Stages of Labor:

1. Stage of cervical effacement and dilation
2. Stage of expulsion
3. Placental stage
4. Recovery stage (maternal homeostatic stabilization)

1. Stage of cervical effacement and dilation:

Begins with onset of regular contractions and ends with complete dilation.

Lasts 6-12 hours for primipara.

Last 6-8 hours for multipara.

Consist of 3 phases:

1. Latent phase:

• longest phase of 1^st stage
• cervix dilates form 0-3or4cm
• irregular contractions
• duration of contractions: 15-30 seconds
• frequency of contractions: 5-30 minutes apart at 1^st and go to 5-10 minutes apart
• mother’s emotions are: elation, energetic, talkative, follows directions, wants natural childbirth
• do teaching at this time
• take BP q hour
• FHR q 30 minutes to 1 hour
• do any preps now
• ask when last BM: if within 24 hours = no enema, but if not, give fleet enema - according to policy.
• Why give enema? May have BM and contaminate sterile field, full colon also hinders delivery
• enema contra-indicated: ROM, vaginal bleeding, pre-term labor, imminent delivery, primipara dilated 6-8cm, multipara dilated 4cm
• May have bathroom privileges if membranes intact
• Membranes intact can get up and walk, increases intensity of contractions
• Check policy may have clear liquids
• Encourage mom to empty her bladder
• B. Active Phase
• Dilate 4-7cm.
• Duration of contraction 30-60 seconds.
• Frequency of contraction 3-5 minutes
• Remember MAD for the active phase:
• M: medications
• A: assess FHR, contractions, v/s, and physical needs
• D: dry lips and dry linens
• Mom is self-focused and less talkative.
• Uses learned breathing patterns.
• Moderate discomfort, may have medication.
• Epidural may be started now.
• Give narcotic: Demerol, Nubain, Stadol.
• Early in this phase may still be able to walk.
• Assess v/s q hr and FHR q 15-30 minutes.
• Sterile vaginal exam as needed to check for dilation.
• Spontaneous ROM.
• Check color of fluid.
• Clear fluid normal with white specks and fleshy odor.
• Green fluid, meconium stain = hypoxia.
• After ROM check FHR.
• If have prolapsed cord, put in Trendelenburg position, lie on L side, or use sterile gloved hand to get presenting part off cord to relieve the pressure and then get ready for immediate C-section.
• Physical needs:
• massage to relieve back pain
• effleurage: gentle massage of abdomen; non-pharmacologic method of pain relief
• moist cloth to forehead
• good mouth care
• keep linens clean and dry
• change position
• baby in posterior position = lot of back pain

Dilate 8-10 cm.

Contraction frequency q 2-3 minutes.

Contraction duration 45-90 seconds.

This phase lasts 1-2 hours.

Metaphor to help remember phase 3: TIRED.

T: tires easily

I: inform mom of progress

R: restless

E: encouragement and praise

D: discomfort

Strong desire to push, only push when fully dilated.

Encourage to do breathing techniques (pant-blow- if not fully dilated).

May hyperventilate. S&S: dizzy, nauseated, tingling in fingers. Tx: breathe in paper bag, helps to re-breathe CO2 so won’t go into respiratory alkalosis.

May have chills, shaking, and diaphoretic due to labor process and being tired.

No meds at this time, causes sedation and respiratory distress in baby.

Give mom and significant other lots of support.

2. Second Stage of Labor.

Much shorter - lasts 1 hour.

Experience intense pressure on bottom (like a BM).

If no ROM, now is the time may be done artificially with an amnihook. Check FHR, can cause cord prolapse.

Crowning: fully dilated will see baby’s head pushing against the perineum.

Presenting part of baby goes under positional changes as it goes through the birth canal.

These changes are called "Mechanisms of Labor" or "Cardinal Movements". Remembered by:

Every Engagement

Darn Descent

Fool Flexion

In Internal rotate

Egypt Extension (restitution) head is out

Eats Raw External Rotation (shoulder rotation)

Eggs Expulsion

Nursing care:

• monitor v/s q 30 minutes
• monitor FHR q 5 minutes
• don’t let mom push until fully dilated
• episiotomy may be done
• as soon as the head is out check for the cord around the neck = Nuchal
• baby is suctioned = nose and mouth
• dry baby off quickly
• lay baby on mom’s abdomen
• when the cord stops pulsating, cut it
• taking care of mom and baby in this stage
• identification bands on baby and mom
• Apgar Scoring:
• Heart rate
• Respiratory rate
• Muscle tone
• Reflexes
• Color
• Immediate care for baby:
• place in trendelenburg
• provide oral and nasopharyngeal suctioning with a bulb syringe
• dry and stimulate to cry; keep warm
• apgar score
• apply umbilical cord clamp
• assess for physical abnormalities
• assess for vernix caseosa and lanugo
• apply ID bands to wrist and ankle
• take foot prints
• erythromycin ointment is put on eyes to prevent opthalmia neonatorium caused by gonorrhea

2. Placental Stage:

Begins immediately after the baby is born and ends when the placenta is delivered.

Lasts 5 min - 30 min.

Can see signs of placental separation:

Shape of uterus changes to like a globe.

Uterus will rise up in the abdomen.

Increase length in umbilical cord.

Gush of blood from the vagina.

Two methods of expulsion:

80% are shiney shultz = fetal side.

20% are dirty duncan = maternal side.

 

 

Blood loss is 250-500cc.

As soon as placenta is delivered mom is given Pit to cause uterus to contract and prevents hemorrhage.

Usually before Pit is given, get baseline v/s, especially BP and pulse.

Can give Ergotrate or Methergine (ergot derivitives) in the delivery room by IM injection.

Also get BP and pulse.

Will keep on these meds oraly q 4-6 hours for x amount of doses.

S/E to report:

HTN

H/A

Palpitations

Smoking is contra-indicated because nicotine is a vasoconstrictor.

Will have mild abdominal cramping.

3. Recovery Stage:

Begins after the delivery of the placenta and continues for 1-4 hours after delivery.

Mom’s physiological stability is restored.

Immediate care:

• BP, pulse and resps q 15 x 4 for 1^st hour, q 30 x 2, q 1 x2, q4.
• Palpate and massage fundus.
• Assessment of lochia.
• Assessment of episiotomy.
• Keep warm with blankets.
• Administer IV or IM oxytocin (or ergot).
• Assess and encourage mom/baby attachments.
• Assist with breast feeding if desired by mom.
• Assess bladder.
• Continuing Care:
• Settle in postpartum room.
• Continue v/s, fundal and lochial assessments.
• Encourage rest and sleep.
• Provide fluids and light meals, if desired.
• Encourage to empty bladder ASAP.
• Assess episiotomy.

Analgesia and Anesthesia:

Causes of Pain:

1. Dilation and effacement during the first stage. Felt in lower abdomen and back.
2. 2^nd stage pain results from pressure of the fetus on the vagina, bowel and bladder. Very acute.
3. Hypoxia in the uterus caused by compression of the uterine blood vessels and contractions to expel the placenta.

Benefits of pain control:

1. Breaks fear, tension and pain cycle.
2. Increases self esteem when you are in control.
3. Can be a more active participant.
4. Conserves energy.

Non-pharmacological pain control:

Pharmacological Pain Control:

1. Systemic analgesics:

1. Given in 1^st stage, active phase, 4-7cm dilated. Narcotics, demerol, nubain, stadol. Will not get it if delivery is expected in 1-3 hours. Variability of FHR does decrease. Monitor v/s closely. Respirations should = 12. Causes orthostatic hypotension. Monitor voiding. Give Narcan for respiratory depression.
2. Barbiturates: classification = sedatives and hypnotics. Do not typically give during labor. May give if delivery is in 24-48 hours. Respiratory distress in baby. Crosses placenta. No antidote. Decreased beat-to-beat variability.
3. Tranquizers: phenergan (promethezine) or vistiril (hydroxizine). Helps calm woman and when given with noracotics, less of the narcotic can be given.

1. Anesthesia;

Two types = regional and general (not used much).

Types of Spinals:

1. Intrathecal.

Med is given in the thecal space directly into the spinal canal of the subarachnoid space. The arachnoid space in the brain in between the dura and the pia and continues on down the spine.

Used to be called "saddle block". Usually numb from the waist down.

Xylocain, Lidocaine, or Marcaine is injected. Will make the woman numb. Put in the L4,L5 space.

Narcotics are also given intrathecal and removes the pain but mom can still move her legs.

Marcaine and Xylocaine mixed together makes it hyperbaric (heavy) and solution will stay low.

Can have a spinal headache if HOB is raised too high.

Once it takes effect, we don’t have to worry about the headache as much.

How to treat the headache: drink plenty of fluids to bring pressure up.

They can become hypotensive. Prevented by IV fluids before the spinal.

Used for episiotomy. Inject in the superficial tissue and nerves of the perineum.

Complications:

1. Pre-term or premature labor.

True labor that begins after the 20^th week and before the 37^th week.

These births are the leading cause of death in the newborn.

7 warning signs:

Often large babies and need to be checked for hypoglycemia (<45). Subject to cold stress because a large baby has a larger body surface but does not have a lot of subq fat. Ineffective thermoregulation mechanism. Poor nervous control. Increased metabolism, increased oxygen needs and baby goes into metabolic acidosis. Cold stress decreases production of surfactant.

Induction of labor.

Intentionally and deliberately stimulate uterine contractions.

When: post-term, diabetic at 36-38 weeks, PIH, intrauterine fetal demise.

Types:

1. Amniotomy.
2. Oxytocin infusion.
3. Prostiglandin gel or suppository.

Before induction is started, tests are performed to determine mother/fetus readiness to deliver.

• non-stress test
• ultra sound
• amniocentesis for L/S ratio
• check cervix for effacement

Stripping of the membranes is often performed in conjunction with pitocin administration.

Done by MD or midwife.

Membranes are separated and pulled down from the lower uterine segment without rupturing them.

The membrane and amniotic fluid act as a wedge to dilate the cervix.

Will start an IV and put pitocin in the IV.

Will start her off on pitocin drip.

Give lowest dose possible (0.5mU/min).

Will do for 15-20 minutes the up is 0.5mU.

Will do step by step until pattern of contractions are started every 2-3 minutes lasting 60 seconds.

Need one infusion with pitocin and one without.

Usually given oxygen.

Lie on L side.

Never leave her alone.

Side Effects of Pitocin:

P: pressure is elevated, pit is a stimulant.

I: intake and output, retained fluid.

T: tetanic contractions.

O: oxygen deceases in fetus.

C: cardiac arrythmias.

I: irregularities in FHR.

N: nausea and vomiting.