1. The Process of Labor and Birth
Chapter 12
The Process of Labor and Birth

2. Labor and Birth Process—Critical Factors
Powers (physiologic forces)
Passageway (maternal pelvis)
Passenger (fetus and placenta)
Passageway + passenger relationship
Psychosocial influences

3. Powers Uterine contractions—primary force
Maternal pushing efforts—secondary force
Characteristics of uterine contractions
Increment
Acme
Decrement

4. Assessment of Uterine Contractions
Characteristics
Frequency
Duration
Intensity
Palpation
Electronic fetal monitoring
Refer to Figure 12-1 for Intensity

5. Electronic Fetal Monitoring
External monitor—tocodynamometer
Noninvasive
Internal monitor—internal pressure catheter
Invasive

6. IMPORTANT TERMS Effacement: shortening and thinning of cervix
Expressed as a percentage (0% to 100%)
Dilation: opening and enlargement of cervix
Expressed in centimeters (1 to 10 cm)

7. Powers Maternal Pushing Efforts
“Bearing down” sensation
Urge to push
No urge to push

8. Passageway Maternal Pelvis and Soft Tissues
Four classic types
Gynecoid—normal female
Android—heart shaped, male
Anthropoid—apelike
Platypelloid—flat oval
Refer to Chapter 5

9. Passenger Fetus and fetal membranes Molding of head Fetal lie
Longitudinal
Transverse
Oblique
Refer to Box 12-2 for fetal skull landmarks
Refer to Figure 12-4 for Fetal Lie

10. Passenger (cont.) Fetal attitude—flexion Fetal presentation Cephalic
Vertex
Military
Brow
Face

11. Advantages of Cephalic Presentations
Head usually largest part of infant
Molding
Optimal shape—smooth and round

12. Breech Presentations Buttocks enter maternal pelvis first
Frank: legs extended toward shoulders
Complete: legs flexed
Footling: one or both feet present first into maternal pelvis
(SACRUM is landmark)
Refer to figure 12-7 for types of breech presentations

13. Disadvantages of Breech Presentation
Risk of cord prolapse
Presenting part less effective in cervical dilation
Risk of cord compression
Risk of prolonged labor

14. Shoulder Presentation
Occurs when fetus in transverse lie
Cannot be delivered vaginally unless rotation occurs
Refer to Figure 12-8 for Shoulder presentation

15. Passageway + Passenger Relationship
Engagement
Station
Ischial spines—0 station
Above ischial spines—(–) minus station
Below ischial spines—(+) plus station
+4 cm means that ...
Refer to Figure 12-9 for station

16. Position Vertex—occiput (O) Face—chin (M = mentum) Breech—sacrum (S)
Shoulder—acromion process (A)
Four quadrants of maternal pelvis
Refer to Figure for position

17. Landmarks Abbreviations are used Examples
First and last letter—maternal pelvis
Middle letter—fetus presenting part
Examples
ROA (right occiput anterior)
ROP
LSP

18. Psychosocial Influences
Other critical factors
Readiness, educational preparedness, etc.
Cultural views of childbirth
Role transition facilitated by positive childbirth experience
Negative experience interferes with bonding and maternal role attainment

19. Signs and Symptoms of Impending Labor

20. Lightening May cause Leg cramps Increased pelvic pressure
Increased urinary frequency
Increased venous stasis
Increased vaginal secretions

21. Other Signs and Symptoms
Braxton Hicks contractions
Cervical changes
Bloody show
Rupture of membranes
Energy spurt
Weight loss, GI disturbances

22. True and False Labor TRUE labor
Leads to dilation and effacement of cervix
Regular contractions
Contractions increase in duration, frequency, and intensity
Refer to Table 12-1 for differences between True & False Labor

23. True and False Labor FALSE labor No cervical changes Contractions
Felt in abdominal region
Do not increase in intensity
Often stop with activity

24. Childbirth Settings and Labor Support

25. Admission Procedures Establish positive relationship
Collect admission data
Initial admission assessments
Focused
Psychosocial assessment
Cultural assessment
Laboratory tests
Refer to Table 12-2 for circumstances that warrant going to birthing center

26. FIRST STAGE OF LABOR Stage of dilation Three phases Friedman curve
Latent phase—0 to 3 cm
Active phase—4 to 7 cm
Transition—8 to 10 cm
Friedman curve
Refer to Table 12-3 for summary of characteristics of first & second stages of labor
Refer to figure for normal pattern graph

27. Nursing Care Ongoing assessment Facilitate a positive birth experience
Manage discomfort
Advocate for patient’s needs
Provide anticipatory guidance

28. Labor Support Presence Promote comfort Environment Personal hygiene
Elimination
Supportive relaxation techniques

29. Fetal Assessment Position Fetal heart sounds Baseline FHR Presence of
Variability
Accelerations
Decelerations
Refer to Figure for accelerations
Refer to Figure for decelerations

30. Interpretation of FHR Tracings
Consider contraction frequency and intensity, stage of labor, and earlier FHR pattern
Reassuring
Non-reassuring
Refer to Box 12-4 for Reassuring v. Non-reassuring

31. Nursing Care FHR decelerations Early: no action Variable and late
Lateral position changes
Oxygen per face mask
Palpation for hyperstimulation
Discontinue oxytocin
Increase IVF rate

32. Second Stage of Labor Full dilation through birth of infant
Urge to push
Promote effective pushing
Closed-glottis
Open-glottis
Position of comfort

33. Preparation for Birth Bulging of the perineum and rectum
Flattening and thinning of the perineum
Increased bloody show
Labia begin to separate

34. Imminent Birth Crowning Burning sensation Intense pressure in rectum
Episiotomy
Midline
Mediolateral
Refer to Figure for Crowning
Refer to Figure for Episiotomy

35. Cardinal Movements of Birth
Descent
Flexion
Internal rotation
Extension
Refer to Figure 12-23

36. Cardinal Movements (cont.)
Restitution
External rotation
Expulsion

37. Birth Animation
You may wish to incorporate this animation into your teaching plan. It may be necessary to download QuickTime—Click on Get QuickTime and install the program.

38. Umbilical Cord Clamping
Controversy regarding when, how
Nurse—inspect cut cord for presence of two arteries and one vein
Collect cord blood sample for laboratory analysis
Refer to Figure for a Vaginal birth sequence

39. Nursing Diagnoses for Intrapartal Patient
Pain
Knowledge deficit
Anxiety
Fatigue
Risk for infection
Impaired fetal gas exchange

40. Third and Fourth Stages of Labor
Immediate care of the newborn
Delivery of the placenta
Monitoring and assisting mother with physiological adjustments following birth
Facilitating maternal-infant attachment
Refer to Table 12-6 for Characteristics of 3rd & 4th Stages of Labor

41. Third Stage Birth of baby to complete delivery of placenta
Smaller, spherical uterus
Elevation of uterus in abdomen
Lengthening and protrusion of cord
Gush of blood from vagina
Refer to Figure for Schultze & Duncan Manner

42. Separation and Expulsion of the Placenta

43. Nursing Care—Third Stage
Observe for signs that placenta has separated
Oxytocic medications to control blood loss
Examine cotyledons
Offer emotional support
Foster infant attachment
Refer to Figure 12-6 for Cotyledons

44. Immediate Care of Newborn
Airway
Warmth
Appraisal—Apgar score
Identification of newborn
Refer to Table 12-7 for APGAR

45. Fourth Stage Delivery of placenta through 1 to 2 hours after birth
Monitor position and firmness of uterus
“Boggy,” soft uterus
Report immediately
Initiate fundal massage

46. FOURTH STAGE Assess lochia Vital signs and urine output
Shivering—offer blankets
Promote comfort
Facilitate attachment and breastfeeding

47. Fourth Stage—Risk Signs
Hypotension
Tachycardia
Excessive bleeding
Noncontracting uterus

48. Promoting Patient Comfort During Labor and Birth
Chapter 13
Promoting Patient Comfort During Labor and Birth

49. Pain During Labor and Birth
Shaped by past experiences
Assessing pain
Physiological, psychological indicators
Patient responses
May be intensified by fear, anxiety, fatigue

50. Physical Causes of Pain
Labor and Birth

51. Pain Neurology Uterine ischemia Visceral pain—dull and aching
Referred pain
Somatic pain—sharp, burning, prickling

52. Pain Perception and Expression
Highly personal and subjective
Affected by gender, culture, ethnicity, and past experiences
Physiological/affective expression
Increased catecholamines
Increased blood pressure and heart rate
Altered respiratory pattern

53. Factors Affecting Maternal Pain Response
Physical
Physiological
Psychological
Anxiety, fear, previous experience
Support systems, childbirth preparation
Environmental

54. Pain Pathways and Childbirth
Multidimensional phenomenon
Affective, physiologic, behavioral, sensory, cognitive
Neural pathway for pain
Gate-control theory

55. Benefits of Comfort and Support
Pain Perception

56. Nonpharmacological Pain Relief Measures
Maternal position and movement
Breathing techniques
Music
Relaxation techniques
Other attention-focusing strategies
Guided imagery

57. Massage and Touch Effleurage Counterpressure Therapeutic touch
Healing touch

58. Other Therapies for Comfort
Hydrotherapy, hypnotherapy, aromatherapy
Application of heat and cold
Biofeedback, TENS, intradermal water block
Acupressure/acupuncture

59. Pharmacological Pain Relief Measures
Timing
Nonpharmacological and pharmacological measures promote positive experience
Informed consent

60. Pharmacological Measures
Sedatives and antiemetics
Barbiturates
Benzodiazepines
H1-Receptor antagonists

61. Analgesics and Anesthetics
Systemic
Opiod agonist analgesics
Opiod agonist-antagonist analgesics
Opiod antagonists
Refer to Boxes 13-1 & 13-2 for analgesic/anesthetic selection based on stage of labor
Refer to Table 13-2 for Commonly used regional blocks

62. Nerve Block Analgesia, Anesthesia
Regional anesthesia
Local perineal infiltration anesthesia
Pudendal nerve block
Spinal anesthesia block
Complications: maternal hypotension, decreased placental perfusion, ineffective breathing pattern

63. Postdural Puncture Headache
Leakage of cerebrospinal fluid
Intensified in upright position
Auditory and visual problems
Autologous epidural blood patch
Discharge instructions

64. Epidural Anesthesia or Analgesia Block
Local anesthetic—epidural space
Pain relief from contractions
Pain relief from birth
Opioid and local anesthetic agent

65. Lumbar Epidural Advantages Complication Minimal trauma to fetal skull
No fetal respiratory depression
Complication
Maternal hypotension

66. Maternal Hypotension Prevention Requires constant nursing attendance
Preload IV fluids
Requires constant nursing attendance
Monitor vital signs

67. Disadvantages of Epidural
Limited mobility
Common side effects
Accidental injection into blood vessel
Sympathetic blockage
Urinary retention, bladder distention

68. Other Nerve Blocks Combined spinal-epidural analgesia
Epidural and intrathecal opioids
Ongoing nursing assessments essential

69. General Anesthesia Major risks Pre-operative preparation
Cricoid pressure
Anesthetic gases and medications
Recovery room nursing care
Refer to Box 13-3 for obstetric complications requiring surgical intervention

70. Nursing Care Related to Comfort Measures
Assessment
Ongoing and collaborative
Diagnoses
Anxiety
Ineffective coping
Acute pain

71. Nursing Care Expected outcomes Plan of care Individualized
Modified as needed
Collaborative approach

72. Caring for the Woman Experiencing Complications During Labor and Birth
Chapter 14
Caring for the Woman Experiencing Complications During Labor and Birth
Refer to Box 14-1 for possible nursing diagnoses

73. Dystocia Long, difficult, or abnormal labor May arise from Powers
Passenger
Passageway
Refer to Box 14-2 for Dystocia

74. Dysfunctional Labor Pattern: Hypertonic
Strong, painful, ineffective contractions
Contributing factor—maternal anxiety
Occiput-posterior malposition of fetus
Management
Rest, hydration, sedation
Facilitate rotation of the fetal head
Refer to Figure 14-1 for Hypertonic & Hypotonic

75. Dysfunctional Labor Pattern: Hypotonic
Contractions decrease in frequency and intensity
Maternal and fetal factors that produce excessive uterine stretching
Management
Walking, position changes
Augmentation of labor

76. Precipitate Labor and Birth
Rapid intense contractions
Nursing considerations
Careful examination for dilation and effacement
Reassure woman and support person
Breathing to avoid pushing and prevent tearing
Careful examination of maternal soft tissue and placenta

77. Pelvic Structure Alterations
Pelvic dystocia
Soft tissue dystocia
Trial of labor
To assess safety of vaginal birth

78. Obstetric Interventions—Amnioinfusion
Risks: infection, overdistention of uterus, increased uterine tone
Nursing
Careful monitoring of infusion, intensity and frequency of contractions, and maternal vital signs
Educate
Pharmacological induction of labor
Nonpharmacological stimulants of labor

79. Obstetric Interventions—Amniotomy
Artificial rupture of membranes
Augment or induce labor
Nursing
Careful monitoring of vital signs, cervical effacement/dilation, station, FHR, contractions
Document regarding amniotic fluid

80. Induction of Labor Indications for induction Bishop score
Cervical ripening agents
Mechanical methods
Oxytocin
Augmentation of labor
Refer to Table 14-1 for Bishop scoring system

81. Induction—Nursing Considerations
Informed consent
Careful monitoring of labor
Discuss pain relief measures
Position changes
Keep patient and support person informed of progress

82. Instrumentation Assistance of Birth
Forceps
Vacuum extraction
Refer to Figure 14-3 for forceps
Refer to Figure 14-4 for vacuum extraction

83. Maternal Complications—Hypertensive Disorders
Preeclampsia-eclampsia, HELLP syndrome
Nursing
Careful assessments
Monitor lab values
Administer platelets as appropriate
Ongoing education
Refer to Box 14-3 for fetal-maternal factors that necessitate immediate interventions
Refer to Box 14-4 for Key parameters to be monitored

84. Maternal Complications—Diabetes
Fetal lung maturity
Intrapartum management—maternal hydration and blood glucose levels
Labor: normal progression of labor
Upright or side-lying position
Encourage breastfeeding

85. Preterm Labor and Birth
Careful maternal monitoring
FHR monitoring ***
Identify and report symptoms suggestive of fetal hypoxia
Assess psychological status

86. Labor and Birth Complications—Fetal
Fetal malpresentation
Version: external or internal
Shoulder dystocia
Cephalopelvic disproportion
Multiple gestation
Non-reassuring FHR patterns
Refer to Figure 14-6 for Version
Refer to Figure 14-7 for McRoberts maneuver

87. Amniotic Fluid Complications
Oligohydramnios
Hydramnios
Meconium
Nuchal cord

88. Complications—Placental Problems
Placenta previa
Placental abruption
Disseminated intravascular coagulation
Refer to Table 14-3 for nursing care of patient experiencing intrapartal hemorrhage

89. Other Complications Uterine rupture Uterine inversion
Obstetric emergency
Uterine inversion
Umbilical cord prolapse

90. Variations—Umbilical Cord and Placenta
Velamentous cord insertion
Fetal vessels separate at distal end and insert into placenta away from the margin
Vasa previa
Fetal vessels cover cervical os
Refer to Figure 14-11

91. Placental Variations Circumvallate placenta Succenturiate placenta
Battledore placenta
Placenta accreta
Placenta increta
Placenta percreta

92. Amniotic Fluid Embolism
Rapidly deteriorating maternal condition
Acute dyspnea, severe hypotension
Rapid delivery after stabilizing mother
Ethical conflict
Save mother versus fetus

93. Collaboration in Perinatal Emergencies
Refer to Box 14-5 for team expectation in obstetric emergency

94. Perinatal Fetal Loss Nursing considerations What to say
What not to say

95. Cesarean Birth Indications Ethical considerations Surgical procedures
Health of mother or fetus is jeopardized
Ethical considerations
Surgical procedures
Surgical and postoperative care
Vaginal birth after cesarean

96. Postterm/Prolonged Pregnancy
Postterm—extends beyond 42 weeks
Risk for fetal/neonatal problems
Increased maternal risk
Management—labor induction
Nursing implications