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Chapter 19: Processes and Stages of Labor and Birth

Terms in this set (85)

Methods of Childbirth Preparation
•Classes taught by certified childbirth educators
•Education alleviates fear
•Greatest difference in methods lies in theory of why they work
•Continuous support through labor
-Less analgesia
-Fewer cesarean, instrument births
-Shorter labor
Programs for Preparation
•Contemporary models focus on interconnectedness of body and spirit
•International Childbirth Education Association (I C E A)
-Philosophy of freedom of choice based on knowledge of options
-Often teach combination of techniques
Body-Conditioning Exercises
•Pelvic tilt
•Pelvic rock
•Kegel exercises
•McRoberts position
-Flex mother's thighs toward shoulders while she is lying on her back
-Stretches hamstring muscles
•Build endurance, strength for labor
Relaxation Exercises
•Necessary to practice before labor
Touch relaxation technique
-Partner's touch enhances woman's ability to release tense muscles
Dissociation relaxation
-Relaxing uninvolved muscles while uterus contracts
Lamaze method
-Paced patterned breathing with controlled muscle relaxation
Bradley method
-Abdominopelvic breathing with focus on natural instincts
Kitzinger method
-Chest breathing with abdominal relaxation
Hypnobirthing
-Deep slow breathing
•Best taught in final trimester
Preparations for Childbirth that Support Individuality
•Incorporation of natural responses
-Vocalization or "sounding"
-Relaxation
-Warm water for showers or bathing
-Visualization
-Birthing ball
•Suggest that couple brings items from home, listen to soothing music, or watch favorite D V Ds
Birth Passageway
-Size of maternal pelvis
-Type of maternal pelvis
▪Gynecoid, android, anthropoid, platyllepoid
-Ability of cervix to dilate, efface
-Ability of vaginal canal, introitus to distend
Birth Passenger: Fetus
•Fetal head
•Fetal attitude
•Fetal lie
•Fetal presentation
•Fetal position
Fetal head
-Composed of bony parts
▪Can hinder childbirth
Fetal skull
▪Face
▪Cranium
▪Vault of cranium
-Overlapping bones (molding)
•Allows skull to pass through narrow parts of maternal pelvis
•Frontal, parietal, occipital bones
-Fetal Sutures
-Membranous joints uniting cranial bones
-Allow for molding
▪Frontal (mitotic)
▪Sagittal
▪Coronal
▪Lambdoidal
▪Fontanelle
-Intersection of sutures
▪Landmarks of significance- Mentum, sinciput, vertex, occiput
Fetal attitude
-Relation of fetal body parts to one another
-Posture of fetus to conform to uterine cavity
-Normal attitude is general flexion
▪Head flexed, chin on chest
▪Arms crossed over chest
▪Legs flexed at knee, thighs on abdomen
-Relationship of fetal spinal column to that of mother
▪Cephalocaudal axis
-Longitudinal (vertical)
▪Fetal spine parallel to woman's spine
-Transverse (horizontal)
▪Fetal spine at right angle to woman's
▪Shoulder presentation
•Fetal presentation
-Determined by fetal lie
-Presenting part
▪Portion of the fetus felt through the cervix on vaginal examination
▪Malpresentations
-Associated with difficulties
-Breech, shoulder
Vertex presentation
▪head flexed
-Most common presentation
Sinciput presentation
- head straight
-Top of head presenting
Brow presentation
-head partially extended
-Fetal forehead presenting
Face presentation
-Head hyperextended
-Fetal chin presenting
Complete breech
-Buttocks and feet present
Frank breech
-Buttocks present
Footling breech
-Single or both feet present
-Shoulder presentation
▪Occurs less than 1% of the time
Engagement
-When largest diameter of the presenting part reaches, passes through pelvic inlet
-Floating (ballottable)
-Dipping
Station
-Ischial spines are zero station
-Presenting part moves from negative (−5) to positive (+4)
Fetal position
-Presenting fetal part of maternal pelvis
▪Right (R) or left (L) side
▪Occiput (O)
▪Mentum (M)
▪Sacrum (S)
▪Acromion (scapula [S c]) process (A)
▪Anterior (A), posterior (P), transverse (T)
-Most common is occiput anterior
Primary force
-Uterine muscular contractions
Secondary force
-Pushing during the second stage of labor
Increment
-Building up, longest phase
Acme
-Peak of contraction
Decrement
-Letting up followed by period of relaxation
Frequency
Time between beginning of one contraction and beginning of next contraction
Duration
Beginning of contraction to completion
Intensity
▪Strength of uterine contraction during acme
Bearing down
▪Maternal abdominal musculature contracts as woman pushes
▪If cervix not completely dilated:
-Cervical edema
-Tearing
-Bruising
-Maternal exhaustion
Readiness
-Fears
-Anxieties
-Fantasies
Preconceived ideas about birth
-Cultural factors
Support system
-Explore options
Possible causes of labor onset
-Between weeks 38 and 42
-No full understanding of biochemical interactions that stimulate labor, birth
-Progesterone withdrawal hypothesis
▪Decreased availability of progesterone to myometrial cells at end of gestation
▪Yet-unknown antiprogestin
Prostaglandin hypothesis
▪Clear indication of inducing labor with vaginal application of prostaglandin E
▪Amnion, decidua focus of research
Corticotropin-releasing hormone hypothesis
▪Sharp increase in C R H at term
▪Stimulates prostaglandin E, F production
Myometrial activity
-Physiologic retraction ring
Effacement
▪Taking up of internal o s, cervical canal into uterine side walls
Cervical dilation
▪Cervical o s, canal widen to approximately 10 c m
Musculature changes in pelvic floor
-Levitor ani muscle, fascia of pelvic floor
▪Draw rectum and vagina upward, forward with each contraction
-Physiologic anesthesia
▪Due to decreased blood supply to perineal area
-Anus everts as fetal head descends
Lightening
▪Fetus settles in pelvic inlet
▪Fundus no longer presses on diaphragm
Braxton Hicks contractions
▪May feel like "drawing" sensations
▪False labor
Cervical changes
▪Ripening for stretching, dilating
Bloody show
▪Mucous plug expelled, resulting in pink-tinged secretions
▪Sign of impending labor
Sudden burst of energy
▪Approximately 24-48 hours before labor
▪Warn woman not to overexert, overeat
Rupture of membranes (R O M)
▪Amniotic membranes rupture, and labor usually begins within 24 hours
Spontaneous R O M (S R O M)
-Height of intense contraction
-If engagement has not occurred, danger that umbilical cord may be expelled with fluid
Artificial ROM (AROM)
by amniohook
Premature ROM (PROM)
...
Preterm PROM (PPROM)
may be preceded by infection
Physiology of Labor Premonitory signs of labor
▪Weight loss
▪Backache
▪Nausea and vomiting
▪Diarrhea
True Labor
-Progressive dilatation and effacement
- Regular contractions
▪Increasing in frequency, duration, intensity
▪Intensity increases with ambulation
-Pain usually starts in back, radiates to abdomen
▪Pain not relieved by ambulation or by resting
▪Cervical dilatation, effacement progressive
▪Contractions do not decrease with:
-Rest
-Warm tub bath
False labor
-Lack of cervical effacement and dilatation
-Irregular contractions do not increase in frequency, duration, and intensity
-Contractions mainly in lower abdomen and groin
-Pain may be relieved by:
▪ambulation
▪changes of position
▪Resting
▪Hot bath or shower
Nurse's response to false labor
-Education
▪False labor common
▪Difficult to distinguish from true labor
-Reassurance
-Interventions
▪Decrease anxiety, discomfort
Theoretical separations
-Laboring woman will not usually experience distinct differences
First Stage -onset of true labor until full dilation: Latent or early phase
-Beginning cervical dilatation and effacement
-No evident fetal descent
-Uterine contractions increase in frequency, duration, and intensity
-Contractions usually mild, regular
Excited, talkative, smiling
First Stage: Active phase
-Cervical dilatation from 4 to 7 c m
-Progressive fetal descent
-Contractions more frequent and intense
-Maternal responses
▪Increased anxiety
▪Concentration
▪Focused
First Stage: Transition phase
-Cervical dilatation from 8 to 10 c m
-Progressive fetal descent
-Contractions more frequent and intense
-Other characteristics
▪Hyperventilation
▪Restlessness
▪Difficulty understanding directions
▪Generalized discomfort
▪Nausea and vomiting
▪Irritability
-Other characteristics
▪Requests for medication
▪Increased need for support
▪Curling of toes
▪Loss of control
-Maternal responses
▪Woman likely to withdraw into self
▪Anxious to "get it over with"
Second Stage
•Begins with complete dilatation (10 c m)
•Ends with birth of baby
•Spontaneous birth (vertex)
•Positional changes of the fetus
•Crowning
-Fetal head encircled by introitus of vagina and birth imminent
•Maternal urge to push
Third Stage of Labor
•From birth of infant to delivery of placenta
•Placental separation
-Increase in bleeding
-Signs
▪Globular-shaped uterus
▪Rise of fundus in abdomen
▪Sudden gush, trickle of blood
Further protrusion of umbilical cord
•Placental delivery
-Retained if not expelled 30 minutes after end of second stage
-Shiny Schultze
▪Fetal side presents
-Dirty Duncan
▪Maternal side presents
Fourth Stage of Labor
•1 to 4 hours after birth, or until homeostasis maintained
•Physiologic readjustment
•Thirsty and hungry
•Shaking
•Bladder is often hypotonic
-Leads to retention
•Uterus remains contracted
Cardiovascular system
-Stressed by uterine contractions, pain, anxiety
-Affected by maternal position
-Intrathoracic pressure increase during bearing down
Elevated output for at least 24 hours after birth
Blood pressure
-Increased cardiac output
▪Systolic B P rises
-Drops during aortocaval compression
-Sympathetic blockade from epidural anesthesia
Fluid and electrolyte balance
-Maintain adequate oral hydration
Respiratory system
-Oxygen demand increases at labor onset
-Possible metabolic acidosis compensated by respiratory alkalosis
-Acid-base changes quickly reversed in fourth stage
Renal system
-Increased maternal renin, plasma, angiotensinogen
-Edema or hematuria may present
Gastrointestinal system
-Gastric empyting prolonged, motility and absorption reduced
-Gastric volume remains over 25 m L
Immune system and other blood values
-Increased white blood cells (WBCs)
-Decreased maternal blood glucose
Pain
-Pain during labor
▪Normal physiologic process
▪First stage pain
-Cervical dilatation
▪Second stage pain
-Uterine muscle cell hypoxia
▪Third stage pain
Uterine contractions
Factors affecting response to pain
▪Preparation for childbirth
▪Individuals respond to painful stimuli
▪Families react to healthcare system based on own culture
▪Nurse needs to identify cultural norms
▪Fatigue and sleep deprivation
▪Previous experience with pain
▪Anxiety
▪Attention and distraction
▪Culture of healthcare
Heart rate changes
-Early decelerations harmless
Acid-base status in labor
-Decrease in fetal p H
Hemodynamic changes
-Fetal, placental reserve enough to last fetus through anoxic periods
Behavioral states
-Two sleep states most prevalent
-Quiet sleep generally lasts less than 40 minutes
Fetal sensation
-Fetus sensitive to light even in utero
-Hearing reliable at 28 weeks
-Fetus aware of pressure sensations, labor
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