Nursing Care of a

CHAPTER 15

Family During
Labor & Birth
GROUP 10

MAGUINDANAO AMILYN L.
MADID RIHAM M.
MACARIMBANG SAHANERAH M.
LABOR
● Is the series of events by which uterine
contractions and abdominal pressure expel a
fetus and placenta from the uterus

● Regular contractions cause progressive

dilatation of the cervix and create sufficient
and muscular uterine force to allow a baby to
be pushed out into the extrauterine world
 THEORIES OF WHY LABOR BEGINS
Labor normally begins between 37wks & 42wks of pregnancy, when a fetus
is sufficiently mature to adapt to extrauterine life, yet not too large to cause
mechanical difficulty with birth.

SOME OF THE THEORIES INCLUDE;

 the uterine muscle stretches from the increasing size of the fetus, which
result in release of prostaglandins.
 The fetus processes on the cervix, which stimulate the release of oxytocin
from the posterior pituitary.
 Oxytocin stimulation works together with prostaglandins to initiate
contractions.
 The placenta reaches a set age, which triggers contractions.
 Rising fetal cortisol level reduces progesterone formations & increase
prostaglandin formation.
 THE COMPONENTS OF
LABOR
A successful labor depends on four integrated concepts, often referred to as
the four Ps.

1. The passage (a woman pelvis) is adequate size and contour.

2. The passenger ( the fetus) is appropriate size and in an
advantages position and presentation.
3. The powers of labor (uterine factors) are adequate.
4. The psyche, or woman psychological state which may either
encourage, or inhibit labor.
1. THE PASSAGE
The passage refers to the route a fetus must travel from the
uterus through the cervix and vagina to the external
perineum.
 2. THE
PASSENGERS
STRUCTURE OF THE FETAL SKULL – the cranium, the uppermost portion
of the skull, is composed of eight bones.
DIAMETERS OF THE FETAL SKULL - the shape of a fetal skull causes it
to be wider in its anteroposterior diameter than in its transverse
diameter.
 MOLDING- is overlapping of skull
bones along the suture lines, which
causes a change in the shape of
the fetal skull to one long and
narrow, a shape that facilitates
passage through the rigid pelvis.

 FETAL PRESENTATION AND

POSITION- other factor that play
in whether a fetus is properly
aligned in the pelvis and is in the
best position to be born are

1. Fetal attitude
2. Fetal lie
3. Fetal presentation
● FETAL PRESENTATION-
demotes the body part
that will first contact the
cervix or be born first and
is determined by the
combination of fetal lie
and the degree of fetal
flexion (attitude).

1. Cephalic
presentation- is the
most frequent type of
presentation,
occurring as often as
96% of the time.
2. BREECH PRESENTATION- means either the buttocks or the
feet are the first body parts that will contact the cervix.

Type Lie attitude Type Lie attitude Type Lie attitude

Complete longlitudin Good frank longlitudin Moderat Footling longlitudina poor

al al e l
3.SHOULDER PRESENTATIONS- in a transverse lie,
a fetus lies horizontally in the pelvis so the longest
fetal axis is perpendicular to that of the mother.
FETAL POSITION- is the
relationship of the presenting
part to a specific quadrant and
side of a woman’s pelvis. For
convenience, the maternal
pelvis is divided into four
quadrants according to the
mother’s right and left (a); right
anterior, (b) left anterior, ©
right posterior, and (D) left
posterior.
FETAL POSITIONS
 ENGAGEMENT- refers to the settling of the presenting part of a fetus far
eno8ugh into the pelvis that it rests at the level of the ischial spines, the
midpoint of the pelvis.
 STATIONS- refers to the relationship for the presenting part of the fetus to
the level of the ischial spines.
MECHANISM ( CARDINAL
MOVEMENTS) OF LABOR

– effective passage of a fetus through the

birth canal involves not only position and
presentations but also a number of
different position changes in order to keep
the smallest diameter of the fetal head
always presenting to the smallest diameter
of the pelvis.

These positions changes are termed

The CARDINAL MOVEMENTS OF LABOR
 3. THE POWER OF LABOR
 The third important requirements for a successful labor is effective powers of labor. This is
the force supplied by the fundus of the uterus and implemented by uterine contractions,
which causes cervical dilatation and then expulsion of the fetus from the uterus.

 UTERINE CONTRACTIONS- during pregnancy, the uterus begins to contract and relax
periodically as if it is rehearsing for labor.

1. ORIGINS – like cardiac contractions, labor contractions begins at a “pacemaker” point

located in the uterine myometrium near one of the uterotubal junctions.

2. PHASES – a contraction consists of three phases; the increment, when the intensity of
the contraction increases, the acme, when the contraction is at its srongest; & the
decrement, when the intensity decreases

3.CONTOUR CHANGES- as labor contractions progress and become regular and strong.
 3. THE POWER OF LABOR
 CERVICAL CHANGES- even more marked than the changes in the body of
the uterus are two changes that occur in the cervix

1. EFFACEMENT – is shortening and thinning of the cervical canal.

2. DILATATIONS- refers to the enlargement or widening of the cervical canal

from an opening a few mm wide to one large enough.
Effacement and
dilation of the cervix
4. THE PSYCHE
The fourth “P” or a woman’s psychological
outlook, refers to the psychological state or
feelings a woman brings into labor.
.
THE
STAGES
Labor is traditionally divided into three stages:

OF LABOR
• The first stage of dilatation, which begins with
the initiation of true labor contractions and ends
when the cervix is fully dilated
• The second stage, extending from the time of
full dilatation until the infant is born
• The third or placental stage, lasting from the
time the infant is born until after the delivery of
the placenta
• the “fourth stage” to emphasize the
importance of close maternal observation
 THE FIRST STAGE
1. LATENT 2. ACTIVE 3. TRANSITION
During the active Contractions reach
The PHASE
latent or early phase
STAGE
of labor, their
PHASE
peak of
phase begins at the
cervical dilatation intensity, occurring
onset of regularly
perceived uterine occurs more rapidly. every 2 to 3 minutes
contractions and Contractions grow with a duration of 60
ends when rapid stronger, lasting 40 to to 70 seconds, and a
cervical dilatation 60 seconds, and occur maximum cervical
begins. approximately every 3 dilatation of 8 to 10
to 5 minutes. cm occurs
 THE SECOND
STAGE
● the time span from full dilatation and cervical effacement to

birth of the infant. A woman typically feels contractions change

from the characteristic crescendo–decrescendo pattern to an
uncontrollable urge to push or bear down with each contraction as if
to move her bowels.
The third stage
 Placental Separation - As the uterus
contracts down on an almost empty interior,
there is such a disproportion between the
placenta and the contracting wall of the
uterus that folding and separation of the
placenta occur.
 Appearing shiny and glistening from the
fetal membranes, this is called a
Schultze presentation

 It looks raw, red, and irregular, with the

ridges or cotyledons that separate blood
collection spaces evident; this is called a
Duncan presentation
 THE MATERNAL PHYSIOLOGIC EFFECTS
AND PSYCHOLOGICAL RESPONSES
• The response to pain
• The response to
fatigue
• The response to fear
FETAL RESPONSES TO
LABOR
● The neurological

system
● The cardiovascular

system
Measuring Progress
in labor
MATERNAL DANGER SIGNS OF LABOR
● High or Low Blood Pressure
● Abnormal Pulse
● Inadequate or Prolonged Contractions
● Abnormal Lower Abdominal Contour
● Increasing Apprehension

FETAL DANGER SIGNS OF LABOR

● High or Low Fetal Heart Rate
● Meconium Staining
● Low Oxygen Saturation
MATERNAL AND FETAL ASSESSMENTS OF
A WOMAN IN FIRST STAGE OF LABOR
THE DETAILED ASSESSMENT DURING
THE FIRST STAGE OF LABOR

The History
 Current Pregnancy History
 Past Pregnancy History
 Past Health History
 Family medical health
MATERNAL AND FETAL ASSESSMENTS OF
A WOMAN IN FIRST STAGE OF LABOR
The Physical examination
 Abdominal and Lower Leg Assessment
Assessing a woman’s abdomen is important to estimate fetal
size by fundal height (which should be at the level of the
xiphoid process at term)
 Determining Fetal Position, Presentation, and Lie
our methods can be used to determine if the fetus is in an optimal position for birt
• Determining the place on the woman’s abdomen where fetal heart tones are
heard strongest
• Abdominal inspection and palpation, called Leopold maneuvers
• Vaginal examination
• Sonography
MATERNAL AND FETAL ASSESSMENTS OF
A WOMAN IN FIRST STAGE OF LABOR
2. Leopold 3. The vaginal 4. Sonography
maneuvers examination
MATERNAL AND FETAL ASSESSMENTS OF
A WOMAN IN FIRST STAGE OF LABOR
5. Assessing 6. Assessment of 7. Vital signs
rupture of pelvic adequacy ○ Termperature
membranes ○ Pulse and respiration
○ Blood pressure
8. Laboratory analysis
○ Blood
○ Urine
 The assessment of urine
contraction
Length of Contractions

Intensity of Contractions
The intensity of a contraction refers to its strength
● Mild, if the uterus does not feel more than
minimally tense
● Moderate, if the uterus feels firm
● Strong, if the uterus feels as hard as a wooden
board or you are unable to indent the uterus with
your fingertips at the peak of the contraction

Frequency of Contractions
Frequency is timed from the beginning of one
contraction to the beginning of the next
THE INITIAL FETAL
ASSESSMENT
● Auscultation of
Fetal Heart Sounds
Fetal heart sounds are
transmitted best through the
convex portion of a fetus
because that is the part that
lies in closest contact with the
uterine wall.
 ELECTRICAL
●MONITORING
Initial Electronic Monitoring
Electronic monitoring is noninvasive, easily applied, and does not
require cervical dilatation or fetal descent before it can be used, so it
can be introduced at any time during labor.
● A pressure transducer or tocodynamometer (toko is Greek for
“contraction”) strapped to the woman’s abdomen or held in place by
stockinette
FETAL HEART RATE AND UTERINE
CONTRACTION Labor monitors trace both the FHR
and the duration and interval of
uterine contractions onto an
oscilloscope screen and produce a
permanent record on paper rolls
(Fig. 15.17)
 FETAL HEART RATE
PAPRMETERS
The Baseline Fetal Heart Rate
A baseline FHR is determined by analyzing the pace of
fetal heartbeats recorded in a minimum of 2 minutes
obtained between contractions. A normal rate is 110 to
160 beats/min.
Variability
Variability should be recorded as:
• Absent: No amplitude range is detectable.
• Minimal: Amplitude range is detectable but is 5
beats/min or fewer.
• Moderate (normal): Amplitude range is 6 to 25
beats/min.
• Marked: Amplitude range is greater than 25 beats/min.
FETAL HEART RATE
PAPARMETERS
Periodic changes
Periodic changes or fluctuations in FHR occur in response to contractions
and fetal movement and are described in terms of accelerations or
decelerations.
1. Accelerations
2. Decelerations- Decelerations are visually apparent, usually
symmetrical, periodic decreases in FHR resulting from pressure on the
fetal head during contractions
 Late Decelerations- Late decelerations are those in which the onset, nadir, and
recovery of the deceleration occur after the beginning, peak, and ending of the
contraction, respectively
 Prolonged Decelerations- Prolonged decelerations are decelerations that are a
decrease from the FHR baseline of 15 beats/min or more and last longer than 2 to 3
minutes but less than 10 minutes. They generally reflect an isolated occurrence,
but they may signify a significant event, such as cord compression or maternal
hypotension.
 Variable Decelerations- The pattern of variable decelerations refers to
decelerations that occur at unpredictable times in relation to contractions. They
may indicate compression of the cord, which can be an ominous development in
terms of fetal well-being
The Care of a Woman During
the First Stage of Labor
 Labor and birth are natural processes, so the
average woman should be able to complete
labor and birth without assistance from medical
interventions.
Six major concepts that make labor and birth as
natural as possible include the following:
• Labor should begin on its own, not be artificially induced.
• Women should be able to move about freely throughout labor, not
be confined to bed.
• Women should receive continuous support from a caring support
person during labor.
• No interventions such as intravenous fluid should be used routinely.
• Women should be allowed to assume a nonsupine position such as
upright and side lying for birth.
• Mother and baby should be housed together after the birth, with
unlimited opportunity for breastfeeding.
The Care of a Woman During the Second
Stage of Labor
 The second stage of labor is the time from full cervical dilatation
to birth of the newborn.
 Even women who have taken childbirth education classes and who
believe they are well prepared for any length or type of contractions
are surprised at the intensity of the pushing sensation they feel in
this stage of labor.
 If the woman has not received an epidural for pain management, she
should push with contractions and rest in between.
 In the past, women were told to hold their breath while they did this.
A General Timetable for Second-
Stage Care
 PREPARING THE PLACE OF BIRTH
 POSITIONING FOR BIRTH
-The Water Birth
 PROMOTING EFFECTIVE SECOND-STAGE
PUSHING
 PERINEAL CLEANING AND MASSAGE
 THE BIRTH
 CUTTING AND CLAMPING THE CORD
 INTRODUCING THE INFANT
The Care of a Woman During the Third and
Fourth Stages of Labor
 The third stage of labor is the time from the birth of the baby until
the placenta is delivered.
 For most women, this is a time of great excitement because the infant
has been born, but this can also be a time of feeling anticlimactic
because the infant has finally arrived after being anticipated for so
long a time.
 The fourth stage of labor includes the first few hours after birth.
 THE DELIVERY OF THE PLACENTA

 THE PERINEAL INSPECTION

 THE IMMEDIATE POSTPARTUM

ASSESSMENT AND NURSING CARE
The Woman With Unique Concerns in
Labor
THE WOMAN WITHOUT A SUPPORT PERSON

THE WOMAN WHO WILL BE PLACING HER BABY FOR

ADOPTION

THE WOMAN WITH CULTURAL CONCERNS

THE WOMAN WHO IS MORBIDLY OBESE