Maternal and Child Health Nursing

Chapter 5: Nursing Care During Labor

LABOR D. LEBOYER METHOD

o A series of events by which abdominal pressure and – Needs manipulating the environment to aid in
uterine contraction expels the fetus and placenta the birthing process.
outside the woman’s body / vagina. – Birthing place is darkened and pleasantly warm
o The process of fetal expulsion along with the products with soft music playing while in labor.
of conception secondary to regular, progressive and – Infant is handled gently and cutting of cord is
frequently occurring uterine contractions. done late and given warm water bath
METHODS OF CHILDBIRTH immediately.
A. READ METHOD LABOR PREPARATION
▪ Breathing Techniques for Labor A. PAIN RELIEF
▪ Relaxation Techniques ▪ NON-PHARMACOLOGIC
▪ Abdominal Breathing o Positioning
▪ Information in Classes o Relaxation Technique
▪ Natural Childbirth Method o Imagery
– also known as Dick-Read Method. A method of o Touch therapy
childbirth based on the premise that fear lead to ▪ NON-PHARMACOLOGIC
tension, which leads to pain. A. Opioids – they give significant pain
relief
B. LAMAZE METHOD Common agents: Meperidine
– Psychoprophylactic Method based on utilization (Demerol) – control drug and Nubain
of Pavlovian conditioned respond theory. Classes
teach replacement of usual response to pain B. Regional Anesthesia
with new, learned responses (effleurage, – Block specific nerve pathways.
breathing, relaxation) in order to block – Relieves pain by blocking nerve
recognition of pain and promote positive sense conduction.
of control in labor. – Lumbar Epidural Anesthesia
Breathing Techniques for labor & (Bone of Spinal Column) – q6h.
Childbirth
1. Breathe Naturally C. Spinal anesthesia
2. Release stress when exhaling – agent injected at the
3. Keep your breathing consistent cerebrospinal fluid (CSF) at the
4. Get some help level of L3-L4.
5. Remind yourself to slow down – hypotension can occur
6. Listen to you coach/partner – spinal headache
7. Don’t pant – increased incidence of urinary
8. Don’t hyperventilate retention.
9. Don’t hold your breath – Mostly on abdominal procedure

C. BRADLEY METHOD D. Local anesthesia

– Husband-coached childbirth. A modification of – used only during actual birth
the Read method emphasizing working in – complication may include
harmony with the body. allergic reaction
Maternal and Child Health Nursing
Chapter 5: Nursing Care During Labor
FIVE ESSENTIAL FACTORS IN LABOR (5P’S) 2. Breech – buttock or lower extremities present
1. Passenger first. Most managed through Caesarean birth.
2. Passageway
3. Power TYPES OF BREECH PRESENTATION
4. Placenta a. Frank Breech - thigh flexed, leg extended on
5. Psychological Response anterior body surface, buttocks presenting.
PASSENGER b. Complete or Full Breech - thighs and leg
o The size, presentation, position of the fetus, fetal flexed, buttocks and feet presenting (baby in
attitude and fetal lie. squatting position)
FETAL HEAD c. Footling breech - one (single footling) or
1. Usually, the largest part of the baby; it has both (double footling) feet are presenting.
profound effect on the birthing process.
2. Bones of skull are joined by membranous sutures,
which allow for overlapping or “molding” of
cranial bones during birth process.
3. Anterior and posterior fontanels are the points of
intersection for the sutures and are important
landmarks.
▪ Anterior fontanel is larger; diamond
shaped and closes about 18 months of
3. Shoulder – presenting part of the scapula, and
age.
baby is on horizontal or transverse position.
▪ Posterior fontanel is smaller, triangular,
Caesarean birth indicated.
and usually closes about 3 months of age.
FETAL POSITION
4. Fontanels are used as landmark for internal
o Relationship of the fetal presenting part to a
examinations during labor to determine the
specific quadrant of a woman’s / maternal body
position of the fetus
pelvis.
FETAL SHOULDERS
o Maternal bony pelvis divided into four quadrants
o Maybe manipulated during delivery to allow passage
(right and left anterior, right and left posterior).
of one shoulder at a time.
Relationship is expressed in three letters
PRESENTATION
abbreviation; first the maternal side (R or L), next
o That part of the fetus which enter in the pelvis in the
the fetal presentation, and last the maternal
birth process.
quadrant (A or P).
TYPES OF PRESENTATION
o Most common positions are:
1. Cephalic – head is presenting part; usually vertex,
A. LOA – Left Occiput Anterior
which is most favorable and ideal for vaginal
- fetal occiput is on maternal left side
birth. Head is flexed with chin on chest.
and toward front, face is down. This is a
Types of Cephalic
favorable delivery position.
Vertex, Brow, Face, Mentum
B. ROA – Right Occiput Anterior
- fetal occiput is on maternal right side
and toward front, face is down. This is a
favorable delivery position.
Maternal and Child Health Nursing
Chapter 5: Nursing Care During Labor
C. LOP – Left Occiput Posterior
- fetal occiput is on maternal left side
and toward back face is up. Mother
experiences much back discomfort
during labor; labor may be slowed;
rotation usually occurs before labor to
anterior position, or health care provider
may rotate at time of delivery. Occiput
positions are managed through forceps
and caesarean sections.
D. ROP – Right Occiput Posterior
- fetal occiput is on maternal right side
and toward back, face is up. Presents
problem similar to LOP.
E. LOT – Left Occiput Transverse
- fetal occiput is transverse the maternal
left side ROT (right occiput transverse)
fetal occiput is transverse the maternal
right side.
F. LSA – Left Sacrum Anterior
- fetal sacrum is on maternal left side
and toward front.
G. RSA – Right Sacrum Anterior
- fetal sacrum is on maternal right side
and toward front.
H. LSA – Left Sacrum Anterior
- fetal sacrum is on maternal left side
and toward front.
I. RSA – Right Sacrum Anterior
- fetal sacrum is on maternal right side
and toward front.
J. LSP – Left Sacrum Posterior
- fetal sacrum is on maternal left side
and toward back.
K. RSP – Right Sacrum Posterior
- fetal sacrum is on maternal right side
and toward back.
ASSESSMENT OF FETAL POSTION CAN BE MADE BY:
A. Leopold’s Maneuver – external palpation of
maternal abdomen to determine fetal contours
or outlines.
B. Vaginal Examination – fontanels and
determination of relationship to maternal bony
pelvis.
C. Rectal Examination – now virtually completely
replaced by vaginal examination.
D. Auscultation of fetal heart tones and
determination of quadrant of maternal
abdomen where best heard. (Correlate with
Leopold’s maneuvers.)
FETAL ATTITUDE
o The degree of flexion a fetus assumes during labor:
the relationship of fetal parts to each another. Normal
or good attitudes are: spinal column is bowed
forward; moderate flexion of the head; flexion of the
arms onto the chest; and flexion of the legs/thighs
unto abdomen. Deviations in these attitudes will
cause difficult, prolonged labor.
FETAL LIE
o The relationship between the long (cephalocaudal)
axis, spinal column of the fetus and the long axis of
the mother’s body.
o A longitudinal lie occurs when cephalocaudal axis of
the fetus is parallel to the woman’s spine.
e.g. Vertex (cephalic), breech.
o A transverse lie occurs when cephalocaudal axis of
the fetal spine is at right angles to the woman’s spine.
e.g. Shoulder presentation.
Maternal and Child Health Nursing
Chapter 5: Nursing Care During Labor
1. When presenting part is at ischial spines, station is 0,
meaning it is “engaged”.
2. If presenting part is above ischial spines, station
expressed as a negative (e.g., -1.-2,-3 ). -4 means
presenting part is still “high” or “floating”
3. “high” or “floating” terms used to denote
“unengaged” presenting part. Soft tissue (Cervix,
vagina); stretches and dilates under the force of
contraction to accommodate the passage of the fetus.
4. If presenting part is below ischial spines, station
expressed as a positive number (e.g., +1, +2) +3 and
+4 means presenting part is at the perineum and can
be seen at the vulva.
e.g. “crowning” as the stage when fetal has
negotiated the pelvic outlet and the largest
diameter of the head is encircled by the external
opening of the vagina.

PASSAGEWAY
o Shape and measurement of maternal pelvis and
distensibility of birth canal.

A. Engagement - settling of the fetal presenting

part far enough into the pelvis (inlet) to be at the
level of the ischial spines. May occur two weeks
before labor in primipara; usually occurs at
Gynecoid – most ideal
beginning of labor in multipara.
Android – more of a male pelvis
Cephalopelvic Disproportion - baby's head is too large to
fit through the mother's pelvis.
POWERS
o Shape and measurement of maternal pelvis and
distensibility of birth canal.

A. Uterine Contractions (Involuntary)

B. Station - relationship of the fetal presenting part
to the level of the ischial spines; measurement of
how far the presenting part has descended into
the pelvis. Referent is ischial spines, palpated
through lateral vaginal wall.
1. Frequency – timed from the beginning of
one contraction to the beginning of the next.
2. Regularity – discernible pattern; better
established as pregnancy progresses.
3. Intensity – strength of contractions; a
relative assessment without a use of a
monitor. May be determined by the
Maternal and Child Health Nursing
Chapter 5: Nursing Care During Labor
“depressability” of the uterus during a
contraction.
4. Duration – length of contraction.
Contraction lasting more than 90 seconds
without a subsequent period of uterine
relaxation may have severe implications for
the fetus and should be reported.
One contraction are composed of increment
(start of contraction), acme (peak of contraction
or highest point), and decrement.
o Duration should last for only 90 seconds. More
than 90 secs will result to fetal distress.
o No adequate oxygenation that goes to the fetus
during a contraction.
VOLUNTARY BEARING DOWN EFFORTS
1. After full dilation of the cervix, the mother can
use her abdominal muscle to help expel the
fetus.
2. These efforts are similar to those for defecation,
but the mother is pushing out the fetus from
the birth canal.
3. Contraction of levator ani muscles
PLACENTA
A. As the placenta usually forms in the fundus of the
uterus, it seldom interferes with the progress of
labor.
B. A low lying marginal partial or complete placenta
previa may require medical intervention to
complete the birth process.
PSYCHOLOGICAL RESPONSE
o A woman who is relaxed, aware, and participating in
the birth process usually has a shorter, less intense
labor. A woman who is fearful has high level of
adrenaline
o Epinephrine and norepinephrine, these are hormone
cathecholamines from the nerve endings, brain, and
adrenal glands which later slow uterine contractions.
THE LABOR PROCESS
o CAUSES
o Actual Cause Unknown. Factors involved include:
A. Progressive uterine distention
B. Increase intrauterine pressure
C. Aging of the placenta
D. Changes in levels of estrogen (increased) -
lactating, progesterone (dropped) – aging
placenta and prostaglandins (increased) –
develop pain
E. Increasing myometrial irritability. – muscle
contract
PRELIMINARY SIGNS OF LABOR
LIGHTENING - settling or descent of the fetal presenting
part into the pelvic brim (2) two weeks before
delivery in primigravida.
INCRESEAD LEVEL OF ACTIVITY - increase in activity is
due to an increase in epinephrine release
initiated by the decrease in progesterone by the
placenta.
BRAXTON HICK’S CONTRACTION - a contraction which
may be interpreted as false labor contractions
RIPENING OF THE CERVIX - an integral or sure sign seen
only in pelvic examination.
BLOODY SHOW - (pinkish vaginal discharge) the mucus
plug that filled the cervical canal during
pregnancy is expelled.
RUPTURE OF MEMBRANES - experience as either a
sudden gush or scanty, slow seeping of the clear
fluid from vagina.
Maternal and Child Health Nursing
Chapter 5: Nursing Care During Labor
UTERINE CONTRACTION - the surest sign that labor has MECHANISM OF LABOR
begun with the initiation of effective productive, (VERTEX PRESENTATION)
involuntary uterine contraction o Series of changes in position and attitude that
the fetus undergoes during it passage through
FIVE THEORIES OF LABOR ONSET the birth canal.
UTERINE STRETCH THEORY - any hollow organ once 1. Engagement
stretch to its maximum potential will always expel 2. Descent
its contents. Stretching of uterine muscles causes 3. Flexion
prostaglandin release. 4. Internal Rotation
PROSTAGLANDIN THEORY - arachidonic acid stored from 5. Extension
amnion, chorion, and decidua’s stimulates 6. Restitution
contractions. 7. External Rotation
PROGESTERONE DEPRIVATION THEORY - sudden drop in 8. Lateral Flexion (Expulsion)
progesterone levels will initiate contractions. A. Engagement
THE THEORY OF AGING PLACENTA - the placenta begins ▪ The biparietal diameter of the head
to generate at 36 weeks and the body perceives it passes the pelvic inlet
as foreign objects. ▪ The head is fixed in the pelvis.
OXYTOCIN STIMULATION THEORY - the production of
the posterior pituitary gland of this substance will
cause uterine contractions.
Anterior – breast milk ; Posterior – oxytocin

DIFFERENCE BETWEEN FALSE LABOR AND TRUE LABOR

FALSE TRUE
CONTRACTIONS irregular, no irregular, no
increase in increase in
frequency and frequency and
intensity intensity
INTERVALS OF longer between shorter between
B. Descent
CONTRACTION contractions contractions
▪ downward movement of the biparietal
PAIN/ lower abdomen, back then radiates
diameter of the fetal head to within the
DISCOMFORT walking has no to the abdomen,
pelvic inlet; progress of the presenting
effect or not relieved by
part through the pelvis.
decreases walking.
NO BLOODY BLOODY SHOW -
SHOW present
NO DILATATION WTH
AND EFFACEMENT AND
EFFACEMENT DILATATION;
FETAL DESCENT
PROGRESSES
Maternal and Child Health Nursing
Chapter 5: Nursing Care During Labor
C. Flexion
▪ As descent occurs, the head bends
forward into the chest, making the
smallest anteroposterior diameter (the
suboccipitobregmatic diameter) the one
presented to the birth canal. Chin flexed
more firmly onto the chest by pressure
on fetal head from maternal soft tissue
(cervix, vaginal walls, pelvic floor)

bringing the shortest diameter of the head F. External Rotation

D. Internal Rotation
▪ during descent, the head enters he
pelvis with the fetal anteposterior head
diameter in a diagonal or transverse
position.
1. Fetal skull rotates along axis from
transverse to anteposterior at pelvic
outlet.
2. Head passes the mid pelvis.
▪ almost after the head, head rotates from
anteposterior position, it assumes to
enter the outlet back to the diagonal or
transverse position of the early part of
labor. The head rotates to full alignment
with back and shoulders for shoulder
delivery mechanisms. To accomodate
the shoulder, the head goes back to its
original position.

G. Expulsion or Lateral Flexion

E. Extension
▪ as occiput is born, the back of the neck
stops beneath the pubic arch and acts as
pivot for the rest of the head. Fetal head
passes under the symphysis pubis and is
delivered, occiput first, allowed by chest
and chin.
▪ once the shoulders are born, the rest of
the body is born spontaneously because
of its smaller size. When the entire body
of the baby has emerged from mother’s
body, birth is complete. This time is
recorded as time of birth.
Maternal and Child Health Nursing
Chapter 5: Nursing Care During Labor

1st Stage of Labour

There are 2 phase:
Latent Phase: time between the onset of the labor and
3-4cm dilation. Lasted between 3-8hrs (lesser in
multiparous)
a. Uterine Contractions
• Regular in frequency
• 4-5 in 10 min, each contraction
may last 40-45s.
Stages of Labor
b. Show (blood-stained mucus discharge)
• Evidence of start of effacement
1st Stage
and dilation.
• from onset of labor to full dilatation of cervix
• Effacement of cervix (thinning of
(10cm)
cervix: 2.5cm paperly thin)
Latent Stage
• Dilation of cervix
• from onset to dilation (3-4cm)
Active Phase: time between the end of latent phase (3-
• cervix fully effaced
4cm dilate) until full dilatation (10cm)
• 3-8 hrs
• longest
Nursing Care during the First Stage of Labor
Active Stage
• End of LP
a. Hospital Admission After a physician or nurse
• Full dilation (10cm)
has evaluated the pt, an admission order is
• 2-6 hrs written. At this point, your duties as a practical
• Cervix dilates 1cm/hr nurse are as follows:
• Shortest phase of the 1st stage of labor 1. Establish a rapport with the pt and
2nd Stage significant others.
• From full dilation of cervix (10cm) to delivery 2. Explain all procedures or routine, which
of fetus will be carried out prior to performing
Passive Stage them. These include:
• No maternal urge to push a. NPO except ice chips while in labor.
• Fetal head is still high in the pelvis b. Activities allowed and disallowed
• Sagittal suture in transverse diameter according to ward policies (i.e.
Active Stage bathroom privileges)
• Should not last c. Use of fetal monitors.
• 2 hrs in nulliparous d. Progress reports.
• 1hr in multiparous e. Visitation policies.
rd f. Where pt’s personal belongings will be
3 Stage
• From delivery of fetus to delivery of placenta maintained.
• More than 30 mins is considered prolonged 3. Orient the pt to the surroundings
th
4 Stage 4. Initiate the pt’s labor chart.
• the most critical period because of the 5. Review the info obtained originally in the
unstable vital signs exam room, verify and transfer the OB
• 1 to 2 hrs after delivery health record to the labor chart per ward
Maternal and Child Health Nursing
Chapter 5: Nursing Care During Labor
policies. You will review the following
information:
Maternal and Child Health Nursing
Chapter 5: Nursing Care During Labor
 Maternal and Child Health Nursing
Chapter 5: Nursing Care During Labor

Two Types of Placenta Delivery

1. Duncan Mechanism
2. Schultze Mechanism
Maternal and Child Health Nursing
Chapter 5: Nursing Care During Labor