very helpful for student

1. Labor & Delivery
Prepared By: Miss Israa Issa

2. Labor Scenario
Sara admitted to the Labor unit with possible rupture
of membranes (ROM). Admission assessment reveals
the following data: right-occipital-posterior position,
longitudinal lie, cervical dilation
4
cm, -
3
station,
effaced
80%
eht fo erutpur suoenatnops dna ,
civlep reh ni erusserp sah ehs setats araS .senarbmem
yltneuqerf erom etaniru ot sdeen dna aera
.

3. Fetal Descent Stations
➢ How far the baby is "down" in the
pelvis, measured by the relationship
of the fetal head to the ischial spine
.
➢ The ischial spine is in (0) Station
➢ If the presenting part is higher than
the ischial spine, the station has a (-
) neg. #.
➢ Positive #s = presenting part has
passed the ischial spine.
➢ Positive (+) 4 is at the outlet.

5. Cervical Effacement and Dilatation
➢ Cervical Effacement:
the progressive
shortening and thinning
of the cervix during
labor. 0 – 100%
➢ Cervical Dilatation: the
increase in diameter of
the cervical opening
measured in
centimeters. 0 – 10 cm.

7. Fetal presentation
the part of the fetus that lies closest to or has entered the
true pelvis .
➢ Cephalic presentations are vertex, brow, face, and
chin .
➢ Breech presentations include frank breech, complete
breech, incomplete breech, and single or double
footling breech .
➢ Shoulder presentations are rare and require cesarean
section or turning before vaginal birth .

9. Fetal attitude
➢ This is the degree of flexion of the fetus body parts
(body, head, and extremities) to each other. Flexion is
resistance to the descent of the fetus down the birth
canal, which causes the head to flex or bend so that the
chin approaches the chest.

10. Types of attitudes.
Flexed head Neutral position head Deflexed head

11. Types of fetal attitudes
A--Complete flexion. B-- Moderate flexion. C--Poor flexion.
D--Hyperextension

12. Engagement
➢ entrance of the presenting part of the fetus into the true
pelvis or the largest diameter of the presenting part into
the true pelvis. In relation to the head, the fetus is said to
be engaged when it reaches the midpelvis or at a zero
(0) station.
➢ also called lightening or dropping, (baby descends into
the pelvic cavity in preparation for birth).

13. FACTORS THAT MAY EXTEND OR INFLUENCE THE DURATION OF LABOR - 4 Ps
➢ Passage: Birth Passage: size and morphology of true pelvis, uterus, cervix,
vagina, and perineum. Parity of woman.
➢ The True Pelvis is primarily important when a vaginal delivery is expected.
➢ Passenger: Presentation of the fetus “part of the fetus that enters the pelvis
first” (breech, transverse). Size of the fetus, moldability of the fetal skull.
➢ Powers: Quality, force and frequency of uterine contractions
➢ Psyche: mother’s attitude toward labor and her preparation for labor.
Culture, Anxiety/Fear

14. The POWERS: Uterine Contractions
➢ Increment: Beginning, building of pressure
➢ Acme: Most intense part of the contraction
➢ Decrement: Diminishing of the contraction
➢ Rest: Period of time between contractions

15. 10/8/2020 15
Characteristics of Contractions
➢ Frequency: How often they occur?
• They are timed from the beginning of a contraction to the beginning of the
next contraction.
➢ Regularity: Is the pattern rhythmic?
➢ Duration: From beginning to end - How long does each contraction last?
➢ Intensity: By palpation mild, moderate, or strong.

16. 10/8/2020 16
Assessment of Contractions
➢ Palpation: Use the fingertips to palpate the fundus of the
uterus
• Mild: Uterus can be indented with gentle pressure at
peak of contraction
• Moderate: Uterus can be indented with firm pressure
at peak of contraction (feels like chin)
• Strong: Uterus feels firm and cannot be indented
during peak of contraction

17. What is Labor?
➢ Onset of rhythmic contractions
➢ Relaxation of the uterine smooth muscles
➢ Effacement or progressive thinning of the cervix
➢ dilation or widening of the cervix
➢ Expulsion of the fetus and products of conception
(placenta and membranes) from the uterus.

18. ➢ It Is the process where by painful , regular uterine
activity (contraction) with progressive cervical
effacement and dilatation accompanied by decent of
the presenting part leads to expelled of the fetus from
the uterus at or beyond 24 (or 28) completed weeks of
pregnancy.

19. 1 LNMP 24 W 28 W 37 W 40W 42W
PTL
Term
Labour
prolonged

20. What causes Labor?
➢ The process begins between 38 and 40th week.
➢ The exact cause of onset is not understood.
➢ There are several hypothesis: Progesterone withdrawal →
relaxation of the myometrium, whereas estrogen stimulates
myometrial contractions and production of prostaglandins.
➢ Oxytocin, a hormone produced by the pituitary, stimulates the
uterus to contract.

21. SIGNS OF IMPENDING LABOR
➢ Lightening
➢ Braxton Hicks contractions
➢ Cervical changes: Effacement
➢ Bloody show: labor 24-48 hrs
➢ Rupture of membranes (ROM)
➢ GI disturbance: N/V, diarrhea, weight loss
➢ Sudden burst of energy (nesting)

22. Diagnosis
A. symptoms:
1. True labour pains – colicky pain in the abdomen and back are characterized by:
False labour pain
True labour pain
character
Irregular
regular
contractions
Short duration, not
progressive
Progressive (increase in
frequency and intensity)
Interval between contractions
and intensity
Not associated with
effacement and dilation
of the cervix
Associated with effacement
and dilation of the cervix
Changes in the cervix
Not associated with bulging of
membranes
Associated with bulging of
membranes
Membranes
Relieved by sedation
Not relieved by sedation
Response to analgesia
Not followed by labour
Followed by labour
Labour

23. 2. Show – blood stained mucous.
3. SROM
B. Signs:
o palpable or recorded uterine contraction
o effacement and dilation of the cervix
o formation of forewater

24. Stages of Labor

25. 1st Stage of Labor: dilatation and effacement
➢ The first stage of labor is referred to as the "dilating" stage.
➢ It is the period from the first true labor contractions to complete
dilatation of the cervix (10cm)
➢ The forces involved are uterine contractions.
➢ The first stage of labor is divided into three phases:
➢ (1) Latent
➢ (2) Active
➢ (3) Transition

26. Latent Phase
➢ Ends when cervix is dilated 4
cm.
➢ Contractions more frequent.
➢ The duration becomes longer.
➢ Intensity - moderate.
➢ Mother is usually alert and
talkative, can walk
➢ Contractions last from 30 to 45
seconds The frequency of
contractions is from 5 to 20
minutes.
➢ True labor is considered to be at
4 cm.
➢ Duration varies, sometimes as
long as 24 hours.

27. Active Phase
➢ Begins when cervix is dilated 4
cm, ends when the cervix is
dilated 8 cm.
➢ Contractions occur every 3 to 5
minutes with a duration of 40 to
60 seconds.
➢ Intensity progresses to strong.
➢ The client focuses more on
breathing techniques in
contractions, less talkative.
➢ Unable to walk
➢ This phase is considered the
onset of true labor.

28. Transition Phase
➢ Begins when cervix is dilated 8
cm, ends when cervix is dilated
10 cm.
➢ Contractions occur every 2 to 3
minutes
➢ Duration of 60 to 90 seconds.
➢ The intensity of contractions is
strong.
➢ Completion of this phase marks
the end of the first stage of
labor.
➢ Urge to push

29. CHARACTERISTICS OF
THE TRANSITION PHASE
➢ Restlessness
➢ Hyperventilation
➢ Bewilderment and anger
➢ Difficulty following
directions
➢ Focus on self
➢ Irritability
➢ Nausea, vomiting
➢ Very warm feeling
➢ Perspiration
➢ Increasing rectal
pressure

30. 2nd Stage: Birth of the Baby
➢ Begins when cervical dilatation is
complete and ends with birth of
the baby.
➢ Impending Signs:
➢ Bulging of the perineum.
➢ Dilatation of the anal orifice.
➢ Nausea, Irritability and
uncooperativeness.
➢ Complaints of severe discomfort.
➢ Dilatation and effacement –
complete –
➢ patient is instructed to push with
each contraction to bring the
presenting part down into the
pelvis

31. Second stage of labor
➢ Verbal encouragement and physical contact help
reassure and encourage the patient.
➢ Monitor the patient's BP and the FHR every 5 minutes and
after each contraction.

32. Third Stage of Labor
➢ The period from birth of the baby through delivery of the
placenta.
➢ Dangerous time because of the possibility of
hemorrhaging.
➢ Signs of the placental separation
➢ a. The uterus becomes globular in shape and firmer.
➢ b. The uterus rises in the abdomen.
➢ c. The umbilical cord descends three inches or more
further out of the vagina.
➢ d. Sudden gush of blood.

33. Nursing Care 3rd stage
➢ Following delivery of the placenta:
➢ Observation of the fundus.
➢ Retention of the tissues in the uterus can lead to uterine atony
and cause hemorrhage.
➢ Massaging the fundus gently will ensure that it remains
contracted.
➢ Allow the mother to bond with the infant. Show the infant to the
mother and allow her to hold the infant

34. 4th stage
➢ Period from the delivery of the placenta until the
uterus remains firm on its own.
➢ Uterus makes its initial readjustment to the non-
pregnant state.
➢ The primary goal is to prevent hemorrhage from the
uterine atony and the cervical or vaginal
lacerations.

35. Management of labour
The management of labour should be commenced during
the antenatal period, and the women should be classified
as high or low risk pregnancy. The medical or surgical
problems should be corrected as in case of (anaemia,
hypertension, urinary tract infection), vaccination should be
given if necessary, and all investigations should be
performed and prepared such as (HIV, HCV, Hbs Ag, blood
grouping…….etc).

36. Also the patient should be advised to attend the antenatal class and
visit the hospital including the labour ward to be familiar to the
place and staff.
Once labour is commenced and the patient arrived to the admission
room the following to be done:
A-Taking history or reviewing the antenatal file.
1-Last menstrual period – expected date of confinement.
2-Time of onset of labor.
3-Frequency and duration of contraction (3-4cm/10min).
4-Presence or absence of amniotic fluid leakage.
5-Presence or absence of show or vaginal bleeding.
6-Past obstetric history especially mode of previous delivery, presentation, mode
of delivery, and weight of previous children.
7-Past medical or surgical history that may affect labor or delivery, especially
diabetes, heart disease, respiratory disease allergies, and any medication.

37. B- Examination:
1. .General:
a-pallor, oedema, varicosities, height, and built.
b-Vital signs (BP, P, T)
c-Examination of heart, lungs, breast and other organs
if necessary
2. .Abdominal Examination:
a-To determine fundal height in cm using tape measure
(to determine gestational age clinically), fetal lie,
presentation, engagement in fifths, size of the fetus,
amount of liquor, fetal heart rate.
b-The frequency and duration of the contraction.

38. 3. .Vaginal Examination: to assess the following.
a-Cervical dilatation in cm and effacement in %.
b-Length of the cervix.
c-Consistency of the cervix
d-Position of the cervix
e-State of the membranes, amount and colour of liquor.
f-fetal presentation, position and station.
g-pelvic architecture.

39. Arrival to the labor ward:
I-first stage of labor:
1-Ensure patient’s privacy by covering her with sheaths or
blankets.
2-Reassure and show great sympathy and interest.
3-Record maternal vital signs every hour (BP, P, T).
4-Take blood for grouping and cross match for high risk
patients.
5-Monitor:
a-high risk patients should have a continuous electronic
fetal heart monitoring.

40. b-low risk patients should have brief electronic fetal
heart monitoring if NORMAL, to be followed by
intermittent auscultation:
-first stage every 15min
-second stage every 5min
6-Limit oral intake to small amount of clear fluid or
frozen pineapple.

41. 7-Encourage spontaneous voiding, catheterization
may be necessary.
8-Test all urine specimen for proteins, sugar, and
acetone.
9-Give IV fluids during labour to avoid dehydration

42. Placenta Assessment
Factor to assess
➢ Placental completeness
➢ Placental size
➢ Assess the maternal surface of the placenta
➢ Assess the fetal surface of the placenta
➢ Assess the characteristic of the fetal membranes:
chorion and amnion
➢ Umbilical cord

43. Nursing diagnosis
- Impaired verbal communication RT language barrier
- Risk for injury (maternal fetal) Rt inadequate power
of labor
- Pain RT contraction
- Fear RT Labor process
- Impaired physical mobility RT fetal monitoring
-Risk for fluid volume deficit RT decrease fluid intake
-Anxiety RT inability to control
-Risk for infection RT ROM or perineum trauma

44. Reference
➢ Lowdermilk, p.(2004).Maternity & women's health care.(8thed).St,Louis.Mosby.
➢ Unit four