Women’s Health Exam 1
LABOR AND BIRTH PROCESSES / NURSING CARE DURING LABOR & BIRTH
OBJECTIVES
Describe the process of labor and the major factors affecting it and the associated nursing interventions that enhance labor
progress.
Describe maternal and fetal adaptations to labor.
Develop a plan of care that enhances labor progress for labor and birth.
Review the factors included in the initial assessment of the woman in labor.
Describe the ongoing assessment of maternal progress during the first, second, and third stages of labor with and without risk
factors identified.
Recognize the physical and psychosocial findings indicative of maternal progress during labor.
Describe the influence of cultural and religious beliefs and practices on the process of labor and birth.
Discuss ways the nurse can use evidence-based practices to enhance the quality of care a woman receives during labor and
birth.
Quick Overview of Anatomy:
Baby sits inside pelvis
Factors Affecting Labor
The 5 P’s of Labor: Passenger, Passageway, Powers, Position of laboring woman, Physiologic response (maternal)
o Passenger: fetus and placenta
Size of fetal head – fontanels allow for some movement; the baby’s head can mold to fit the mother’s pelvis; if the
baby’s head is bigger than the mom’s pelvis = cephalopelvis disproportion
Fetal presentation
Fetal Lie – relation of the long axis (spine) of the fetus to the long axis of the mother; longitudinal (baby’s spine is
longitudinal to mother’s spine)
Attitude – the relation of the fetal body parts to one another; vertex with full flexion or general flexion ; military
Position – relationship of the presenting part to the four quadrants of the mother’s pelvis
First letter – tells us the location of the presenting part, in either the right or the left side of the pelvis
Second letter – presenting part of the fetus
Third letter – location of the presenting part to the anterior, posterior, or transverse portion of the pelvis
o Passageway: birth canal
Bony pelvis
Soft tissues – lower uterine segment – retraction ring
Cervix, pelvic floor, vagina, introitus
Presentation – Part of the fetus that enters the pelvic inlet first
Cephalic – head first
o Vertex – general flexion and the occiput is the general presenting part
o Face
o External cephalic version – version of the fetus from breech to vertex presentation; 36/37 weeks is ideal for performing
this
Breech – buttock, foot, or feet
o Frank Breech
Lie – Longitudinal or vertical
Presentation – breech (incomplete)
Presenting Part – sacrum
Attitude – flexion, except for legs at knees
o Single Footling Breech
Lie – Longitudinal or vertical
Presentation – breech (incomplete)
Presenting part – sacrum
Attitude – flexion, except for one leg at hip and knee
o Complete Breech
, Lie – longitudinal or vertical
Presentation – breech (sacrum and feet presenting)
Presenting part – sacrum with feet
Attitude – general flexion
Shoulder
o Lie – transverse or horizontal
o Presentation – shoulder
o Presenting part – scapula (Sc)
o Attitude – Flexion
Presenting Part – part of fetus that lies closest to internal os
Occiput or Mentum – hyperextended, mentum = chin
Sacrum
Scapula
Fetal Station – Engagement
How close the presenting part is to the ischial spine
If it is equal with the ischial spine 0 spine
Negative – baby is higher up in the pelvis
Positive – baby is further down into the pelvis
The 5 P’s of Labor – Powers:
Primary powers – uterine contractions Frequency, duration and intensity
Secondary powers – maternal bearing-down efforts - “Push!
Primary Powers – Contractions
The shortening of a muscle in response to a stimulus with return to its original length
o Increment – building up; longest phase of contraction
o Acme – peak
o Decrement – letting up
o Assess for frequency, duration and intensity
Uterine Tonus: the degree of pressure exerted by the uterine musculature as measured by intrauterine pressure
Measured by mmHg
Normal baseline tonus between contractions 8-12 mm Hg
Pressure at peak of contraction ranges between 35-75 mmHg
Intensity of contractions – the rise in intrauterine pressure above baseline brought about by a contraction
o Normally, 30-50 mmHg intensity is necessary for effective labor
o Measured externally by palpation or by internal uterine pressure catheter (IUPC)
Contractions exert downward pressure on the fetus, pushing it against the cervix, acting as a dilating wedge.
Longitudinal traction on the cervix by the upper portion of the uterus as it contracts and retracts leads to cervical effacement
and dilation
Shortening and thickening of upper uterine segment leads to fetal descent
Responsible for Cervical Change
o Effacement Shortening and thinning of the cervix (0-100%)
o Dilation Widening or opening of the cervix (0-10 cms)
o Ferguson Reflex
Urge to bear down
Leads to Secondary Powers – bearing down
Intensity Assessment Per Palpation
Mild – tip of nose Slightly tense fundus (top of uterus) that is easy to indent with fingertips
Moderate – chin Firm fundus that is difficulty to indent with fingertips
Strong – forehead Rigid board-like fundus that is almost impossible to indent with fingertips
The 5 P’s of Labor – Position of the Laboring Woman
Upright position – gravity aids and brings the baby down
o Standing
o Squatting
“All fours” position – relieves pressure off the sacrum
, Lithotomy position – in stirrups
Semi-recumbent position
Lateral position
The 5 P’s of Labor – Psychologic Response – Maternal
Unique to each woman Adolescent?
Cultural beliefs Adoption?
Previous experience Relationship with spouse/significant other
Anxiety level Labor support – family, spouse, doula, birth attendant
Environment Physical/psychological condition entering labor
Wanted or unwanted pregnancy? Pain -tolerance/expectations for pain management
, Physiologic Adaptation to LABOR
Maternal adaptation – Woman exhibits both objective and subjective symptoms
o Cardiovascular changes
400 ml. of blood emptied from uterus into maternal vascular system during a contraction
C.O. during contractions increased by 51% by end of 1st stage
C.O. peaks 10-30 min after vaginal birth and C/S; returns to prelabor baseline within one hour postpartum
Slight decrease in heart rate accompanies increase in C.O.
Both systolic and diastolic pressures increase during contractions; return to baseline between contractions
Systolic values increase more than diastolic
Supine hypotension – gravid abdomen ways too much and it smashes the aorta and vena cava; the blood and
oxygen isn’t coming through to the placenta; usually left lateral increases perfusion by getting the baby off of
those blood vessels
Valsalva maneuver during pushing – Intrathoracic pressure, venous return, venous pressure. C.O. and BP and
pulse temporarily. Fetal hypoxia may occur; process reverses when woman takes a breath
o Respiratory changes
Increased RR as a result of increased physical activity, pain, anxiety and increased oxygen consumption
Hyperventilation can occur in response to pain – respiratory alkolosis, hypocapnia
Common in transition – overwhelming urge to push
How can you treat hyperventilation? Model how they should breathe
o Renal changes
Spontaneous voiding may be difficult due to pain, position, pressure of baby, tissue edema
Epidural influences
Proteinuria of +1 normal as result of muscle tissue breakdown from work of labor
o Integumentary changes
Skin flushed as a result of pain, work of labor
Extreme stretching of perineum during second stage
Degree of distensibility varies with individuals
Lacerations and minute tears in perineum and vagina can occur
o Musculoskeletal changes
Backache (unrelated to fetal position) and joint ache common as result of increased joint laxity at term
Leg cramps common – never massage a pregnant woman’s calf – you could dislodge a clot
o Neurologic changes
Sensorial changes can occur as woman progresses through labor
Initially calm, happy about being in labor
Increased seriousness as labor progresses and requires focusing on coping techniques
Elation and fatigue after giving birth
Endorphins effecting pain perception
o Gastrointestinal changes
During labor GI motility and absorption of solid foods decreased; stomach-emptying time slowed
Nausea and vomiting of undigested food after onset of labor common
Nausea and vomiting common in transition and full dilation
BM during labor and delivery process common
o Endocrine changes
Onset of labor may be triggered by decreased progesterone & increased estrogen, prostaglandins, and oxytocin
Metabolism increases
Blood glucose decreases with work of labor
Physiologic Adaptation to Labor – Fetal Adaption
Fetal heart rate (FHR)
o Term gestation normal range 110-160
o Temporary accelerations and decelerations occur in response to fetal movement, contractions, vaginal exams, fetal cord
compression, etc.
Stress to uterofetoplacental unit causes characteristic FHR patterns
During contractions, fetal circulation decreases through spiral arterioles with subsequent decreased perfusion through
intervillous space – Fetal adaptation
o C.O. = stroke volume x heart rate
LABOR AND BIRTH PROCESSES / NURSING CARE DURING LABOR & BIRTH
OBJECTIVES
Describe the process of labor and the major factors affecting it and the associated nursing interventions that enhance labor
progress.
Describe maternal and fetal adaptations to labor.
Develop a plan of care that enhances labor progress for labor and birth.
Review the factors included in the initial assessment of the woman in labor.
Describe the ongoing assessment of maternal progress during the first, second, and third stages of labor with and without risk
factors identified.
Recognize the physical and psychosocial findings indicative of maternal progress during labor.
Describe the influence of cultural and religious beliefs and practices on the process of labor and birth.
Discuss ways the nurse can use evidence-based practices to enhance the quality of care a woman receives during labor and
birth.
Quick Overview of Anatomy:
Baby sits inside pelvis
Factors Affecting Labor
The 5 P’s of Labor: Passenger, Passageway, Powers, Position of laboring woman, Physiologic response (maternal)
o Passenger: fetus and placenta
Size of fetal head – fontanels allow for some movement; the baby’s head can mold to fit the mother’s pelvis; if the
baby’s head is bigger than the mom’s pelvis = cephalopelvis disproportion
Fetal presentation
Fetal Lie – relation of the long axis (spine) of the fetus to the long axis of the mother; longitudinal (baby’s spine is
longitudinal to mother’s spine)
Attitude – the relation of the fetal body parts to one another; vertex with full flexion or general flexion ; military
Position – relationship of the presenting part to the four quadrants of the mother’s pelvis
First letter – tells us the location of the presenting part, in either the right or the left side of the pelvis
Second letter – presenting part of the fetus
Third letter – location of the presenting part to the anterior, posterior, or transverse portion of the pelvis
o Passageway: birth canal
Bony pelvis
Soft tissues – lower uterine segment – retraction ring
Cervix, pelvic floor, vagina, introitus
Presentation – Part of the fetus that enters the pelvic inlet first
Cephalic – head first
o Vertex – general flexion and the occiput is the general presenting part
o Face
o External cephalic version – version of the fetus from breech to vertex presentation; 36/37 weeks is ideal for performing
this
Breech – buttock, foot, or feet
o Frank Breech
Lie – Longitudinal or vertical
Presentation – breech (incomplete)
Presenting Part – sacrum
Attitude – flexion, except for legs at knees
o Single Footling Breech
Lie – Longitudinal or vertical
Presentation – breech (incomplete)
Presenting part – sacrum
Attitude – flexion, except for one leg at hip and knee
o Complete Breech
, Lie – longitudinal or vertical
Presentation – breech (sacrum and feet presenting)
Presenting part – sacrum with feet
Attitude – general flexion
Shoulder
o Lie – transverse or horizontal
o Presentation – shoulder
o Presenting part – scapula (Sc)
o Attitude – Flexion
Presenting Part – part of fetus that lies closest to internal os
Occiput or Mentum – hyperextended, mentum = chin
Sacrum
Scapula
Fetal Station – Engagement
How close the presenting part is to the ischial spine
If it is equal with the ischial spine 0 spine
Negative – baby is higher up in the pelvis
Positive – baby is further down into the pelvis
The 5 P’s of Labor – Powers:
Primary powers – uterine contractions Frequency, duration and intensity
Secondary powers – maternal bearing-down efforts - “Push!
Primary Powers – Contractions
The shortening of a muscle in response to a stimulus with return to its original length
o Increment – building up; longest phase of contraction
o Acme – peak
o Decrement – letting up
o Assess for frequency, duration and intensity
Uterine Tonus: the degree of pressure exerted by the uterine musculature as measured by intrauterine pressure
Measured by mmHg
Normal baseline tonus between contractions 8-12 mm Hg
Pressure at peak of contraction ranges between 35-75 mmHg
Intensity of contractions – the rise in intrauterine pressure above baseline brought about by a contraction
o Normally, 30-50 mmHg intensity is necessary for effective labor
o Measured externally by palpation or by internal uterine pressure catheter (IUPC)
Contractions exert downward pressure on the fetus, pushing it against the cervix, acting as a dilating wedge.
Longitudinal traction on the cervix by the upper portion of the uterus as it contracts and retracts leads to cervical effacement
and dilation
Shortening and thickening of upper uterine segment leads to fetal descent
Responsible for Cervical Change
o Effacement Shortening and thinning of the cervix (0-100%)
o Dilation Widening or opening of the cervix (0-10 cms)
o Ferguson Reflex
Urge to bear down
Leads to Secondary Powers – bearing down
Intensity Assessment Per Palpation
Mild – tip of nose Slightly tense fundus (top of uterus) that is easy to indent with fingertips
Moderate – chin Firm fundus that is difficulty to indent with fingertips
Strong – forehead Rigid board-like fundus that is almost impossible to indent with fingertips
The 5 P’s of Labor – Position of the Laboring Woman
Upright position – gravity aids and brings the baby down
o Standing
o Squatting
“All fours” position – relieves pressure off the sacrum
, Lithotomy position – in stirrups
Semi-recumbent position
Lateral position
The 5 P’s of Labor – Psychologic Response – Maternal
Unique to each woman Adolescent?
Cultural beliefs Adoption?
Previous experience Relationship with spouse/significant other
Anxiety level Labor support – family, spouse, doula, birth attendant
Environment Physical/psychological condition entering labor
Wanted or unwanted pregnancy? Pain -tolerance/expectations for pain management
, Physiologic Adaptation to LABOR
Maternal adaptation – Woman exhibits both objective and subjective symptoms
o Cardiovascular changes
400 ml. of blood emptied from uterus into maternal vascular system during a contraction
C.O. during contractions increased by 51% by end of 1st stage
C.O. peaks 10-30 min after vaginal birth and C/S; returns to prelabor baseline within one hour postpartum
Slight decrease in heart rate accompanies increase in C.O.
Both systolic and diastolic pressures increase during contractions; return to baseline between contractions
Systolic values increase more than diastolic
Supine hypotension – gravid abdomen ways too much and it smashes the aorta and vena cava; the blood and
oxygen isn’t coming through to the placenta; usually left lateral increases perfusion by getting the baby off of
those blood vessels
Valsalva maneuver during pushing – Intrathoracic pressure, venous return, venous pressure. C.O. and BP and
pulse temporarily. Fetal hypoxia may occur; process reverses when woman takes a breath
o Respiratory changes
Increased RR as a result of increased physical activity, pain, anxiety and increased oxygen consumption
Hyperventilation can occur in response to pain – respiratory alkolosis, hypocapnia
Common in transition – overwhelming urge to push
How can you treat hyperventilation? Model how they should breathe
o Renal changes
Spontaneous voiding may be difficult due to pain, position, pressure of baby, tissue edema
Epidural influences
Proteinuria of +1 normal as result of muscle tissue breakdown from work of labor
o Integumentary changes
Skin flushed as a result of pain, work of labor
Extreme stretching of perineum during second stage
Degree of distensibility varies with individuals
Lacerations and minute tears in perineum and vagina can occur
o Musculoskeletal changes
Backache (unrelated to fetal position) and joint ache common as result of increased joint laxity at term
Leg cramps common – never massage a pregnant woman’s calf – you could dislodge a clot
o Neurologic changes
Sensorial changes can occur as woman progresses through labor
Initially calm, happy about being in labor
Increased seriousness as labor progresses and requires focusing on coping techniques
Elation and fatigue after giving birth
Endorphins effecting pain perception
o Gastrointestinal changes
During labor GI motility and absorption of solid foods decreased; stomach-emptying time slowed
Nausea and vomiting of undigested food after onset of labor common
Nausea and vomiting common in transition and full dilation
BM during labor and delivery process common
o Endocrine changes
Onset of labor may be triggered by decreased progesterone & increased estrogen, prostaglandins, and oxytocin
Metabolism increases
Blood glucose decreases with work of labor
Physiologic Adaptation to Labor – Fetal Adaption
Fetal heart rate (FHR)
o Term gestation normal range 110-160
o Temporary accelerations and decelerations occur in response to fetal movement, contractions, vaginal exams, fetal cord
compression, etc.
Stress to uterofetoplacental unit causes characteristic FHR patterns
During contractions, fetal circulation decreases through spiral arterioles with subsequent decreased perfusion through
intervillous space – Fetal adaptation
o C.O. = stroke volume x heart rate
