE SYMPHYSIS PUBIS. (MEASURED BY
INTERNAL EXAMINATION)
AVERAGE = 12.5 TO 13 CMS
b. TRUE CONJUGATE/ CONJUGATA
VERA = THE DISTANCE BETWEEN THE
MIDPOINT OF THE SACRAL PROMONTORY TO
THE UPPER MARGIN OF THE SYMPHYSIS
PUBIS.
VERY IMPORTANT MEASUREMENT BECAUSE
IT IS THE DIAMETER OF THE PELVIC INLET
AVERAGE = 11.5 CM.
C. OBSTETRIC CONJUGATE = DISTANCE
BETWEEN THE MIDPOINT OF SACRAL
PROMONTORY TO THE MIDLINE OF THE
SYMPHYSIS PUBIS WHICH IS ASCERTAINED BY
SUBTRACTING 1 TO 1.5 CM FROM THE
DIAGONAL CONJUGATE
AVERAGE = 11 CM
POWERS
a. INVOLUNTARY UTERINE
CONTRACTIONS
b. VOLUNTARY UTERINE CONTRACTIONS
PHASES OF UTERINE CONTRACTIONS:
1. INCREMENT = WHEN THE INTENSITY
OF THE CONTRACTIONS INCREASES
2. ACME = WHEN THE CONTRACTIONS
ARE AT ITS STRONGEST
3. DECREMENT = WHEN THE INTENSITY
DECREASES
CHARACTERISTICS OF UTERINE
CONTRACTIONS:
1. DURATION = REFERS TO THE LENGTH
OF CONTRACTIONS STARTING FROM THE
BEGINNING OF ONE CONTRACTION TO THE
END OF SAME CONTRACTION.
2. FREQUENCY = STARTS FROM THE
BEGINNING OF ONE CONTRACTION TO THE
BEGINNING OF THE NEXT CONTRACTION.
3. INTERVAL = REFERS TO THE
REGULARITY OF CONTRACTIONS. IT STARTS
FROM THE END OF ONE CONTRACTION TO
THE BEGINNING OF THE NEXT CONTRACTION.
4. INTENSITY = REFERS TO THE
STRENGTH OF UTERINE CONTRACTIONS.
a. MILD - IF THE FUNDUS IS
SLIGHTLY TENSE & EASY TO INDENT WITH
FINGERTIPS
b. MODERATE - IF THE FUNDUS IS
FIRM & IS DIFFICULT TO INDENT WITH
FINGERTIPS
c. STRONG - IF THE FUNDUS IS
HARD & RIGID & ALMOST IMPOSSIBLE TO
INDENT
** AS LABOR CONTRACTIONS PROGRESS &
BECOME REGULAR & STRONG, THE UTERUS
GRADUALLY DIFFERENTIATES ITSELF INTO
TWO DISTINCT FUNCTIONAL AREAS. THE
UPPER PORTION BECOMES THICKER &
ACTIVE. PREPARING TO EXERT ITS
STRENGTH NECESSARY TO EXPEL THE FETUS,
THE LOWER PORTION BECOME THIN
WALLED, SUPPLE & PASSIVE, SO THE FETUS
CAN BE EXPELLED OUT EASILY. THE
BOUNDARY BETWEEN THE TWO PORTIONS
BECOMES MARKED BY A RIDGE CALLED
“PHYSIOLOGIC RETRACTION RING"
IN A DIFFICULT LABOR, THE RING MAY
BECOME PROMINENT & OBSERVABLE AS AN
ABDOMINAL INDENTATION. THIS IS TERMED
AS "PATHOLOGIC RETRACTION RING" OR
"BANDL'S RING" A DANGER SIGN THAT
SIGNIFIES IMPENDING RUPTURE OF THE
LOWER UTERINE SEGMENT.
CERVICAL CHANGES:
- EVEN MORE MARKED THAN THE
CHANGES IN THE BODY OF THE UTERUS ARE
TWO CHANGES THAT OCCUR IN THE CERVIX:
1.EFFACEMENT = SHORTENING & THINNING
OF THE CERVICAL CANAL. NORMALLY THE
CANAL IS 1-2 CM LONG. WITH EFFACEMENT,
THIS CANAL VIRTUALLY DISAPPEARS.THIS IS
EXPRESSED IN PERCENTAGE (%)
2. DILATATION - REFERS TO THE
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.
PLACENTAL IMPLANTATION
a. IF THE PLACENTA HAS IMPLANTED
NORMALLY IN THE FUNDAL PORTION OF THE
UTERUS ( ANTERIOR OR POSTERIOR), IT
RARELY CAUSE TROUBLE DURING LABOR &
DELIVERY.
b. WHEN MAL IMPLANTATION OF THE
PLACENTA OCCURS IN THE LOWER UTERINE
SEGMENT, IT NECESSITATES MEDICAL OR
SURGICAL INTERVENTION.
PRELIMINARY/ PRODROMAL SIGNS OF
LABOR
A. LIGHTENING = THE SETTLING OF THEn
FETAL HEAD INTO THE PELVIC BRIM. IN
PRIMIS, IT OCCURS 2 WEEKS BEFORE EDC
(10-14 DAYS). IN MULTIS, ON OR BEFORE
LABOR ONSET.
RESULTS OF LIGHTENING:
1. INCREASE IN URINARY FREQUENCY
2. RELIEF OF ABDOMINAL TIGHTNESS &
DIAPHRAGMATIC PRESSURE
3. SHOOTING PAINS DOWN THE LEGS DUE
TO PRESSURE ON THE SCIATIC NERVE.
4. INCREASE IN THE AMOUNT OF
VAGINAL DISCHARGES
5. LOSS OF WEIGHT OF ABOUT 2-3 LBS
ONE TO TWO DAYS BEFORE LABOR ONSET =
DECREASE IN PROGESTERONE THUS
DECREASE IN FLUID RETENTION
6. RIPENING OF THE CERVIX = FROM
GOODELL'S SIGN THE CERVIX BECOMES
"BUTTER SOFT"
IN ADDITION. APPLY A WARM SALINE
SATURATED OS ON THE PROLAPSED CORD TO
PREVENT DRYING OF THE CORD.
B. SHOW - THIS IS DUE TO PRESSURE OF THE
DESCENDING PRESENTING PART OF THE
FETUS WHICH CAUSES RUPTURE OF MINUTE
CAPILLARIES IN THE MUCUS MEMBRANE OF
THE CERVIX.BLOOD MIXES WITH MUCUS
WHEN OPERCULUM ( MUCUS PLUG) IS
RELEASED.
SIGNS OF LABOR
UTERINE CONTRACTIONS - THE SUREST
SIGN THAT LABOR HAS BEGUN IS THE
INITIATION OF EFFECTIVE PRODUCTIVE
UTERINE CONTRACTIONS.
DIFFERENCES BETWEEN TRUE LABOR &
FALSE LABOR:
FALSE LABOR TRUE LABOR
1 CONTRACTIONS 1 MAY BE SLIGHTLY
REMAIN IRREGULAR IRREGULAR AT
FIRST BUT BECOME
REGULAR IN A
MATTER OF HRS.
2 GENERALLY 2 FIRST FELT IN THE
CONFINED TO THE LOWER BACK &
ABDOMEN SWEEP AROUND TO
THE ABDOMEN IN A 4. THEORY OF THE AGING PLACENTA - AS
GIRDLE LIKE THE PLACENTA AGES. IT BECOMES LESS
FASHION EFFICIENT & AS A RESULT, IT PRODUCES LESS
& LESS AMOUNT OF PROGESTERONE &
3 NO INCREASE 3 INCREASE IN ALLOWS CONCENTRATION OF
DURATION, INTENSITY,
PROSTAGLANDIN & ESTROGEN TO RISE
INTENSITY & DURATION &
FREQUENCY FREQUENCY STEADILY WHICH RESULTS TO RHYTHMIC
REGULAR & STRONG UTERINE
4 OFTEN CONTINUE NO CONTRACTIONS.
DISAPPEARS IF THE MATTER WHAT THE
WOMAN AMBULATES WOMAN’S LEVEL OF 5. PROSTAGLANDIN THEORY - WHEN
ACTIVITY WALKING
PREGNANCY REACHES TERM, THE FETAL
INTENSIFIES
CONTRACTIONS. MEMBRANE PRODUCE LARGE AMOUNTS OF
ARACHIDONIC ACID WHICH IS CONVERTED BY
5 ABSENT CERVICAL 5 ACCOMPANIED BY MATERNAL DECIDUA INTO PROSTAGLANDIN,
CHANGES. CERVICAL ANOTHER HORMONE THAT INITIATES
EFFACEMENT & UTERINE CONTRACTIONS.
DILATATION (MOST
IMPORTANT
DIFFERENCE) LENGTH OF LABOR
STAGE PRIMIS MULTIS
6 NO BLOOD SHOW 6 BLOOD SHOW
1st STAGE 10-12 HRS 6-8 HRS
7 PROGRESSIVE
FETAL DESCENT 2nd STAGE 30MIN 2 HRS 20 TO 90 MIN

THEORIES OF LABOR ONSET: AVE. 50 MIN AVE. 20 MIN

3rd STAGE 5 TO 20 MIN 5 TO 20 MIN

1.OXYTOCIN STIMULATION THEORY - AS
PREGNANCY NEARS TERM. OXYTOCIN
PRODUCTION BY THE PPG INCREASE & AS A
RESULT, THE UTERUS BECOME
INCREASINGLY SENSITIVE TO OXYTOCIN.
OXYTOCIN STIMULATES UTERINE
CONTRACTIONS.
2. UTERINE STRETCH THEORY - ANY
HOLLOW MUSCULAR ORGAN WHEN
STRETCHED TO CAPACITY WILL CONTRACT &
EMPTY.
3. PROGESTERONE DEPRIVATION
THEORY - PROGESTERONE MAINTAINS
PREGNANCY BY ITS RELAXANT EFFECT ON
THE SMOOTH MUSCLES OF THE UTERUS. AS
PREGNANCY NEARS TERM. PROGESTERONE
PRODUCTION DECREASE. WHEN
PROGESTERONE LEVEL DROPS. UTERINE
CONTRACTION OCCURS.
4th STAGE 2 TO 4 HRS 2 TO 4 HRS
STAGES OF LABOR
A. FIRST STAGE OF LABOR ( STAGE OF
DILATATION) - FROM THE ONSET OF
TRUE LABOR PAINS & ENDS WITH
COMPLETE DILATATION OF THE CERVIX.
(10 CM).
1. LATENT PHASE
DILATATION: 0-3 CMS
INTENSITY: MILD & SHORT CONTRACTIONS
DURATION: 20-40 SECONDS
INTERVAL: 15 - 20 MINS
ELECTRONIC FETAL MONITORING:
1. EXTERNAL OR INDIRECT MONITORING
 a. APPLIED WHEN MEMBRANES ARE
STILL INTACT SUCH AS TOCODYNAMOMETER
AND UTERINE TRANSDUCER.
2. INTERNAL OR DIRECT MONITORING
a. APPLIED WHEN MEMBRANES HAVE
RUPTURED & CERVIX HAS DILATED 2-3 CM.
** MOTHER IS EXCITED WITH SOME DEGREE
OF APPREHENSION BUT STILL WITH ABILITY
TO COMMUNICATE.
** TAKES UP 8 OF THE 12 HOUR FIRST STAGE.
2. ACTIVE PHASE
DILATATION: 4 - 7 CMS.
INTENSITY: MODERATE
DURATION: 40 - 60 SECONDS
INTERVAL: 3 -5 MINUTES
** THIS PHASE LASTS APPROXIMATELY 3
HOURS IN A NULLIPARA & 2 HOURS IN A
MULTIPARA.
** ANESTHESIA IS GIVEN DURING THIS PHASE
AT 5-6 CM DILATATION.
TYPES OF ANESTHESIA
a. PARACERVICAL - TRANSVAGINAL
INJECTION INTO EITHER SIDE OF THE
CERVIX. PATIENT ON LITHOTOMY POSITION.
COUPLED WITH A LOCAL ANESTHETIC,
RESULTS IN A PAINLESS CHILDBIRTH
(UTERINE CONTRACTIONS ARE NOT FELT BY
THE MOTHER)
b. PUDENDAL - INJECTION THROUGH THE
SACROSPINOUS LIGAMENT INTO POSTERIOR
AREOLAR TISSUES TO REDUCE PERCEPTION
OF PAIN DURING SECOND STAGE & MAKE
MOTHER COMFORTABLE. PATIENT IS ON
LITHOTOMY POSITION.
SIDE EFFECT: ECCHYMOSIS PURPLISH
DISCOLORATION OF THE SKIN DUE TO BLOOD
IN THE SUBCUTANEOUS TISSUES
NURSING CARE: APPLY ICE BAG TO
THE AREA ON THE FIRST DAY WHICH COULD
REDUCE SWELLING.
c. EPIDURAL - INJECTION OF LOCAL
ANESTHETIC AT THE LUMBAR LEVEL
OUTSIDE THE DURA MATER
** POST SPINAL HEADACHES MAY BE DUE TO
LEAKAGE OF ANESTHETICS INTO THE CSF OR
INJECTION OF AIR AT TIME OF NEEDLE
INSERTION.
NURSING MX:
** FLAT ON BED FOR 12 HOURS & INCREASE
FLUID INTAKE.
NURSING MX:
- TURN TO SIDE
- PROMPT ELEVATION OF LEGS
- ADMINISTRATION OF VASOPRESSOR &
02 AS ORDERED
***
SURE SIGN THAT THE BABY IS ABOUT TO BE
BORN IS THE BULGING OF THE PERINEUM.
IN GENERAL. PRIMIGRAVIDAS ARE
TRANSPORTED FROM LR TO DR WHEN THERE
IS BULGING OF THE PERINEUM (10 CM);
MULTIPARAS ARE TRANSPORTED AT 7-8 CM
CERVICAL DILATATION OR AT +1+2***
3. TRANSITION PHASE
DILATATION: 8 - 10 CM
INTENSITY: STRONG
DURATION: 60 - 90 SECONDS
INTERVAL: 2-3 MINUTES
STATION: +1 +2
**WHEN THE MOOD OF THE WOMAN
SUDDENLY CHANGES & THE NATURE OF THE
CONTRACTIONS INTENSIFY**
CHARACTERISTICS:
1. IF THE MEMBRANES ARE STILL INTACT,
THIS PERIOD IS MARKED BY A SUDDEN GUSH
OF AMNIOTIC FLUID, AS FETUS IS PUSHED TO
THE BIRTH CANAL.
2. IF SPONTANEOUS RUPTURE DOES NOT
OCCUR, AMNIOTOMY ( SNIPPING OF BOW
WITH A STERILE POINTED INSTRUMENT TO
ALLOW AMNIOTIC FLUID TO DRAIN) IS DONE
TO PREVENT FETUS FROM ASPIRATING THE
AMNIOTIC FLUID AS IT MAKES ITS DIFFERENT
POSITION CHANGES. AMNIOTOMY HOWEVER
CANNOT BE DONE IF STATION IS STILL AT
"MINUS" AS THIS CAN LEAD TO CORD
COMPRESSION.
3. THERE IS AN UNCONTROLLABLE URGE
TO PUSH WITH CONTRACTIONS, A SIGN OF AN
IMPENDING SECOND STAGE OF LABOR.
4. PERINEAL PREPARATION- THE PUBIC
HAIR ON THE LOWER HALF OF THE VULVA &
THE PERINEUM IS REMOVED BY SHAVING TO
MAKE IT CLEAN & TAUT.
REASONS FOR ADMINISTRATION OF
ENEMA:
 a. TO PREVENT INFECTION TO BOTH THE
MOTHER & THE FETUS.
b. IT HELPS TO INCREASE UTERINE
CONTRACTIONS.
c. PREVENTS POSTPARTUM DISCOMFORT
d. TO FACILITATE THE DESCENT OF THE
FETUS TO THE BIRTH CANAL.
CONTRAINDICATIONS OF ENEMA:
a. MALPRESENTATION & POSITION
b. VAGINAL BLEEDING
c. RUPTURED BAG OF WATERS
d. CROWNING
e. PLACENTA PREVIA
NOTE: CHECKING THE BLOOD PRESSURE SHOULD BE DONE
MIDWAY BETWEEN CONTRACTIONS BECAUSE IT NORMALLY
INCREASES DURING A CONTRACTION.
FHR SHOULD NOT BE TAKEN DURING
UTERINE CONTRACTIONS SINCE IT TENDS TO
SLOW DOWN AS INDUCED BY THE
COMPRESSION OF THE FETAL HEAD DURING
UTERINE CONTRACTIONS
NURSING ALERT: ANY CHANGE IN THE FHR
THE FIRST NURSING ACTION IS TO CHANGE
THE POSITION OF THE MOTHER"
NURSING ACTIONS:
** PRIMARILY COMFORT MEASURES**
a. SACRAL PRESSURE (APPLYING
PRESSURE WITH THE HEEL OF THE HAND ON
THE SACRUM) RELIEVES DISCOMFORT FROM
CONTRACTIONS
b. PROPER BEARING DOWN TECHNIQUE.
c. CONTROLLED CHEST ( COSTAL)
BREATHING DURING CONTRACTIONS.
d. EMOTIONAL SUPPORT
B. SECOND STAGE OF LABOR (STAGE OF
EXPULSION) = BEGINS WITH COMPLETE
DILATATION (10 CM) & ENDS WITH THE
DELIVERY OF THE BABY.
= MOST CRITICAL STAGE ON THE PART
OF THE FETUS CARDINAL MOVEMENTS/
MECHANISM OF LABOR / FETAL POSITION
CHANGES:
1. DESCENT = DOWNWARD MOVEMENT OF
THE BIPARIETAL DIAMETER OF THE FETAL
HEAD TO WITHIN THE PELVIC INLET. THE
PRESSURE OF THE FETUS ON THE SACRAL
NERVES CAUSES THE MOTHER TO
EXPERIENCE A PUSHING SENSATION.
2. FLEXION = AS DESCENT OCCURS,
PRESSURE FROM THE PELVIC FLOOR CAUSES
THE FETAL HEAD TO BEND FORWARD ONTO
THE CHEST. THIS PERMITS THE SMALLEST AP
DIAMETER (SUBOCCIPITOBREGMATIC
DIAMETER) TO PRESENT IN THE OUTLET.
3. INTERNAL ROTATION - OCCIPUT
ROTATES UNTIL IT IS SUPERIOR. OR JUST
BELOW THE SYMPHYSIS PUBIS SO THE
SMALLEST DIAMETER IS PRESENTED TO THE
PELVIC OUTLET.
4. EXTENSION = AS THE HEAD COMES OUT.
THE BACK OF THE NECK STOPS AT THE PUBIC
ARCH & ACTS AS A PIVOT FOR THE REST OF
THE HEAD. THE HEAD EXTENDS & THE
FOREHEAD, NOSE, MOUTH & FINALLY THE
CHIN APPEAR.
5. EXTERNAL ROTATION (RESTITUTION) -
AS THE HEAD IS BORN IT ROTATES BRIEFLY
FROM THE POSITION IT OCCUPIED WHEN IT
WAS ENGAGED.
** WHEN THE BIPARIETAL DIAMETER OF THE
FETAL HEAD HAS PASSED THE PELVIC INLET,
THE PALPABLE PORTION OF THE FETAL HEAD
IS APPROXIMATELY AT STATION +2). ONE
SHOULDER IS ANTERIOR TO THE SYMPHYSIS
PUBIS & THE OTHER IS POSTERIOR TO THE
PELVIC FLOOR.)
6.EXPULSION = WITH THE DELIVERY OF THE
SHOULDERS, THE REST OF THE BABY IS BORN
EASILY & SMOOTHLY BECAUSE OF ITS
SMALLER SIZE & BIRTH IS COMPLETED.
NURSING CARE
a. WHEN POSITIONING LEGS IN LITHOTOMY
POSITION. PUT THEM UP AT THE SAME
TIME TO PREVENT INJURY TO THE
UTERINE LIGAMENTS.
b. AS SOON AS THE FETAL HEAD CROWNS.
INSTRUCT THE MOTHER NOT TO PUSH BUT
TO PANT INSTEAD (RAPID & SHALLOW
BREATHING), TO PREVENT RAPID
EXPULSION OF THE BABY.
C. IF PANTING IS DEEP & RAPID, CALLED
HYPERVENTILATION.THE PATIENT WILL
EXPERIENCE LIGHTHEADEDNESS & TINGLING
SENSATION OF THE FINGERS LEADING TO
CARPOPEDAL SPASMS BECAUSE OF
RESPIRATORY ALKALOSIS.
MX:
- LET THE PATIENT BREATHE INTO A
PAPER BAG TO RECOVER LOST CARBON
DIOXIDE. (A CUPPED HAND WILL SERVE THE
SAME PURPOSE)
d. ASSIST IN EPISIOTOMY - INCISION
MADE IN THE PERINEUM PRIMARILY TO:
1. PREVENT LACERATIONS
2. PREVENT PROLONGED & SEVERE
STRETCHING OF MUSCLES SUPPORTING
BLADDER OR RECTUM
3. REDUCE DURATION OF SECOND STAGE OF
LABOR WHEN THERE IS HYPERTENSION &
FETAL DISTRESS
4. ENLARGE OUTLET, AS IN BREECH
PRESENTATION OR FORCEPS DELIVERY
TYPES OF EPISIOTOMY
1. MEDIAN - FROM MIDDLE PORTION OF
THE LOWER VAGINAL BORDER DIRECTED
TOWARDS THE ANUS.
2. MEDIOLATERAL - BEGINS IN THE
MIDLINE BUT DIRECTED LATERALLY AWAY
FROM THE ANUS.
** NATURAL ANESTHESIA IS USED IN
EPISIOTOMY - MEANING NO ANESTHETIC IS
INJECTED BECAUSE PRESSURE OF THE FETAL
PRESENTING PART AGAINST THE PERINEUM
IS SO INTENSE THAT NERVE ENDINGS FOR
PAIN ARE MOMENTARILY DEADENED.
e. APPLY THE MODIFIED RITGEN'S MANEUVER
** COVER THE ANUS WITH STERILE
TOWEL & EXERT UPWARD & FORWARD
PRESSURE ON THE FETAL CHIN. WHILE
EXERTING GENTLE PRESSURE WITH TWO
FINGERS ON THE HEAD TO CONTROL
EMERGING HEAD. THIS WILL NOT ONLY
SUPPORT THE PERINEUM THUS PREVENTING
LACERATIONS BUT WILL ALSO FAVOR
FLEXION SO THAT THE SMALLEST
SUBOCCIPITOBREGMATIC DIAMETER OF THE
FETAL HEAD IS PRESENTED.
** EASE THE HEAD OUT IN-BETWEEN
CONTRACTIONS & IMMEDIATELY WIPE THE
NOSE & MOUTH OF SECRETIONS TO
ESTABLISH A PATENT AIRWAY
(pg287)