LABOR & DELIVERY

Lecture 6

Introduction
Uterus: pear-shaped muscle made of 3 layers:
Endometrium inner lining - shed during menses.
Myometrium - muscle layer middle
Perimetrium - outer layer -extra support to whole
structure.
THEORIES of LABOR:
Combination of factors start labor:
Oxytocin & prostaglandin - most important
biochemical factors in stimulating uterine
contractions.
Estrogen uterus response & progesterone it.

THEORIES:

Oxytocin Stimulation: Term uterus sensitive to

oxytocin d/t pressure exerted on cervix by
fetus.
Progesterone Withdrawl: progesterone by fetus
& prostaglandins in chorioamnion results in
uterine contxs.
Estrogen Stimulation: progesterone allows
estrogen to contractile response of uterus.
Fetal Cortisol: Changes biochemistry of fetal
membrane: progesterone & prostaglandin in
placenta.
Distention: uterine muscles stretch causing
prostaglandin.
Amniotic membranes (sac) makes arachidonic
Acid Prostaglandin - ^ uterine contractility.

Premonitory signs of labor: weeks before real labor

AKA False Labor
Lightening: Fetus settles into pelvic cavity.
Braxton-Hicks: Irregular intermittent contractions; false
labor; DO NOT initiate true labor.
Cervical changes: cervix effaces [thins] & dilates slightly
Baby's head in pelvis pushes against cervix causing
relaxation and effacement.
Burst of Energy: Nesting instinct; cleans house, sets up
nursery. epinephrine resulting from progesterone
Cervix in posterior position.

Signs True Labor: closer to time of delivery

Uterine Contractions: regular & frequent compared to

Braxton-Hicks. Stronger w. time.
Bloody Show: pink tinged secretions d/t softening
cervix.(aka mucous plug)
Rupture of Membranes: (ROM) Labor in 24 hrs.
Multiparas sooner. Big gush or slow trickle.
Clear/odorless. Green/brown, danger sign
Meconium aspiration > distress/infection.
Immediate medical attention.

PROM or prolonged ROM intrauterine infection

[pathogens reach fetus]

Difference Between True & False Labor:

True Labor
A. regular contxs
B. discomfort begins in back & spreads to abdomen.
C. progressive cervical dilation/effacement
D. Interval between contx.s become shorter
E. intensity of contx.s with ambulation
F. contx.s in duration & intensity
False Labor
A. irregular contx.s
B. discomfort localized in abdomen
C. no change
D. No change
E. Ambulation has no effect
F. No change

STAGES of LABOR
4 in All !

First Stage
Onset of true labor to complete dilation = 10 cm.
~ 6-18 hrs. primapara; 2-10 hrs. multipara.
Cervix becomes more anterior.

3 phases: Latent, Active, Transitional.

Latent: Dilation 0-3 cms. Contx.s mild/irregular.
Active: 4-7 cms. Contx.s 5-8 min. apart.
Lasts 45-60 sec; moderate - strong intensity.
Transitional: Dilation 8-10 cms. Contx.s 1-2
min. apart; 60 90 sec.; strong intensity.
No pushing til fully dilated.

Second Stage: Birthing of Baby

Delivery of infant:
up to 1 hr. or ~ 20 contxs primip.
20 min. or ~ 10 contxs in multip. Can last up to 3 hrs.!
Cardinal movements occur here.
Most difficult & uncomfortable part of labor.
Crowning occurs at +4 -+5 station.
Strong urge to push & bear down as infant passes through
vagina & rectum may have BM.
Positions: Sitting, Side Lying, Standing, Squatting, All Fours,
Kneeling.

Crowning - External view

Cardinal Movements - Internal motions

Third Stage
Delivery of placenta ~ 5 - 30 min.
Separation should be automatic [uterus contracts & mom
bears down]
Dont palpate non-contracted uterus possible eversion.
Maternal vessels still open.

MD/MW presses on contracted uterus. Credes

Maneuver
Pitocin > placenta delivered to avoid retained placenta.
If no spontaneous delivery of placenta, manually removed.

Antibiotics

Fourth Stage
Placenta out; mother recovers in LDR
Labor, delivery, & recovery
Lasts ~ 1 hr. unless complications arise.
Then pt. transferred to PP unit.

Nursing Interventions During Labor

Triage - Admit client to birthing area

[MD determines true labor]

Emotional support & encourage rest
Progress of labor
Monitor/document contractions & FHR q 15 min.

Monitor/document maternal VS q 1 - 4 hr

Assess

pain & provide pain relief as

prescribed .

Nursing Interventions Cont.

* Provide comfort measures [back rub, ice chips]
* Explain equipment & procedures.
* Observe & document time of ROM

Supine hypotension Position on side - pressure

off vena cava
Role of coach during active/transitional stages
Assist with pushing during 2nd stage.
Record time of delivery, Apgar score,
spontaneous cry, & resuscitative efforts to infant
Monitor infant for extrauterine life adjustment
Encourage family bonding > delivery

Breathing Techniques
Slow chest: 6-12 easy breaths/min. Used in early labor.
Combination: quicker, lighter breaths
Used during active labor; one slow breath in beginning &
quicker breaths to follow.
Pant-Blow: 3 - 4 quick breaths, with forceful exhalation.
Used @ end of 1st stage when contx.s strongest.

Elimination
Monitor UO q 2-4 hr.
Pressure of fetal head reduces bladder tone.
Full bladder > inhibits labor.
Catheterize. Remove > delivery.

Hydration
IV to hydrate; pt. diaphoretic & NPO x ice chips.
Lactated ringers; good volume expander.

Assessing Progress of Labor

Dilation: 010 cm. [opening cervix]

Effacement: 0 100 % [thinning cervix]
Station: Relationship of presenting part to pelvic
ischial spines -midway in pelvic cavity.
0 station aka engaged.
-1 to -5 above 0
+1 to +5 (outlet) below 0
+4/+5: baby's head out.

Mechanism of Labor: passage of fetus thru birth

canal involves position changes called: Cardinal
Movements of Labor: mechanical & spontaneous. 2nd stage
Engagement: presenting part enters midpoint of pelvis @
ischial spines.
Descent: downward movement thru pelvic inlet,
thru dilated cervix, reaches posterior vaginal
floor. Mom feels like pushing. Widest part [head] passed
thru pelvis. active forces of labor.
Flexion: pressure from pelvic floor causes head to
flex towards chest; chin touches chest.

Internal Rotation: occiput [back of head] in

diagonal position & rotates towards face down
position. / to (occurs as body parts press on bony pelvic
structures)

Extension: top of head delivered & extends as

face & chin are delivered.
External Rotation: head rotates back to
previous lateral position. Rest of body is
delivered.

Factors affecting labor process:

4 Ps [Powers of Labor]
Passenger
Passageway
Powers
psyche

Passenger: [infant]
Fetal head: widest part of body; most difficult to pass
thru vaginal canal; passage depends on bones, sutures,
fontanelles.
Cranium - 8 bones meet @ suture lines
Cranial bones move & overlap, allows skull to pass thru
birth canal.
Fontanelles: soft spaces created by junctures of suture
lines - covered by membranes; compress during delivery
to aid in passage of fetus.
Molding of infant head.

Passenger cont.
Skull widest @ antero-posterior diameter [front
to back] than @ transverse diameter [across].
Antero-posterior diameter measures differently
@ different locations.

Occipitomental diameter- widest - measured from chin to

posterior fontanelle = 13.5 cm
Smallest diameter - lower occiput to anterior fontanelle
(suboccipitobregmatic) = 9.5 cm
Complete flexion allows smallest diameter of fetal
skull to enter pelvis most easily.

B. Fetal Attitude: degree of flexion of fetal

head; chin touches sternum.
Complete flexion: allows smallest diameter of skull
to pass thru pelvic cavity. Best position!
Moderate flexion: head less flexed making
diameter wider (aka military or neutral)
Poor flexion: brow or face presentation; presents
skull diameter too wide making delivery difficult.

Friedmans Curve

Friedman's Curve describes progress of two variables

over time: dilation of cervix and descent of baby.

Labor is dysfunctional when cervix stops dilating or

fetal descent stops or both.

Possible diagnosis of "failure to progress"

C-section indicated.
Maybe due to CPD (cephalo pelvic disproportion or
epidural anesthesia (can slow labor).

C. Fetal lie: [position of fetus in utero] relationship of long

axis of fetus [spine] to long axis of mother:
1. Longitudinal vertex/breech; vertical in
relation to mom; ~ 99%.
2. Transverse horizontal in relation to mom; < 1 %.
C/S; ^ in grand multip stretched uterine muscles; try
version.
3. Oblique - diagonal
D. Fetal presentation: part of fetal head enters pelvis;
1. Cephalic 95.5%
2. Breech 3.5%
3. Face 0.3%
4. Shoulder 0.4% [transverse lie]

E. Fetal position: occiput is landmark

Described in 3 letters:
1st : presenting part in relation to mothers R or L.
Middle: presenting part [occiput, mentum, sacrum]
Last: landmark is anterior, posterior, transverse in relation
to mothers spine. Anterior (A) back of head against
symphysis pubis & face towards spine. Posterior (P) Back
of head = mothers spine; painful contxs. Transverse (T)
= fetus sideways.
Common positions in vertex presentations: *LOA, ROT,
ROP, ROA, LOT, LOP.

Passageway:
Refers to fetus passing thru uterus, cervix, vaginal
canal. Single most important determinant to mechanism
of labor.

A. 4 Types of pelvis:

1. Gynecoid 50% of women; rounded, oval

shape; easy vaginal delivery; considered normal
female pelvis

2. Android 20 % of women; vaginal delivery difficult;

prob. C/S; true male pelvis

3. Anthropoid oval; assisted vaginal birth usually with

forceps; 20-25%

Platypelloid < 5 % of women;

flattened pelvis; vag. del. difficult

4.

B. Structure of Pelvis: bones held together by

ligaments. Supports/protects organs inside.

False Pelvis: Outer - broader. Hip bones.

True Pelvis: Internal narrower. Holds bladder, rectum, &
reprod. Organs.
True pelvis - 3 parts - inlet, midpelvis, outlet.
[Most important in childbirth]

If pelvis too small, home birth not done.

CPD - cephalopelvic disproportion > C/S.

PELVIC INLET:
Antero-posterior diameter - front to back ~ 12.5
cm. (diagonal conjugate)

True conjugate - actual opening of outlet.

Subtract width of symphysis pubis [1.5 cm] from
diagonal conjugate. 12.5 1.5 = 11.0 cm.
(complete flexion = 9.5cm diameter)
Transverse diameter [across] ~ 13.5 cm

MIDPELVIS: narrowest part of pelvis that fetus

must pass through - ischial spines
PELVIC OUTLET: Trouble passing through pelvic
opening, pelvis too small or poor fetal attitude.

Soft Tissue: Ligaments, Uterus, cervix, vaginal

canal

Powers:
Uterine contxs: primary force moving fetus thru
maternal pelvis during 1st stage of labor.
Maternal Efforts: woman adds voluntary pushing
force to force of contx.s during 2nd stage of
labor to propel fetus thru pelvis.

Psyche:
Psychologic Response to birth process:
Prepared for childbirth - Childbirth classes-Prenatal care.
Previous childbirth experience - Complicated?
Support from significant other - Separated? Marital
strain? FOB involved? Abuse?
Emotional status - anxious/depressed, drug use, psych
hx
Culture - background may influence response to pain.
Some moan, some stoic, some verbally expressive.
Fear/anxiety exacerbate pain uterine dysfunction &
ineffectual labor & posttraumatic stress disorder

Maternal/Fetal Evaluation
During Labor
With Electronic
External/Internal
Monitoring

EFM electronic fetal monitoring

Measures:
Fetal Heart Rate (FHR) and Uterine Contractions (UC)
External Toco (UC) and Cardio (FHR)
Toco transducer uses graph paper [60 sec intervals]
UC assessed for intensity, length, frequency.
Abdominal palpation. Uterus hard then soft.

3 Phases of UC:
a. increment
b. acme [peak]
c. decrement
As contractions intensify, labor progresses.
Vaginal Exam - dilation, effacement, station, &
presentation.

Assessment:
Intermittent - 20 minute tracing standard.
Continuous - for active labor or with complications.
Duration: beg. of contx. to end of same contx.
Lasts ~ 30 sec. [early] to ~ 60 sec. [active].
Frequency: beg. of one contx. to beg. of next.
~ q 5 -30 min. early labor; q 2-3 min. active labor.
Resting Tone: period of uterine rest bet. contx.s.
Measure by palpation; internally measures ~10 mmHg.

Be Careful Not To.

Rely

on verbal clues from mother regarding

contractions & labor progress.
Misleading, giving false impression of good
labor pattern.
Contractions may be more or less intense
than what pt. reports.
RN may miss forceful contractions d/t
excellent coping skills or high pain tolerance

External Fetal Monitoring

Also Records:

Fetal Heart Rate (cardio transducer) FHR

Advantages:
Evaluates contractions & FHR
Provides written record of both
Disadvantages:
May be inaccurate due to maternal/fetal
movements.
Need experienced clinician to read otherwise info
can be misinterpreted.

Internal Monitoring
More Accurate !
Fetal scalp electrode: wire electrode attached to scalp of
fetus -monitors FHR accurately & continuously.
Advantages: precise assessment of FHR; not affected by
fetal movement.
Disadvantages: lacerations of fetal scalp, mom cant
ambulate.

IUPC -intrauterine pressure catheter inserted into

uterine cavity to monitor contx.s
precisely/continuously.
Advantages: precise assessment of maternal
contractions. Mom can turn side to side.
Measures Intensity: strength of UC internally
[30-50mmHg during peak of contx]
Disadvantages: risk of maternal infection, mom cant
ambulate.

Fetal Heart Rate

Baseline average fetal heart rate that occurs
between contx.s during 10 min. period.
Normal 110/120 - 160 [accels/decels not counted]
Bradycardia FHR < 110 for 10 minutes;
<100bpm sign of fetal hypoxia; danger sign.
Seen with prolapsed cord

Tachycardia FHR > 160 for 10 minutes.

assoc. with maternal temp. and infection such as
chorioamnionitis.

Variability [FHR] aka Baseline Variability

Fluctuations in FHR. Normal & expected

finding. Should always be present; appears as jitters.
Clinical Significance- fetal well-being.
Caused by natural pacemaker ability of FH d/t
effects of sympathetic & parasympathetic
nervous system.
Nursing Interventions- cont. monitoring & assess
tracing q 15 min. Should show 6-25 bpm
fluctuations within one min. period.
120 135 reassuring

Main Causes of decreased variability include:

Hypoxemia/acidosis (due to fetal distress)
Fetal sleep cycles
Drugs (Analgesics, barbiturates, tranquilizers, anesthetics)
Prematurity
Arrhythmias
Fetal tachycardia
Preexisting neurological abnormality
Congenital anomalies

Decreased variability of FHR

Nursing Interventions:
* accoustic stimulation to wake fetus
* Narcan
* Amnioinfusion - decreases cord comp; dilutes mec.
* Left/right lateral position or knee-chest; notify MD;
fetal scalp pH, possible emergency C/S; IVF, O2
Flat tracing or minimal aka non-reactive tracing
[pencil mark pattern] indicates fetal distress; must be
corrected or delivered ASAP. Experienced RN usually able
to determine reason for non-reactive tracing.

How Do Uterine Contractions Affect Fetal Heart Rate?

Uterine contractions can affect fetal heart rate by increasing or decreasing that rate in association with any given contraction.
The three primary mechanisms by which uterine contractions can cause a decrease in fetal heart rate are compression of:

Fetal head compression

Umbilical cord compression
Uterine myometrial vessel compression

Decelerations: decreases in FHR.

Early deceleration of FHR- periodic in FHR
Cause = head compression during contx.s
Shape= onset of decel to peak > than 30 sec.
Nadir of decel (lowest point) & peak of contx. (highest
point) coincide. Mirror image of contx.
Range= lasts as long as contx.; resolves with end of
contx. Occurs late in labor when head has descended.
Clinical Significance= normal; if it occurs early in labor
before head fully descends, may be indication for
cephalo-pelvic disproportion [CPD].

Late deceleration of FHR:

Cause= uteroplacental insufficiency or blood

flow thru uterus during contx.s
Shape nadir of decel. occurs > end of contx.
range - occur 30-40 seconds > contx. starts &
continue > contx. ends
clinical significance needs immediate attention;
possible fetal distress. Could be d/t pitocin that is
causing hypertonic uterus.[ too many contx.- no
time for recovery]

Nursing Interventions:
-Left lateral position takes pressure
off aorta & vena cava; circulation to
uterus.
- IV flow rate Circulation
oxygen - face mask [5liters/min].
D/C pitocin & document
assist with fetal blood sampling
[measures acidosis in fetus which
signifies hypoxia]
Prepare for emergency C/S if decels.
persist

Variable deceleration of FHR

Cause: compressed umbilical cord
Shape U or V shaped waves in FHR
Range no pattern; occur in relation to contx.s
Clinical Significance fetus lying on cord; could be
dangerous if persist.
Occurs more > ROM [less fluid as cushion]
V = C variable decels = cord compression
E = H early decels = head compression
A = O accelerations = OK
L = P late decels = Placental insufficiency
Bradycardia = R/O prolapsed cord [emergency]!

Nursing Interventions

oxygen via face mask; IV fluids

change maternal position; take pressure off
cord
continue monitoring w.EFM
follow hospital protocol: MD will do
amnioinfusion > ROM to supplement amniotic
fluid thats left; provides fluid barrier to prevent
further cord compression.
Sterile, warm 500 ml NS/RL inserted into uterus
EFM observed for improved FHR pattern.

4. Accelerations of FHR: temporary abrupt increase in

FHR above normal baseline.
cause- fetal movement; contractions *
shape-FHR rises w. return to baseline; can occur @
same time as contx. or independently.
Premie < 32 wks.; 10 bpm rise lasting 10 sec. ok
32 wks. or >, 15 bpm rise baseline lasting 15 sec. ok
ex. 135 to 150s for 30 seconds.
clinical significance: normal; signifies fetal well-being.
FHR meeting demands of labor process well.

Fetal Blood Sampling- assesses fetal hypoxia; from fetal

scalp [cervix dilated 3-4 cm]. Clean scalp w. iodine.
Results: 7.25ph > normal
7.20 -7.24 preacidotic
< 7.2 + acidosis; indicates hypoxia [ O2]
Role of Coach in Labor & Delivery

emotional support
physical support touch, massage
reduce anxiety
bonding with newborn as a couple

Obstetrical Procedures

Episiotomy: incision on perineum to

enlarge vaginal outlet. New trend: not done
routinely.

Types:

(in 2nd stage)

Median vertical incision.

Medio-lateral slanted to R/L of perineum; done
if tear anticipated.
Advantages: median or midline epis.
medio-lateral prevents tearing towards
rectum. Less chance of laceration.
Disadvantages: medio-lateral -longer
to heal.

Forceps: double bladed instrument to assist passage of

fetus. Not routinely done today.

When 2nd stage labor has stopped d/t epidural

Infant in abnormal position; posterior position in birth
canal; macrosomia.

[Outlet] Low forcep delivery: fetal head @ + 2, +3

station. Some anesthesia used.
Midforceps & High forceps: not done ^ birth trauma.

Cervical lacerations; Newborns > facial palsy or subdural

hematoma; forcep marks on face.

Vacuum Assisted Delivery:

disk shaped cup placed on scalp & vacuum
pressure applied; pull will deliver infant.
No anesthesia - fewer cervical lacerations.
Not done in preterm infants d/t soft skull.
Used in C/S.
Not used > scalp pH done; risk for hematoma
[vacuum pressure].
Can cause caput for ~ 1 wk. Used
w.macrosomia.

VBAC [vaginal birth after cesarean]

OK after low abd. incision; Not after classical
incision - risk for uterine rupture.
New Trend: not routinely done anymore. ** Pros & cons

1st baby: breech, fetal distress, pre-eclampsia

Should space deliveries ~18 mos. apart. to
prevent rupture

Types of Uterine Incisions:

Low transverse = Pfannenstiel = bikini cut.
Most desired & less visible. Right above pubic bone.
Vertical=classical incision. Visible scar; emergency
cases; crash C/S. Quick access to baby.

Cesarean Delivery ( C-section)

Major Indications for C/S:

Active genital herpes or overgrowth of genital warts

HIV infection
CPD (cephalopelvic disproportion)
Severe HTN (toxemia)
Failure to progress with labor
Previous C/S with classical incision (vertical)
Placenta previa
Placental abruption separation of placenta from uterus
Cord Prolapse; Macrosomia = large fetus
Breech positions; Fetal Distress & Transverse fetal lie

Induction of Labor: start labor. Goal: NSVD

Without Meds.- Natural
Amniotomy: Artificial ROM; amnio hook; break sac.
Monitor for poss.prolapsed cord.
Continue EFM. Usu.starts contx.s & labor
progresses [@ 3 cm dilation]

With Meds. Pitocin drug of choice. 1/3 rd deliveries @

term in US done by induction. Reason: Life in uterus no longer
beneficial

*Fetal maturity 39 wks, post dates 41-42 wks.

*Cervical Readiness- ripe; 3 cm. dilated.
*Longitudinal lie; presenting part engaged
*Fetal Demise, Arrest of Labor
Induction - give Pitocin IVPB, ^ slowly as labor
progresses; shut off if contxs too strong. Need MD
order.

Augmentation: assisting labor thats in progress.

Pitocin used.

Contraindications:

Maternal: placenta previa; active herpes; structural

abnormalities; previous vertical uterine scar
Fetal: transverse or breech; fetal distress; premie.

Nursing Interventions:
IVF 10 units Pitocin in 1000 ml. RL
Start rate @ 1 milliunit/min - pump
Gradually to establish effective contx. pattern
Monitor UC for frequency, rate, intensity
Monitor FHR for signs of fetal distress
Maternal BP, pulse, temp
I&O
Notify MD of progress
Chart q 15 min on graph
Prepare for delivery: radiant warmer, O2, suctioning,
Hyper-stimulation of uterus; shut off pitocin as per MD.

Bishops score: determines cervical readiness for

induction; looks at 5 factors. Score 8 favorable.
Multip can be induced @ 5
Primip can be induced @ 7
Uterus/cervix should respond to induction.
Score < 5 low probability of success. Ripen cervix 1st.

Bishop Scoring System - evaluates cervical readiness

for induction. 5 elements measured:
Score Cervical Cervical Station Cervical
Position
dilation effacement
consistency
_______cm.________%_______________________________
0
closed
0-30
-3
firm
posterior

1-2

40-50

-2

3-4

60-70

-1, 0

>5

>80

+1, +2

medium

mid

soft

anterior

Cervical Ripening: Artificial softening of cervix before

labor.
Prostaglandin gel 0.5mg.or dinoprostone 10mg.=[cervidil]
2-3 times q 12 for max. of 24 hrs.
* Done if cervix unripe or thick & undilated.