N12-MCN Labor and Delivery LABOR AND DELIVERY [Intrapartum] (11/16/11) Labor process by w/c the fetus and

d the products of conception are expelled as the result of regular, progressive, frequent contractions Theories of Labor: 1. Uterine Stretch Theory (prostaglandin cause uterine contractions) 2. Oxytocin Theory 3. Progesterone Deprivation Theory ( estrogen) progesterone, Platypelloid Passenger: Important Landmarks: Sinciput brow Bregma anterior fontanel Vertex area between anterior and posterior fontanels Lambda posterior fontanel Occiput occipital bone Mentum chin

4. Prostaglandin Cascade Theory (adrenal, uterus, fetus interact) Factors Affecting Labor: Passageway adequacy of pelvis, birth canal; ability of the uterine segment to distend, cervix to dilate, vaginal canal to distend Passenger fetus Power frequency, duration, strength of uterine contractions Placental factors site of placental insertion Psyche factors clients psychological state

Fetal Skull - Vault = 2 frontal bones + 2 parietal bones + occipital bone - Face - Base of skull *Sutures membranous spaces between cranial bones *Fontanels intersections of cranial structures Bregma Large, round Membranous floor Bounded by 4 bones Lambda - Small, triangular - Bony floor - 3 bones (occipital + 2 parietal) - Ossified by 8-12 weeks

- Ossified by 18 mos. or 1 y/o Passageway: Types of pelvis: - Gynecoid Android Anthropoid

1. Size of fetal head *Molding change in the shape of fetal skull 2. Fetal Presentation Cephalic (vertex, face, brow) Breech (frank, single or double footling, complete)

N12-MCN Labor and Delivery Shoulder (transverse lie) Cephalic: A. Vertex head completely flexed; suboccipitobregmatic diameter (smallest); presenting part: occiput B. Military occipitofrontal diameter; presenting part: top of head C. Brow head partially extended; occipitomental diameter (largest); presenting part: brow D. Face head completely extended; submentobregmatic diameter; presenting part: face/mentum Breech: 3 % According to attitude of fetus and hips; landmark: sacrum A. Complete knees and hips are flexed B. Frank hips flexed, knees extended C. Footling hips and knees extended single or double footling Shoulder presenting part: shoulder; landmark: acromion process of Scapula 3. Fetal Attitude relationship of fetal parts to one another 4. Fetal Lie relationship between the long axis of the fetal body to the long axis of womans body 5. Fetal position relationship of reference point of presenting part (O, S, Sc, M) and maternal pelvis (A, P) Power: Frequency Start of one contraction to the start of next contraction Duration start of one contraction to the end of the same contraction Intensity strength of contraction 3 Phases of Contraction: Increment longest, increase Acme peak Decrement decrease Premonitory Signs of Labor: *Lightening uterine and fetal descent into pelvic cavity; 23 weeks prior to labor *Braxton Hicks Contraction intermittent, irregularly occurring contraction *Cervical changes softening/ripening and effacement of cervix *Rupture of amniotic membranes * energy, tension/fatigue *Weight loss lbs 2-3 days prior to onset of labor *Urinary frequency *Backache True Labor vs. False Labor True Labor False Labor - regular - irregular - increasing frequency and intensity - shorter intervals - discomfort begins in back - discomfort in lower and radiates to abdomen abdomen and groin - continue while sleeping - sedation does not stop contractions - bloody show present - thinning and opening of cervix 6 Major concepts: - Labor should begin on its own - Women should be able to move about freely throughout the labor, not confined to bed. - Women should receive continuous support during labor - No intervention such as IV fluid should be used routinely

Women should be allowed to assume a non-supine position during delivery Mother and baby should be housed together after birth, with unlimited opportunity for breastfeeding

Stages of Labor: 1st Stage from the onset of contractions until cervix is effaced and dilated Latent phase 4-6 hrs; 3-4 cm Active phase 3-7 cm; rupture of membranes Transition phase 8 10 cm; complete cervical effacement and dilatation 2nd Stage (Expulsive Stage) begins with complete cervical effacement and dilatation and ends with the delivery of newborn within 1 hour after complete dilatation sever contractions; duration=50 90 secs, 2-3 mins interval *Station relationship of presenting part to the level of Ischial Mechanisms of Labor: Descent Flexion Internal Rotation Extension External Rotation Expulsion Caring: Preparing place of birth Positioning Perineal Cleaning Episiotomy surgical incision of perineum; midline or mediolateral - Ritgens Maneuver place a sterile towel over the rectum and press forward on the fetal chin while the other hand is pressed downward on the occiput *Perineum bulge, appears tense, anus become everted, stool may be expelled *Crowning 3rd Stage (Placental Stage) -

N12-MCN Labor and Delivery from the delivery of the newborn to the delivery of the placenta Signs that placenta has loosened: - Lengthening of the umbilical cord - Sudden gush of blood - Change in shape of uterus - Firm contraction of uterus - Appearance of placenta in vaginal opening Presentation of Placental Delivery: Schultze shiny and glistening (fetal portion) Duncan raw, red, and irregular (maternal portion) th 4 Stage from the delivery of placenta to 4 hrs after