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Normal labor
Labor is described as the process by which the fetus, placenta and membranes are expelled through the birth canal. Normal labor occurs at term and is spontaneous in onset with the fetus presenting by the vertex. The process is completed within 18 hours and no complications arise.
❖ Initiation of labor:
The exact mechanism that initiates labor is unknown. Theories include the following:
1. Uterine stretch theory: uterus becomes stretched, pressure increase causing physiologic changes that initiate labor. stretching causes a release of prostaglandins.
2. As pregnancy advances, the uterus becomes more sensitive to oxytocin (pressure on cervix stimulate production of oxytocin).
3. As pregnancy advances, progesterone is less effective in controlling rhythmic uterine contractions that occur normally throughout pregnancy.
4. There is increased production of prostaglandins by fetal membranes and uterine deciduas as pregnancy advances.
5. In later pregnancy, the fetus produces increased levels of cortisone which inhibit progesterone production from the placenta.
6. Placental aging and deterioration triggers the initiation of contractions.
❖ General terms:
1. Lie: a comparison of the long axis of the fetus with the long axis of the mother. Fetal lie is either, longitudinal, transverse or oblique. In longitudinal lie either the fetal head presents or the buttocks present. In transverse lie, the shoulders present.
2. Presentation: the part of the fetus deepest in the birth canal. Presentation may be vertex, face, brow, breech or shoulder.
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3. Presenting part: portion of the fetus deepest in the birth canal and felt on vaginal examination.
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4. Attitude: relationship of fetal parts to each other (normal flexion).
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5. Position: Position refers to the location of a fi xed reference point on the fetal presenting part in relation to a specific q uadrant of the maternal pelvis. The presenting part can be right anterior, left anterior, right posterior, and left posterior. These four quadrants designate whether the presenting part is directed toward the front, back, right, or left of the passageway.
It is the relationship of landmark on the fetal presenting part to the front (anterior = A) back (posterior = P) or side (transverse = T) of the mothers pelvis. Landmarks on the fetal presenting parts include head = occiput (O) buttocks = sacrum (S), shoulder = scapula or acromion (A), face = chin of mentum (M).
Example: a fetus presenting by the vertex with his occipit on the left anterior part of the woman’s pelvis would have his presentation and position described as LOA or lift occiput anterior.
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❖ Factors affecting labor:
• Powers (physiological forces)
• Passageway (maternal pelvis)
• Passenger (fetus and placenta)
• Passageway _ Passenger and their relationship
(engagement, attitude, position)
• Psychosocial influences (previous experiences, emotional status)
Successful labor and delivery depend on adequate pelvic dimensions, adequate fetal dimensions, presentation and adequate uterine contractions.
A. Pelvic dimensions:
1. Adequate pelvic inlet. AP diameter, normal shape.
2. Adequate midpelvis: Ischia spines don’t protrude into bony canal.
3. Adequate outlet: adequate distance between tubrosities and coccyx.
B. Fetal dimensions:
Important fetal dimensions influenced by fetal size, posture, lie, and presentation. Fetal position is also an important factor in successful labor.
C. Uterine contractions:
1. Uterine contractions are involuntary, occurring at regular intervals and having adequate intensity.
2. During uterine contractions, the active upper portion becomes thicker, while the lower uterine segment stretches and becomes thinner.
True and false labor contractions
|True labor contractions |false labor contractions |
|Result in progressive cervical dilation and effacement. |Do not result in progressive cervical dilation and effacement. |
|Occur at regular intervals. |Occur at irregular intervals. |
|Intervals between contractions decrease. |Intervals remain the same or increase. |
|Intensity increases. |Intensity decrease or remains the same. |
|Location mainly in back and abdomen. |Location mainly in groin and abdomen. |
|Generally intensified by walking. |Generally unaffected by walking. |
|Not affected by mild sedation. |Generally relived by mild sedation. |
|Dilation and effacement of the cervix are progressive. |There is no change in the cervix. |
❖ Events preliminary to labor (Signs and symptoms of lablor):
Pre-labor is the term given to the last few weeks of pregnancy during which time a number of changes occurring.
1. Lightening, the setting of the fetus in the lower uterine segment occurs 2-3 weeks before the onset of labor in the primigravida and later during labor in the multigravida.
a. The woman’s breathing becomes easier as the fetus falls away from the diaphragm.
b. Lordosis of the spine is increased, walking is more difficult because the pelvic joints are more mobile and relaxed, leg cramping may increase Backache may increase.
c. Frequency of micturation occurs because of the pressure on the bladder.
2. Vaginal secretions may increase.
3. Mucus plug is discharged from the cervix along with a small amount of blood from surrounding capillaries, referred as SHOW (bloody show). Its presence often indicates that labor will begin within 24 to 48 hours.
4. Taking up of the cervix. The cervix is drawn up and gradually merges into the lower uterine segment. The cervix becomes soft and effaced “thinned”. This softening and thinning is called cervical effacement
5. False labor contractions may occur.
6. Membranes may rupture.
7. As the pregnancy approaches term, most women become more aware of irregular contractions called Braxton-Hicks contractions. As the contractions increase in frequency (they may occur as often as every 10 to 20 minutes), they may be associated with increased discomfort.
Stages of labor
1. The 1st stage is that of dilation of the cervix. It begins with regular rhythmic contractions and is complete when the cervix is fully dilated 10 cm (takes most of the time)
2. The 2nd stage of labor is the expulsion of the fetus. It begins when the cervix is fully dilated and is completed when the baby is completely born.
3. The 3rd stage of labor includes separation and expulsion of placenta and membranes. It lasts from the birth of the baby until the placenta and the membranes have been expelled. (about half an hour)
4. The 4th stage lasts from delivery of the placenta until the postpartum condition of the woman has become stabilized “usually 1-2 hour after delivery”
➢ Note: the 1st stage consists of 3 phases:
a. Latent phase: cervical dilation is 0-3 cm
Begins with the establishment of regular contractions (labor pains). Labor pains are often initially felt as sensations similar to painful menstrual cramping and are usually accompanied by low back pain. Contractions during this phase are typically about 5 minutes apart, last 30 to 45 seconds, and are considered to be mild. Usually, woman is excited about labor and talkative. It takes up to 10-14 hours.
b. Active phase: cervical dilation is 4-7 cm.
The active phase of labor is characterized by more active contractions. The contractions become more frequent (every 3 to 5 minutes), last longer (60 seconds), and are of a moderate to strong intensity.
Cervical dilation during this phase advances more quickly as the contractions are often more efficient. While the length of the active phase is variable, nulliparous women generally progress at an average speed of 1 cm of dilation per hour and multiparas at 1.5 cm of cervical dilation per hour.
c. Transitional phase: cervical dilation is 7-10 cm
The transition phase is the most intense phase of labor. Transition is characterized by frequent, strong contractions that occur every 2 to 3 minutes and last 60 to 90 seconds on average.
Other sensations that a woman may feel during transition include rectal pressure, an
increased urge to bear down, an increase in bloody show, and spontaneous rupture of the membranes (if they have not already ruptured).
Mechanism of labor
If the woman’s pelvis is adequate, size and position of the fetus are adequate and uterine contractions are regular and of adequate intensity, the fetus will move through the birth canal. The position and rotational changes of the fetus as he/she moves down the birth canal will be affected by resistance offered by the woman’s bony pelvis, cervix and surrounding tissues
A. Engagement:
When biparietal diameter of fetal head has passed through pelvic inlet.
1. Primigravida: occurs up to 2 weeks before onset of labor
2. Multigravida: usually occurs with onset of labor.
3. Since biparietal diameter of fetal head and AP diameter is narrowest of pelvic inlet, the fetal head usually enters pelvis in a transverse position.
The fetal head enters the maternal inlet in the occiput transverse or the oblique position because the pelvic inlet is widest from side to side.
B. Descent:
Occurs throughout labor and is essential for rotations of the fetus prior to birth:
1. Accomplished by force of uterine contractions on fetal portion in funds, during second stage of labor the bearing down increases intra-abdominal pressure thus augmenting effects of uterine contractions.
2. Degree of descent described as:
a. Floating: presenting part is not engaged in pelvic inlet.
b. Fixed presenting part has entered pelvis
c. Engagement: presenting part has passed pelvic inlet
d. Station O: presenting part has reached the level of ischial spine
e. Stations (-1,-2,-3,-4) presenting part in 1,2,3,4 cm above the level of ischial spine.
f. Stations (+1, +2, +3, +4) presenting part in 1, 2, 3, 4 cm below the level of ischial spine. A station of +4 indicates that presenting part is on pelvic floor.
C. Flexion
Resistance to descent causes head to flex so that the chin is close to the chest. This cause the smallest fetal head diameter, subocciputobregmatic (9.5 cm) to present through the canal.
D. Internal rotation:
In accommodating to the birth canal, the fetal occiput rotates interiorly from its original position toward the symphysis pubis.
E. Extension:
As the fetal head descends further, it meets resistance from the perineal muscles and is forced to extend. The fetal head becomes visible at the vulvovaginal ring. Its largest diameter is encircled (crowing) and the head then emerges from the vagina.
The head is born in extension as the occiput slides under the symphysis and the face is directed toward the rectum. The fetal brow, nose, and chin then emerge.
F. External rotation:
When the head emerged, the shoulder are undergoing internal rotation to accommodate to the birth canal, the head now born, rotates as the shoulders undergo the internal rotation.
G. Expulsion
Following delivery of the infant’s head and internal rotation of the shoulder, the anterior shoulder rest beneath the symphonies pubis. The posterior shoulder is born followed by the anterior shoulder and the rest o the body.
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Nursing management during labor
Assessment:
When the woman present at the hospital, she will experience a mixture of excitement and apprehension. She should ideally be welcomed and her partner. Skill in inspiring confidence and establishing a trusting relationship with a woman is an integral part of good nursing care.
❖ History taking and baseline data:
1. Introduce yourself, ask for name of woman’s midwife or physician and if he or she has been notified that the woman was coming to the hospital or birth center.
2. Establish baseline information
a. Gravidity, parity, expected date of delivery.
b. When did contractions begin? How far apart are they? How long do they last?
c. Have the membranes ruptured? Color? Consistency? Amount of fluid?
d. Is there any bloody show?
e. How much discomfort is the woman experiencing?
f. What, if any problem has the woman had in this pregnancy? Problems in past pregnancies?
g. Blood type and Rh?
3. Establish baseline vital signs.
a. Temperature elevations suggest infection
b. Blood pressure measure between contractions.
c. Pulse: some elevation of pulse, respiration and blood pressure may be due to anxiety. Blood pressure elevations of 140 mmHg systolic and 90 mmHg diastolic suggest hypertensive disorder of pregnancy.
d. Respiration.
Methods for determining fetal presentation
1. Leopold’s maneuvers: determined by abdominal palpation.
a. The 1st maneuver: to determine if fetal head or breech is in uterine funds. Head feels hard and round, freely movable and ballotable breech feels large, nodular and softer.
b. The 2nd maneuver to determine the position of fetal extremities the fetal back and the anterior shoulder. Place hand on the abdomen to identify the location of the back and small parts palpate down sides of uterus, applying gentle but deep pressure onside of fetal back along continuous structure will be felt, side with fetal extremities will feel nodular, reflecting portions of fetal extremities.
c. The 3rd maneuver: to determine is presenting and if engagement has occurred. Grasp the lower uterine segment between the thumb and fingers of one hand to feel. If presenting part is movable, engagement has not occurred, if engagement has occurred fetal part feels fixed in the pelvis
d. The 4th maneuver: to confirm the findings of the 3rd maneuver and to determine the flexion of the vertex.
2. Vaginal examination:
Vaginal examination should preceded by abdominal examination and the woman’s bladder must be empty.
• Indications:
- To make a positive diagnosis of labor.
- To make a positive identification of presentation.
- To determine whether the head is engaged in case of doubt.
- To ascertain whether the fore waters have ruptured or to rupture them artificially.
- To exclude cord prolapsed after rupture of membranes.
- To assess progress or delay in labor.
- To apply a fetal scalp electrode.
- To confirm full dilation of the cervix.
➢ Notes:
- It is not always the only way of obtaining this information
- It should be avoided if there is any frank bleeding unless the placenta is positively known to be in the upper uterine segment
- It is an aseptic procedure, sterile gloves are required.
- It usually increases frequency and intensity of uterine contractions.
3. Ultrasonography
4. X-ray rarely used today (replaced by ultrasonography)
Assessing uterine contractions
(Intensity, Frequency and Duration)
1. Place fingertips gently on the funds.
2. As contraction begins, tension will be felt under the fingertips. Uterus will become harder, then slowly soften.
3. The intensity may be described as follows:
a. Mild: the uterine muscle is somewhat tense.
b. Moderate: the uterine muscle is moderately firm.
c. Strong: the uterine muscle is so firm that it seems almost board-like.
4. The frequency is measured in minutes, represents the time from the beginning of one contraction until the beginning of the next.
5. Duration of contraction is timed from the moment the uterus first begins to tighten until it relaxes again.
6. As labor progresses, the character of the contraction changes and they last longer.
7. When the cervix becomes completely dilated, the contractions become very strong, last for 60 seconds and occur at 2-3 minute intervals.
Assessing fetal heart tones
1. Note location, rate and character.
2. Determine the position, presentation and lie of the fetus.
3. Place the fetal stethoscope on the abdomen over the back or chest of the fetus.
4. Listen and count the beat for one minute.
5. Check the rate before, during, and after a contraction to detect slowing or irregularities (120-160 BPM normal)
6. Differentiate between FHT and other abdominal sounds.
a. FHT, very rapid, some what muffled ticking sound.
b. Uterine bruit, murmur, dilated uterine vessels, material pulse.
c. Fetal pulse (umbilical arteries) is synchronous with funic soufflé.
7. Check FHR immediately following rupture of the membranes. Sudden release of fluid may cause prolapsed of the umbilical cord.
Fetal monitoring
The purposes of continuous fetal monitoring during labor are:
1. To monitor the progress of a women’s contraction pattern.
2. To monitor the condition of the fetus in response to the stress of uterine contractions.
Women’s reaction to being monitored varies:
1. Some women are reassured by hearing the continuous fetal heart sound.
2. Some women \ couples use the printout of the contraction pattern to assist them in using breathing techniques.
3. Some women experience discomfort because of the abdominal straps & their interference with movement as well as difficulty assuming a comfortable position.
❖ External monitoring (indirect):
- Separate transducers are secured to the women’s abdomen.
- A tokodynamometer translates abdominal tension.
- An ultrasound transducer translates fetal heart sound into electrical signals that are recorded on a strip chart.
- The ultrasound transducer device should be applied over the abdomen where the sharp fetal heart sound is heard .the transducer needs to be adjusted when fetus changes position.
- The tokodynamometer recording uterine contraction will need to be reapplied over the fundus as the fetus & uterus descend during labor.
- The measurement by external monitoring of the intensity of uterine contractions is not accurate.
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❖ Internal monitoring (direct):
- A method of recording intrauterine pressure and FHR through internal measurement.
- More accurate than external monitoring.
- Fetal electrocardiograph obtained by a small electrode clipped to the presenting part.
➢ Note:
1. The membranes must be ruptured.
2. The cervix must be dilated 3-4 cm.
3. The station must be (-2) or lower.
- Uterine contractions are recorded by means of a catheter placed in uterine cavity behind the presenting part.
- The catheter filled with distilled water and is connected to an external transducer that converts pressure to electronic signals.
- Monitor strips record the quality of the uterine contractions and fetal heart patterns simultaneously.
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❖ Interpretation:
- FHR must be checked initially for rate in the absence of or in between contraction.
- A change from the baseline is termed as fluctuation and is either acceleration or deceleration.
- Acceleration or deceleration of the FHR are due to:
1. Mechanical effects or uterine pressure applied directly to the fetal head and / or umbilical cord.
2. Uterine pressure applied directly to the intervillous space which leads to decrease blood flow.
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❖ Acceleration:
Of more than 60 BPM above the baseline is considered sever and indicates fetal compromise e.g. fetal hypoxia , fetal immaturity or breech presentation .
An acceleration is defined as an increase in the FHR of 15 bpm above the fetal heart baseline that lasts for at least 15 to 30 seconds. Accelerations are considered a sign of fetal well-being when they accompany fetal movement.
Thus, when a fetus is active in utero, accelerations are normally present. Consequently, when the fetus is sleeping or not moving, limited FHR accelerations may be noted. When contractions are present, accelerations are often noted as a response to the contraction.
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Top. Fetal heart rate accelerations.
Bottom. Uterine contractions.
❖ Deceleration :
1. Early Deceleration.
- Wave-form approximates a mirror image of the pattern of intrauterine pressure (contractions)
- Pattern is often uniform in appearance.
- Begins near the onset of contraction
- Lowest level of FHR occurs at the peak of the intrauterine pressure (contraction).
- FHR does not fall below 100 BPM.
- Not usually cause change in acid-base balance.
- Caused by fetal head pressure (which cause vagal stimulation which decrease in HR), May occur during vaginal examinations, uterine contractions, and during placement of the internal mode of fetal monitoring.
- need no intervention.
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Top. Early decelerations.
Bottom. Uterine contractions.
2. Late deceleration:
- Manifests a smooth uniform heart pattern.
- Begins later in contracting phase of uterus (as the contraction reaches its peak) and resolved when the contraction ends.
- Usually less than 90 seconds in duration.
- Frequently associated with fetal tachycardia.
- Passage of meconium may occur.
- Associated with progressive fetal hypoxia and acidosis.
- Due to acute uteroplacental insufficiency as a result of a decreased intervillous space blood flow (in this circumstance a decrease in blood flow from the uterus to the placenta results in fetal hypoxia and late decelerations).
- Should be reported immediately.
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Late decelerations.
Bottom. Uterine contractions.
- Late deceleration can be avoided by:
a) Careful maintenance of maternal pressure within normal limits
b) Careful infusion of oxytocins and anesthetics .
- Late deceleration can be modified by :
a) Discontinue oxytocin if being given .
b) Chang the woman's position to the left side
c) Administer oxygen and IV fluid
d) Obtain fetal blood sample to measure degree of hypoxia and acidosis
e) If persist, labor may be terminated by Cesarean or Forceps delivery
3-Variable deceleration
- Decelerations are variable in terms of their onset, frequency, duration, and intensity.
- The decrease in FHR below the baseline is 15 bpm or more, lasts at least 15 seconds, and returns to the baseline in less than 2 minutes from the time of onset.
- Due to umbilical cord compression
- Non uniform and has no relation to contractions
- In severe deceleration, FHR may fall by 70 BPM and last longer than 60 seconds.
- Usually relieved by changing position of the woman to relieve pressure on the cord When sever cord prolapse should be suspected
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Top. Variable decelerations.
Bottom. Uterine contractions.
4-Combined deceleration : difficult to identify the FHR pattern
Tachycardia is generally defined as a sustained baseline fetal heart rate greater than 160 beats
per minute for a duration of 10 minutes or longer. A number of conditions are associated with fetal tachycardia:
• Fetal hypoxia
• Maternal fever
• Maternal medications
• Infection
• Fetal anemia
• Maternal hyperthyroidism
Bradycardia is defined as a sustained
(greater than 10 minutes) baseline FHR of less than 110 to 120 bpm. Fetal bradycardia may be associated with:
• Late hypoxia
• Medications: (e.g., propanolol)
• Maternal hypotension
• Prolonged umbilical cord compression
• Bradyarrhythmias
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Assessing woman's / couples expectations and concerns
1- What are their concerns?
2- How anxious are they?
3- What has been their preparation for labor?
4- What is their understanding of labor process?
5- What are their expectations of the labor and delivery process?
6- How will are they coping and how will are they communicating with each other?
Nursing Diagnosis
1- Anxiety related to uncertainties/misconception of the labor and birthing process, hospital, environment, fear for self and baby.
2- Pain and discomfort related to uterine contraction ,passage of the fetus through the birth canal, possible tearing of the perineum
3- Potential for ineffective coping related to length and discomfort of labor process, fatigue, decreased energy
4- Potential for blood loss related to complication
5- Potential for infection related to rupture membranes
Nursing Intervention
Reduce anxiety
- Monitor the woman's/couples concerns
- Keep the woman's/couple up to date on the woman's progress during labor
- Explain any procedure that need to be performed or any unexpected event that may occur
- If the woman is in true labor, the perineal area may be shaved to promote cleanliness, to reduce postpartum infection and to make episiotomy repair easier
- An enema may be necessary to increase the space available for passage of the fetus and decrease fecal contamination of the field during labor
Reduce pain and discomfort, promote effective coping throughout the state of labor as described in the following:
1st stage of labor
Latent phase (0-3cm).
1- Monitor progress of labor, take and record vital signs, contractions (usually 5-10minutes apart, lasting 20-40second), fetal heart sounds every1-2houre,temperature every 4hours unless elevated
2- Provide clear liquids if permitted
3- Allow the woman to walk about, provided presenting part is engaged and membranes have not ruptured
4- Encourage diversionary activity such as reading or watching TV.
5- Evaluate and teach breathing techniques helpful in coping with active and transitional phase of the 1st stage and breathing and pushing techniques for 2nd stage.
6- Involve partner or support person in the woman's care such as providing back massage and timing of contractions
7- Provide privacy for the couple between periods of giving care
8- Encourage the woman to void approximately every 2 hours to keep bladder empty
.Active phase (4-7cm)
Contractions are usually 2-5 minutes apart, lasting 30-50 seconds
1. Monitor progress of labor, take and record vital signs, Contractions and fetal heart sounds every 30 minutes
2. Be aware that the woman may begin to feel unable to cope with discomfort and may begin to lose control
3. Partner or nurse should help the woman to concentrate on breathing and relaxation techniques with each contraction
4. Provide comfort measures:
- Side-lying position is usually more comfortable, remove pressure of gravid uterus on inferior vena cava and increase blood flow to the placenta
- Provide sacral hand pressure and backrest
- Change damp or soiled linen
- Assist with mouth care
- Sponge bathe face, neck and back
- Continue to provide encouragement and information
- Administer prescribed analgesia as prescribed
5. Maintain hydration and glucose level of woman. Low glucose level decrease intensity of contractions (I.V) fluid may be necessary
Transitional phase (7-10cm).
A- Characteristics:
- contractions are usually 2-3 minutes apart, lasting 50-60 seconds
- This stage averages 10 contractions or 20 minutes for multigravida, 20 contractions or 40 minutes for primigravida
- Generally it is the most difficult of the phase of the 1st stage
- Bloody show increases as more capillary vessels in the cervix rupture
- Nausea and vomiting may occur because of reflex action as the cervix stretches and begins to retract over the fetal head
- Woman may experience or have potential amnesia between contractions, may be restless and cry during feelings
B-Nursing Interventions:
- Monitor progress of labor, vital signs, contractions and fetal heart sounds every15 minutes
- Assist with controlled breathing as contractions occur
- Discourage the woman from bearing down until cervical dilatation is complete
- Encourage the women to rest between contractions to conserve energy
- Provide concise and brief explanations because woman is irritable
- Remind the woman that labor is nearing an end
- Prepare the woman for movement to the delivery room
2nd and 3rd stage of labor
A-Characteristics:
- Full cervical dilation occurs, infant is delivered
- Usually primigravida has an average of 20 contraction and multigravida an average of 10 contraction
Possible nursing diagnoses
- Pain related to increasing frequency, duration, and intensity of contractions
- Knowledge deficit related to pain management techniques for active labor
- Anxiety related to the previous birth experience
- Fatigue related to a prolonged latent phase labor
- Risk for infection related to prolonged rupture of membranes
B-Nursing Interventions
- Monitor F.H.R, contractions and blood pressure every 5 minutes
- Assist the woman into lithatomy position
- Coach for most effective pushing, only with contractions using abdominal muscles
- If the partner or support person is present, have him to support woman and see birth if desired
- Adjust delivery mirror, so the women can see birth if desired
- Cleanse vulva and perineal area
- Check equipment needed for infant resuscitation
- Keep the woman/couple informed of progress of delivery
- The woman may need to be catheterized, if bladder is full
- When the vulvovaginal ring encircles the head, an episiotomy may be performed to prevent tearing of the perineum
- Episiotomy is a surgical incision of the perineum that is performed to enlarge the vaginal orifice during the second stage of labor.
- When the head is delivered, mucus is wiped from face and aspirated from the nose and mouth by bulb syringe
- If loops of umbilical cord are around the infants neck, they are loosened and slipped from around the neck. If unable to be loosened the cord is clamped with two clamps and cut between them. The nurse then places a plastic clamp on the umbilical cord approximately 0.5 to 1 inch (1.2 to 2.5 cm) from the newborn’s abdomen.
- When the baby is delivered, the infant is shown to the mother/couple and then give to the nurse or pediatrician for normal newborn care and finally returned to the mother
- Placenta usually separates and delivered within 15-20 minutes following delivery of the baby
- Vaginal canal and cervix are inspected for lacerations or injury, if episiotomy has been performed, it is now sutured
- The woman perineal area is cleansed and a sterile perineal pad applied
- The woman is assisted from delivery table to abed or stretcher; she is moved with her newborn to the recovery room and accompanied by support person
- As the placenta separates from the uterine wall, it is important that the uterus continues to contract. The contractions minimize the bleeding that results from the open blood vessels left at the placental attachment site. Failure of the uterus to contract adequately with separation of the placenta can result in excessive blood loss or hemorrhage.
- To enhance the uterine contractions after expulsion of the placenta, oxytocin is often given (IV or IM).
- Once the placenta has been delivered, the nurse carefully examines it to ensure that all cotyledons are intact. If any part of the placenta is missing, the nurse immediately reports this finding to the attending physician. Because retained placental fragments can contribute to postpartum hemorrhage or infection, the physician may perform a manual exploration of the uterus to remove any remaining placental tissue.
- Initiate attachment between the mother and the newborn. The infant is in a stage of alertness during the first hour after birth and is responsive to voice, touch, and gaze. The nurse can facilitate eye-to-eye contact between the patient and her neonate by dimming the room lights. This occasion also provides an excellent time to initiate breastfeeding if the mother wishes to do so.
Expected Outcomes:
- Manages anxiety, vital signs at acceptable levels
- Copes with pain, use breathing techniques
- Remains in control, absence of untoward bleeding
- No evidence of infection
4th stage of labor
- Considered to be the stage of recovery period but in the same time it is a critical period for the mother and the newborn
- It is the first two hours post-birth, the mother starts readjustment to the non-pregnant state and body systems begin to stabilize
- The primary danger for the mother is hemorrhage
- The safety of the mother depends on frequent assessment and timely interventions of alert nurses
- During is the first hour for physical assessment, all factors except temperature are assessed every 15 minutes then every 30 minutes during the second hour
Factors to be assessed :
- Blood pressure :slightly elevated
- Pulse: 50-70/minute (return within one hour)
- Fundus: firm and 2cm below or at level of umbilicus, but if it was soft, message is done until firm
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- Bladder
- Emotional status
- Lochia: if blood comes in spurts, cervical tear is suspected
- Perineum: assess sutures of episiotomy
- Discomfort (after pain): as a result of uterine contraction
Nursing Interventions:
Provide a quiet environment for the woman to promote as much rest as possible for at least two hours
1) Potential for hemorrhage related to uterine atony and trauma
- The fundus remains firm with gentle massage
- Massaging expels blood and clots (uterus contract)
- If uterus doesn't respond and bleeding continue, I.V Pitocin is administered
- Lochia is bright red (scant, moderate, heavy)
- Assess the amount of bleeding by checking the perineal pads and under buttocks
Note :
- Saturated pad (tail to tail) =100ml blood
- Loss of 100ml blood/15min is considered heavy
- Vital signs every 15minutes
- Notify the physician
2) Potential for urinary retention related to child birth trauma, effect of full bladder on the uterus (position, contraction)
- Hemorrhage (atony of bladder retention)
- Warm water poured over the vulva to relax urethral sphincter
- Catheter may be prescribed
3) Alteration in comfort level related to after pain and childbirth trauma
- Uterine contractions (strong, painful; specially in multipara)
- Explain the normal physiology of after pains
- Encourage the mother to empty her bladder frequency
- Cover her abdomen with a warmed blanket
- Administer analgesics as prescribed
- Encourage self-relaxation techniques
For Episiotomy and Hemorrhoids:
- Encourage side lying position
- Apply ice packs for 2hours
- Administer analgesics as prescribed
- Encourage self- relaxation techniques
4) Self care deficit (bathing) related to fatigue and medications
- Wash the mothers’ face and hands and place a warm blanket over her
5) Potential for injury related to ambulating without assistance
- Bed rest for at least two hours
Note: rapid decrease in intra-abdominal pressure will lead to dilation of blood vessels supplying the intestine (Splachnic engorgement) that will lead to pooling of blood in the viscera and then to Orthostatic hypotension
- Dangling her feet for five minutes
- Not to ambulate for the first time without assistance
6) Potential fluid volume deficit related to restriction during delivery
- Woman is thirsty and request fluid as soon as possible
- Clear fluids with moderate amount are permitted
- Drinking too much and too quickly vomiting
- I.V infusion may be prescribed
- Accurate intake and output readings are maintained
- After the first hour alight diet is ordered
7) Potential distress of the human spirit related to lack of support person
8) Potential altered bonding related to fatigue and postpartum discomfort
- Initial response of the mother: positive or negative (return by time and bond with her baby)
Immediate Care of the Newborn
The sequence of procedures may differ from one birth setting to another
In more traditional settings, the care is performed immediately after birth
In other settings, many aspects are performed after the parents have had an hour or more to become acquainted with their newborn
Assessment and Interventions:
1) Immediately after delivery, dry the infant “a wet small newborn loses up to 200 calories/kg/minute in the delivery room through evaporation, convection and radiation” drying the infant cuts this heat loss in half
2) Aspirate mucus from the mouth and pharynx with suction catheter
3) Evaluate infant’s condition by Apgar Scoring System at 1-5minutes after birth
Apgar Scoring Chart
[pic]
a) Infants scoring (7-10): are free of immediate stress
b) Infants scoring (4-6): are moderately depressed
c) Infants scoring (0-3): are severely depressed
4) Cord care: cord is tied off approximately 2.5cm from abdominal wall using a cotton cord tie, plastic clamp or rubber band. Count the number of vessels, fewer than three vessels has been associated with renal and cardiac anomalies
5) Eye care: prophylactic treatment against Ophthalmia Neonatorum (Gonorrheal conjunctivitis). Two drops of 1% silver nitrate solution or erythromycin is placed in the conjunctival sac of the infants eye.
The infant of a mother with known gonorrheal disease should receive penicillin intramuscularly.
6) Vitamin K: 1mg may be administered in the delivery room or nursery
The newborn has no intestinal flora to manufacture vitamin k which is important in preventing hemorrhagic disease in the newborn period.
7) Identification:
a) Apply ID band or bracelet to infants arm, include mothers name, hospital number, infants sex and time and date of birth
b) Apply bracelet with the same information on the mothers wrist
c) After cleaning the soles of the infants feet, take footprints of the infant and fingerprints of the mother
8) Weight and measure the infant
9) Assess the infant for gestational age and general wellbeing
Care of the Mother and Newborn during the Postpartum Period
The Puerperium:
Is the period beginning after delivery and ending when the woman's body has returned closely as possible to its pre-pregnant state.
The period lasts approximately 6 weeks
Physiologic changes:
1) Uterine changes (Involution): uterus returns to pregravid status
a) The fundus is usually midline and about at the level of the umbilicus after delivery. The level of the fundus descends about 1cm each day until the 10th day, it has descent into the pelvic cavity and can no longer be palpated
b) Post delivery Lochia (a vaginal discharge) consisting of fatty epithelial cell, shreds of membranes, deciduas and blood is red (Lochia Rubra) for about 2-3 days. It then progresses to a pallor or brownish color (Lochia serosa ) followed by a whitish or yellowish color (Lochia Alba) in the 7th-10th day. Lochia usually ceases by three weeks and the placental site is completely healed by the 6th week.
2) The vaginal wall, uterine ligaments and the muscles of pelvic floor and abdominal wall regain most of their tone during puerperium
3) Postpartum diuresis occurs between the 2nd and 5th postpartum day as extracellular water accumulated during pregnancy begins to be excreted. Diuresis may also occur shortly after delivery if urinary output was obstructed by presenting part or I.V fluids were given during labor
4) Breasts:
a) With loss of the placenta, circulating level of estrogen and progesterone will decrease, while increase level of prolactine thus initiating lactation in the postpartum woman.
b) Colostrum: a yellowish fluid containing more minerals and protein but less sugar and fat than mature breast milk and having a laxative effect on the infant is secreted for the first 2 day postpartum.
c) Mature milk secretion is usually present by the 3rd postpartum day but may present earlier if a woman breast-feeds immediately after delivery
d) Breast engorgement with milk, venous and lymphatic stasis and swollen, tense and tender breast tissue may occur between day 3 and 5 postpartum
5) Ovulation: immediately after delivery, blood level of estrogen and progesterone severely diminished, F.S.H level is still low for 7-10 days after delivery, F.S.H increase by the 3rd week, ovulation reoccur in the non lactating woman by the 10th to 12th week, and she may menstruate 6-8 weeks post delivery (usually there is no ovulation at the first menstruation)
6) In the lactating woman ovulation and menstruation may not occur by 3 months or more.
It is important to educate patients that since ovulation can precede menstruation, breastfeeding is not a reliable method of contraception.
7) Involution is a term that describes the process whereby the uterus returns to the nonpregnant state. The uterus undergoes a dramatic reduction in size although it will remain slightly larger than its size before the first pregnancy.
Note : Involution of the uterus may be delayed by many causes as infection and the term subinvolution is used .
Subinvolution is the failure of the uterus to return to the nonpregnant state.
8) Cardiovascular system: immediately after delivery, the pulse rate will be decreased around 50 beats per minute and restored after 48 hours after delivery due to vagal stimulation. The intravascular blood volume increased due to shifting of fluid to the blood vessels. Blood volume returns to prepreganacny state by the end of the second week.
9) G.I.T increase tendency for constipation.
10) Skin: increase perspiration (diaphoresis) and diminished skin discoloration.
Assessment
• Immediate postpartum assessment :
The first hour after delivery of the placenta (4th stage) is a critical period; postpartum hemorrhage is most likely to occur at this time
1. Check fundus frequently.
2- Inspect perineum frequently for visible signs of bleeding
3. Evaluate V/S at frequent intervals
4. Avoid leaving the woman alone at this time since changes in condition can occur precipitously
• Subsequent postpartum assessment:
1. Check firmness of the fundus at regular intervals
2. Inspect the perineum regularly for frank bleeding
a- Note color, amount and odor of the Lochia
b- Count the number of perineal pads that are saturated in each 8 hours period
3. Assess V/S at least once daily and more frequently if indicated.
Nursing Diagnosis :
1. Potential bleeding related to vaginal delivery, episiotomy, uterine atony, complication…
2. Discomfort (backache, uterine cramping, breast engorgement…) related to process of labor
3. Urinary retention related to bladder trauma
4. Constipation related to episiotomy, decreased muscle tone of intestine
5. Risk for infection related to prolonged labor, vaginal delivery, laceration…
6. Knowledge deficit related to inadequate childbirth / parenting preparation, lack of self-confidence.
7. Anxiety related to chronic fatigue, adapting anew family member, inability to integrate that with labor experience.
Planning:
During planning goals are set in priority:
1. Saturate no more than one pad per hour.
2. Void within 6-8 hours Post delivery.
3. Verbalize acceptance of labor process after expressing concerns.
4. Verbalize increased comfort following initiation of comfort measures.
5. No signs of infection will appear.
Implementation:
1. Prevention of hemorrhage:
• v/s should be within normal limits.
• Uterus must be palpated at frequent intervals to ascertain that it is not filled with blood.
• Pads must be checked frequently to ensure that blood loss is not excessive.
• Lochia may be described as light, moderate or heavy.
• Uterus, normally is firm or may be returned to a state of firmness with gentle massage.
• Perineal pad that is soaked from tail to tail=100 ml of blood, when hemorrhage is suspected save all pads.
• If pad is soaked within 15 minutes or blood is seen under buttocks, check and observe vital signs and color of the mother.
2. Prevention of bladder distension:
• Palpation of bladder comes with palpation of the fundus.
• The full bladder forces the uterus upward and to the right of the midline interfere with contractility of uterine muscles hemorrhage.
• Distention lead to atony of bladder retention.
• Check the woman's voiding pattern, most women void with sufficient amount within 8 hours of delivery.
• If the woman's meatus or bladder has been traumatized during deliver, she may need to be catheterized, until the urinary tract swelling has subsided.
• Teach the woman to void every several hours to keep her bladder empty. This may help to reduce uterine cramping and promote comfort
3. Maintain comfort:
• Mothers need to be in bed for at least 2 hours after delivery, most mothers ambulate within 8-12 hours after delivery.
• When assisting the woman to ambulate for the first time, have her sit on the edge of bed for 5 minutes then ambulate with assistance to void falling because of fainting and dizziness.
• Counsel the woman to avoid stair climbing as much as possible for the first several days at home.
4. Breast care:
- Assess the condition of the woman’s breast and nipple.
- Teach the woman to wash her breast with worm water to avoid removing protective skin oil.
- Teach the woman to wear a brassier that provides good support during the night and day time.
- Lactation suppressants such as estrogen or androgens may be given to bottle-feeding mothers to suppress milk production and breast engorgement.
- Check the breasts for signs of engorgement (swollen, tender, tense, and shiny breast skin).
a. If the breasts engorged and the woman is breast feeding:
1. Allow worm to hot shower water to flow over the breasts to improve comfort.
2. Hot compresses on the breast may improve comfort.
3. Express some milk manually or by breast pump to improve comfort and allow nipples more available for infant feeding.
4. A mild analgesic may be used to improve comfort.
b. If the breasts engorged and the woman is bottle feeding:
1. Teach the woman to wear a supportive binder day and night.
2. Teach the woman to avoid handling her breast since this stimulates more milk production.
3. Suggests ice bags to the breasts to provide comfort.
4. Moderately strong analgesics may be need to provide comfort.
5. Diet and elimination:
1. Review the woman’s dietary intake with her.
2. Emphasize foods high in iron, protein and vitamins to aid the healing process. Foods such as fresh fruits and vegetables with high fiber will help reestablish normal bowel habits.
3. If the woman is breast-feeding, she should add between 500-900 additional calories daily for milk production.
4. She also needs 20 gm protein more than before she was pregnant and additional calcium, phosphorus, vitamins (A, D, E, C, B1, B2, and niacin), zinc and iodine.
6. Resuming of sex
1. Sexual intercourse may be resumed when perineal and uterine wounds have healed.
2. Healing occurs within 2-4 weeks. However, evaluation by the midwife or physician during the following up visit is necessary. Therefore, methods of contraception should be reviewed.
For women who are bottle-feeding, menstruation usually returns within 6-8 weeks after delivery (75% menstruate by the twelfth postpartal week).
Note: nursing mothers may ovulate even if they are experiencing amenorrhea and so a form of contraception should be used if pregnancy is to be avoided.
7. Maintain cleanliness:
- Vulva is cleaned and sterile pad is applied.
- Linen is changed
- Teach the woman to carry out perineal care, warm water over the perineum after voiding.
- Sitz baths may be used.
Evaluation:
- Evaluation of progress and out-comes is a continuous activity through this stage.
- The nurse evaluates physiologic recovery from pregnancy and labor and development of parent-infant relationships (attachment).
- If the evaluation process identifies that results fall short of achieving any goal, further assessment, planning, and implementation are needed to be done.
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