THE 4 PS OF LABOR POWER OF LABOR

 The forces acting to expel the fetus and placenta PRIMARY FORCE= uterine muscular contractions SECONDARY FORCE= use of abdominal muscle in bearing down .

 It is supplied by the fundus of the uterus and implemented by uterine contractions  A process that causes cervical dilatation and then expulsion of the fetus from the uterus  After full dilatation of the cervix, the primary power is supplemented by the use of the abdominal muscles.  Its important for women to understand that they should not bear down with their abdominal muscles until cervix is fully dilated. PHASES OF UTERINE CONTRACTIONS y y y 1. Increment-when intensity of contraction increases 2. Acme when contraction is at strongest 3. Decrement - when intensity decreases

PSYCHE
The psyche refers to the psychological state or feelings that women bring into labor with them feeling of apprehension or fright may also include sense of excitement or awe Woman who manage best in labor typically are those who have a strong state of selfesteem and a meaningful support system Women without adequate support can have an experience so frightening and stressful they can develop PTSD/Post-traumatic Stress Disorder.

THE PASSENGER
Fetal Attitude - Attitude describes the degree of flexion a fetus assumes during labor. refers to the relation of the fetal parts to one another. Types:     Full Flexion Moderate Flexion (Military Attitude) Partial Extension Poor Flexion, Complete Extension

y y y

Full Flexion - The spinal column is bowed forward, the head is flexed forward that the chin touches the sternum, the arms are flexed and folded on the chest. The thighs are flexed onto the abdomen, and the calves are pressed against the posterior aspect of the thighs. Moderate Flexion (Military Attitude) - If the chin is not touching the chest but is in an alert or military position. Partial Extension - Presents the brow of the head to the birth canal. Poor Flexion, Complete Extension - The back is arched, the neck is extended and a fetus is in complete extension.

Fetal Lie - refers to the relationship of the long axis of the fetus to that of the mother Longitudinal Lie long axis of the fetus is parallel to the mother Transverse Lie long axis of the fetus is perpendicular to that of the mother Oblique Lie forms an acute angle in relation to the axis of the mother. - Usually converted during the course of early labor to either longitudinal or transverse lie.

Fetal Position - the relationship of the presenting part to a specific quadrant of a womans pelvis. - Position is indicated by an abbreviation of three letters: First letter defines whether the landmark is pointing to the mothers right(R) or left (L). The middle letter denotes the fetal landmark. The last letter defines whether the landmark points anteriorly (A), posteriorly (P), or transversely (T).

FOUR QUADRANTS (mother) > RIGHT ANTERIOR > LEFT ANTERIOR > RIGHT POSTERIOR > LEFT POSTERIOR

FOUR PARTS (fetus) > OCCIPUT [O] > CHIN (MENTUM) [M] > SACRUM [Sa] > SCAPULA/ACROMION > PROCESS [A]

Fetal Presentation - refers to the fetal parts that enters the pelvis passing through the birth canal during labor - Determined by body part lying closest to the maternal pelvis Types: y Cephalic presentation - Fetal head is the body part that will first contact the cervix.  Vertex or Occiput - head is fully flexed on the chin;  Sinciput - head partially flexed;  Brow - head is extended or bent backwards  Face - when head is sharply extended causing the occiput to come in contact with the back of the fetus  Chin - head is hyperextended with chin as presenting part Breech presentation - either the buttocks or the feet are the first body parts that will contact the cervix.  Frank - buttocks are the presenting part  Complete - the legs and the thighs are flexed onto the abdomen  Footling - one or both feet are extended at the knees and hips Shoulder presentation - The presenting part is usually one of the shoulders (acromion process), an iliac crest, a hand, or an elbow.  Shoulder transverse - Side-to-side presentation, with the fetal head on one side and the butt on the other  Compound - occurs when there is prolapsed of the fetal hand alongside the vertex, breech or shoulder presentation

THE PASSAGEWAY
Passage - refers to the route the fetus must travel from the uterus through the cervix and vagina to the external perineum - For the fetus to pass through the pelvis, the pelvis must be of adequate size. The female bony pelvis is divided into: o False pelvis: superior half above the pelvic brim and has no obstetric importance. o True pelvis: inferior half below the pelvic brim and related to childbirth. Pelvic measurements are important to determine the adequacy of the pelvic size: Diagonal conjugate (the anterior-posterior diameter of the inlet)

- Distance bet. the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis. Transverse diameter (narrowest diameter at the outlet) - The diameter of the pelvic inlet measured between the two most widely separated points.

True Conjugate/Conjugate Vera - Diameter of pelvic inlet. Ischial Tuberosity Diameter - The distance between the ischial tuberosities, or the transverse diameter of the outlet.

Pelvic Types: Traditional obstetrics characterizes four types of pelvises: Gynecoid: Ideal shape, with round to slightly oval (obstetrical inlet slightly less transverse) inlet: best chances for normal vaginal delivery. Android: triangular inlet, and prominent ischial spines, more angulated pubic arch. Anthropoid: inlet transverse is greater than inlet obstetrical diameter. Platypelloid: Flat inlet with shortened obstetrical diameter.

STAGES OF LABOR
Going through the birth of your child is a wonderful and unique experience. No two deliveries are alike and there is no way to tell how your delivery is going to be. What we can tell you is the stages you will go through during this process and what you can generally expect. Childbirth can be broken into three stages:

FIRST STAGE OF LABOR:

Dilating Stage
The first stage of labor is the longest and is broken down into three phases: Early labor phase: Starts from the onset of labor until the cervix is dilated to 3 cm. Active labor phase: Continues until the cervix is dilated to 7 cm. Transition phase: Continues until the cervix is fully dilated to 10 cm. Each phase is full of different emotions and physical challenges. It is one big adventure you are about to take and we would like to give you a guide for it. Early Labor Phase: What to do: During this phase you should just relax. It is not necessary for you to rush to the hospital or birth center. It will be more comfortable for you to spend this time at home, in familiar territory. If early labor is during the day you should do simple routines around the house. Keep yourself occupied but still conserve some of your energy. Drink plenty of water and eat small snacks. Keep track of the time of your contractions. If early labor begins during the night it is a good idea to try and get some sleep. If you cant fall asleep, do things that will distract you like cleaning out your closet, packing your bag, or making sack lunches for the next day.

What to expect:
y y y y y y

Duration will last approximately 8-12 hours Your cervix will efface and dilate to 3 cm Contractions will last about 30-45 seconds, giving you 5-30 minutes of rest in between contractions Contractions are typically mild, somewhat irregular, but progressively stronger and closer together Contractions may feel like aching in your lower back, menstrual cramps, and pressure or tightening in the pelvis area Your water may break; also known as amniotic sac rupture (this can happen any time within the first stage)

When monitoring contractions observe the following:

y y y y

Growing more intense Following a regular pattern Lasting longer Becoming closer together

When your water breaks (amniotic sac ruptures) note the following:
y y y

Color of fluid Odor of fluid Time rupture occurred

Tips for the support person:

y y y y y

Practice timing contractions Be a calming influence Offer comfort, reassurance, and support Suggest activities that will distract her Keep up your own strength, you will need it!

Active Labor Phase: What to do: It is about time for you to head to the hospital or birth center. Your contractions will be stronger, longer and closer together. It is very important that you have all the support you can get. Now is also a good time for you to start your breathing techniques and try some relaxation exercises for you to use in between contractions. You should switch positions often during this time. You may want to try walking or taking a nice bath. Continue to drink water and remember to urinate periodically. What to expect:
y y y y y

Duration will last about 3-5 hours Your cervix will dilate from 4cm to 7cm Contractions during this phase will last about 45-60 seconds with 3-5 minutes rest in between Contractions will feel stronger and longer This is usually the time that you head to the hospital or birth center

Tips for the support person:

y y y y y y

Give your undivided attention Offer verbal reassurance and encouragement Massage her abdomen and lower back Keep track of contractions (if she is being monitored, ask how the machine works) Go through the breathing techniques with her Help make her comfortable (prop pillows, get her water, apply touch)

y y y

Remind her to change positions frequently (take her for a walk or offer her a bath) Continue with distractions (music, reading a book, playing a simple card game) Don't feel badly if she is not responding to you

Transition Phase: What to do: During this phase you will rely heavily on your support person. This is the hardest phase but it is also the shortest. Think "one contraction at a time." This may be hard to do if the contractions are very close together, but just think about how far you have come. When you feel an urge to push, tell your health care provider. What to expect:
y y y y y y

Duration will last about 30 min-2 hrs Your cervix will dilate from 8cm to 10cm Contractions during this phase will last about 60-90 seconds with a 30 second-2 minute rest in between Contractions are long, strong, intense, and may overlap This is the hardest phase but thankfully the shortest You may experience hot flashes, chills, nausea, vomiting, or gas

Tips for the support person:

y y y y y y

Offer lots of encouragement and praise Avoid small talk Continue breathing with her Help guide her through her contractions with encouragement Encourage her to relax in between contractions Don't feel hurt if she seems to be angry, it's just part of transition!

SECOND STAGE OF LABOR:

Delivery/Expulsive Stage
The second stage of childbirth is pushing and delivery of your baby. Up until this point your body has been doing all the work for you. Now that your cervix has fully dilated to 10 cm it is time for your help. Time to PUSH! Pushing and what to expect:
y y y y y y y y

The entire process of the second stage lasts anywhere from 20 minutes to 2 hours Contractions will last about 45-90 seconds with a 3-5 minute rest in between You will have a strong natural urge to push You will feel strong pressure at your rectum You will likely have a slight bowel or urination accident Your baby's head will eventually crown (become visible) You will feel a burning, stinging sensation during crowning During crowning you will be instructed by your health care provider not push

Pushing and what to do:

y y y

Get into a pushing position (one that uses gravity to your advantage) Push when you feel the urge Relax your pelvic floor and anal area (Kegel exercises can help)

y y y y

Rest between contractions so you can regain your strength Use a mirror so you can see your progress (this can be very encouraging!) Use all your energy to push Do not feel discouraged if your baby's head emerges and then slips back into the vagina (this process can take two steps forward and one step back)

Tips for the support person:

y y y y y

Help her to be relaxed and comfortable (give her ice chips if you can and support her in her position) Encourage, encourage, encourage Be her guide through her contractions Affirm what a great job she has done and is doing Don't feel bad if she becomes angry or emotional with you

What your baby is doing: While you are in labor your baby is taking steps to enter this world. 1. Your baby's head will turn to one side and the chin will automatically rest on the chest so the back of the head can lead the way. 2. Once you are fully dilated, your baby's head leads the way and the head and torso begin to turn to face your back as they enter your vagina. 3. Next your baby's head will begin to emerge or "crown" through the vaginal opening. 4. Once your baby's head is out, the head and shoulders again turn to face your side. This position allows your baby to easily slip out.
Delivery and what to expect:

Keep in mind your baby has been soaking in a sac full of amniotic fluid for nine months. He/she has been through contractions, and your very narrow birth canal. The results of this journey include:
y y y y y

Cone-shaped head Vernix coating (cheesy substance that coats the fetus in the uterus) Puffy eyes Lanugo (fine downy hair that cover the shoulders, back, forehead, and temple) Enlarged genitals

MECHANISM of LABOR E = Engagement It is the mechanism wherein the fetus engages to the pelvis. It is also called lightening or dropping. D = Descent Descent is the mechanism where the fetal head begins its journey through the pelvis. Assessment measurement is termed as station. F = Flexion Is the mechanism where the fetal head is nodding or flexing forward toward its chest.

IR = Internal Rotation This occurs from the occiput transverse position to the occiput anterior position while descending. E = Extension This enables the head to emerge when the fetus is in cephalic position. This begins when the head is crowning. R = Restitution It is the realignment of the head of the fetus with the body as the fetus head emerges. ER = External Rotation This mechanism is where the shoulders rotate externally once the head emerges and restitution occurs so that the shoulders would be in the anteroposterior diameter of the mothers pelvis. E = Expulsion It is the birth of the entire body of the fetus.

THIRD STAGE OF LABOR:

PLACENTAL STAGE
The third stage of labor starts after the baby is born and ends after delivery of the placenta. It usually lasts for 15 minutes. There are 2 phases involved in the placental stage of labor: Placental separation and placental expulsion. Placental separation As the uterus contracts down at regular intervals on its diminishing content, the area of placental attachment is greatly reduced. The great disproportion between the reduced size of the placental site and the size of the placenta brings about a folding or festooning on the maternal surface of the placenta, and the separation takes place. Active bleeding on the maternal surface of the placenta begins with separation; this bleeding helps to separate the placenta still further by pushing it away from its attachment site. As separation is completed, the placenta sinks to the lower uterine segment to the upper vagina. SIGNS OF PLACENTAL SEPARATION (usually appears 5 mins after the birth of the baby)      Lengthening of the umbilical cord Sudden gush of vaginal blood Change in the shape of uterus (The womb becomes round in shape /globular, firmer uterus Calkins sign) Firm contraction of the uterus Appearance of placenta at vaginal opening

If the placenta separates first at its center and lastly at its edges, it tends to fold on itself like an umbrella and presents at the vaginal opening with the fetal surface evident. This signifies that the placenta has become detached first at its center, and is usually a collection of blood and clots is found in the sac or membranes. The placenta is called Schultz placenta. If the placenta separates first at its edges it slides along the uterine surface and presents at the vagina with the maternal surface evident. It looks raw, red, and irregular, with the ridges and cotyledons that separate blood collection spaces showing. Suggests that the placenta has separated first at its edges, and in this type that bleeding usually occurs at the time of separation. The placenta is called Duncan placenta. Placental expulsion After separation, the placenta is delivered either by natural bearing-down effort of the mother or by gentle pressure on the contracted uterine fundus by the physician or nurse-midwife (Credes maneuver).

FOURTH STAGE OF LABOR:

RECOVERY STAGE
The fourth stage of labor is the period from the delivery of the placenta until the uterus remains firm on its own. In this stabilization phase, the uterus makes its initial readjustment to the nonpregnant state. The primary goal is to prevent hemorrhage from the uterine atony and the cervical or vaginal lacerations. NURSING ASSESSMENT: Lochia Observe the amount and characteristics of lochia. 1-3 days red; blood with only small particles of decidua and mucus (lochia rubra) 3-10 days pink or brownish ; blood, mucus, and invading leukocytes (lochia serosa) 10-14 days colorless or white; largely mucus; leukocyte count is high (lochia alba)

Bladder During pregnancy,2000-3000 ml excess fluid accumulates easily increases output of a postpartal woman from 1500 ml to 3000 ml/day during the 2nd and 5th day after birth. Assess womans abdomen frequently in the postpartal period. On palpation, a full bladders in felt as a hard or firm area just above the symphysis pubis. On percussion (placing one finger flat on the womans abdomen over the bladder and tapping it with the middle finger of the other hand), a full bladder sounds resonant. As the bladder fills, it displaces the uterus; uterine position is therefore a good gauge of whether the bladder is full or empty.

Perineum Because of the great amount of pressure experienced during birth, the perineum develops edema and generalized tenderness.

Blood Pressure Should also be monitored because a decrease may indicate bleeding.

Pamantasan ng Lungsod ng Maynila (University of the City of Manila) Intramuros, Manila College of Nursing

Written Report in RLE

Submitted by: AQUINO, Paul Gerald C. CANLAS, Joyline G.

Submitted to:

Prof. Lady Anne O. De Jesus, RN, RM, MAN

Clinical Instructor