CHILDBIRTH PREPARATION CLASSES AND LABOR & DELIVERY

(MANAGEMENT)
Monday, September 5, 2022 4:33 PM

CHILDBIRTH PREPARATION CLASSES

- Non pharmacologic pain reduction during labor.

- To decrease fear & anxiety

1. The Bradley (partner coached) method

- Pain is reduced by abdominal breathing

2. Psychosexual method

- conscientious relaxation & levels of progressive breathing that encourages the woman to “ flow with” rather than struggle with contractions.

3. Dick-read method

- Fear leads to tension, which leads to pain

- Relaxation techniques

- Avoidance of medicines

4. Lamaze method

- Use controlled breathing & therefore reduce pain during labor.

- Previously termed psychoprophylactic method ( meaning preventing pain in labor (prophylaxis) by use of the mind (psyche)

- Conscious application of conditioned responses to stimuli

- Chest breathing in early labor

- Increase rate as labor progresses

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LABOR & DELIVERY (MANAGEMENT)

Labor - physical & mechanical process in which the baby, the placenta & fetal membranes are propelled through the pelvis & are expelled from the birth canal.

Delivery - actual event of birth

5 P’S IN LABOR & DELIVER

1. Passenger = the fetus

2. Passageway = the birth canal

3. Powers of labor= force of uterine contractions

4. Placental implantation

5. Psychological state or feelings that women bring to labor

THE FETAL SKULL - from an obstetrical point of view, the fetal skull is the most important part of the fetus because:

○ It is the largest part of the body

○ It is the most frequent presenting part

○ It is the least compressible of all parts

• Cranial Bones: sphenoidal, frontal, ethmoidal, temporal, parietal

• Membrane spaces - suture lines are important because they allow the bones to move and overlap, changing the shape of the fetal head in order to fit through the birth canal, a process called molding.

1. Sagittal suture line - the membranous interspace which joins the 2 parietal bones.

2. Coronal suture line - the membranous interspace which joins the frontal bone and the parietal bones.

3. 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 9.5
II. Bitemporal = 8 cm.
III. Bimastoid = 7 cm.
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.

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 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: multiparity, contracted pelvis, placental previa

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 Types of fetal presentation

Vertical/ longitudinal lie:

- Cephalic presentation (96%) - means that the head is the body part that first contacts the cervix.

○ Vertex/ occiput ( most common) = the head is fully flexed on the chest making the parietal bones or the space between the fontanelles, the

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:

a. Occiput “o”- vertex presentation

b. Mentum “m”(chin) –face presentation

c. Sacrum “ sa”– in breech presentation

d. 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”)

II 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

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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:

 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

 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.

 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

III 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.

 Mild – if the fundus is slightly tense & easy to indent with fingertips

 Moderate – if the fundus is firm & is difficult to indent with fingertips

 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 functioning 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.

IV PLACENTAL IMPLANTATION

- If the placenta has implanted normally in the fundal portion of the uterus ( anterior or posterior), it rarely cause trouble during labor & delivery.

- When malimplantation 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 the fetal head into the pelvic brim. In primis, it occurs 2 weeks before EDC ( 10-14 days). In multis, on or before labor onset.

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 Results of lightening:

1. Increase in urinary frequency

2. Relief of abdominal tightness & diapragmatic 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 goodel’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.
FALSE LABOR TRUE LABOR
1. Contractions remain irregular 1. May be slightly irregular at first but become regular in a matter of hrs
2. Generally confined to the abdomen 2. First felt in the lower back & sweep around to the abdomen in a girdle like fashion
3. No increase duration, intensity, & frequency 3. Increase in intensity, duration, & frequency
4. Often disappears if the woman ambulates 4. Continue no matter what the woman's level of activity walking intensifies contractions
5. Absent cervical changes 5. Accompanied by cervical effacement & dilatation (most important difference)
6. No blood show 6. Blood show
7. Progressive fetal descent

Theories of labor onset:

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.

4. Theory of the aging placenta - As the placenta ages, it becomes less efficient & as a result , it produces less & less amount of progesterone & allows concentration of prostaglandin & estrogen to rise steadily
which results to rhythmic regular & Strong uterine contractions.

5. Prostaglandin theory - When pregnancy reaches term, the fetal membrane produce large amounts of arachidonic acid which is converted by maternal decidua into prostaglandin, another hormone that initiates
uterine contractions.

------------------------------ 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:

 External or indirect monitoring - Applied when membranes are still intact such as tocodynamometer and uterine transducer.

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  Internal or direct monitoring - 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

○ 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)

○ 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.

○ 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.

- Turn to side

- Prompt elevation of legs

- Administration of vasopressor & O2 as ordered

*A 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:

○ 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.

○ 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.

○ There is an uncontrollable urge to push with contractions, a sign of an impending second stage of labor.

○ 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:

 To prevent infection to both the mother & the fetus.

 It helps to increase uterine contractions

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  It helps to increase uterine contractions

 Prevents postpartum discomfort

 To facilitate the descent of the fetus to the birth canal.

Contraindications of enema: Malpresentation & position, Vaginal bleeding, Ruptured bag of waters, Crowning, 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 contraction.

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:

○ When positioning legs in lithotomy position, put them up at the same time to prevent injury to the uterine ligaments.

○ 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.

○ 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)

○ Assist in episiotomy – incision made in the perineum primarily to:

1. Prevent lacerations

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 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

 Median - from middle portion of the lower vaginal border directed towards the anus.

 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.

○ 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.

Remember:

- The first principle in the care of the newborn is to establish & maintain a patent airway.

- The head should be delivered in between contractions.

- Insert two fingers into the vagina so as to feel for the presence of a cord looped around the neck ( nuchal cord ). If so, but loose, slip it down the shoulders or up over the head; but if tight, clamp cord twice an
inch apart, and then cut in-between.

- As the head rotates, deliver the anterior shoulder by exerting a gentle downward push & then slowly give an upward lift to deliver the posterior shoulder.

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