Labour

LABOUR

Mrs. P. Vadivukkarasi Ramanadin,
Asst. Professor,
Mata Sahib Kaur College of Nursing,
Mohali, Punjab.

INTRODUCTION
3

Normal labour and delivery is a physiologic
process in which the attendant closely monitor
the woman and fetus, with little medical
Intervention required.

Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012

DEFINITION
4

It is the process of expulsion of fetus, placenta
and its membranes through the birth canal.


NORMAL LABOUR / EUTOCIA
5

Normal labor occurs
 at term,
 spontaneous in onset,
 fetus presenting by the vertex,
 it complete within 18 hours,
 no complication arise.


STAGES OF LABOUR
6

 First stage (or) Dilating stage
 Second stage (or) Pushing stage (or) pelvic

stage
 Third stage (or) Placental stage
 Fourth stage (or) Recovery stage


FIRST STAGE

OR

DILATING STAGE

7 Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012

DEFINITION
8

It starts with regular and rhythmic uterine
contractions till completion of full cervical
dilatation (10cm).

DURATION :
 For primi gravida 16hrs to 18hrs.
 For multi gravida 6hsrs to 10hrs.


ONSET OF LABOUR
9

1.Prelabour
2.Lightening
3. Frequency of micturition
4.Taking up of cervix and Cervical Effacement


Difference between True labor and False labor
Niggling / Spurious labor / False labor True labor

Uterine contraction : Uterine contraction :
Not always present Always present
Lasts for 3 to 4 minutes Not exceed > 90 seconds
Irregular Regular and rhythmic
Felt in lower back radiates to lower Felt in back or abdomen above navel
Portion of abdomen
May or may not be painful Abdominal tightening ,discomfort and
Can stop with comfort measures Pain will not stop with comfort measures
No back ache May have back ache
Intensity stop with position changes, Increase intensity with walking
Walking
Cervix : Cervix :
No shortness , Soft Shortening
No dilatation Dilatation
No tensed membrane Tensed membrane
Posterior position Anterior position
No show Show presents

Fetus : Fetus :
No head engagement Head engagement

CAUSES OF ONSET OF LABOR
11

Exact cause is unknown .

i ) Hormonal factors :
Formation of Oxytocin receptors in uterine muscles by
the influence of Estrogen . Which act with Prostaglandin
secreted from Decidua and membrane triggers the uterine
contraction. Emotional and physical stress stimulates
Hypothalamus to release Oxytocin which triggers the
uterine contraction .

ii ) Mechanical factors :
Pressure exerted by presenting part to the os of cervix
initiates uterine contraction Mohali, Punjab 8/25/2012
Mata Sahib Kaur College of Nursing,

PHASES OF FIRST STAGE OF LABOR
12

Have 3 phases

* Latent phases
* Active phases
* Transition phases


MATERNAL PROGRESS IN I STAGE OF LABOR
Criteria Latent phase Active phase Transition phase
Duration
Primi gravida 8 – 10 hrs 3 – 6 hrs 2 hrs
Multi gravida 5 hrs 4 hrs 1 hr

Contraction
Strength Mild – Moderate Moderate – Strong Strong – Very strong
Rhythm Irregular More regular Regular
Frequency 5 – 30 mts 3 – 5 mts 2 – 3 mts
Duration 30 – 45 seconds 40 – 70 seconds 45 - 90 seconds

Cervical dilatation 0 – 3 cm 4 – 7 cm 8 – 10 cm
1.2 cm / hr in Primi 1 cm / hr in Primi
1.5 cm / hr in Multi 2 cm / hr in Multi

Station of the head
Primi gravida 0 +2 cm +3 and above
Multi gravida -2 to 0 cm +1 to +2 cm

Show Brownish Pale pink Pink to bloody Bloody mucus
discharge mucus


PHYSILOGY OF I STAGE OF LABOUR
14

I . UTERINE ACTION

II . MECHANICAL FACTORS


I.UTERING ACTION
15

1.Fundal dominance
2.Polarity
3.Contraction and retraction
4. Formation of upper and lower uterine segment
5.Retraction Ring
6.Cervical effacement
7. Cervical dilatation
8. Show


II. MECHANICAL FACTORS
16

1. Formation of the fore waters
2. General fluid pressure
3. Rupture of the membrane
4. Fetal Axis pressure


RECOGNITION OF I STAGE OF LABOR
17

 Show
 Uterine Contraction
 Rupture of membrane


NURSING MANAGEMENT


NURSING DIAGNOSES IN THE FIRST STAGE OF
LABOUR
19

 Acute pain / Impaired comfort related to contraction –
related hypoxia, dilatation of tissues and pressure on
adjacent structures as evidenced by verbal reports,
restlessness, muscle tension and narrowed focus

 Impaired urinary elimination related to altered intake,
dehydration as evidenced by urinary retention / slow
progression o f labour

 Fatigue related to discomfort / pain / increased energy
requirement / altered coping ability

Cont . . .
20

 Risk for mild anxiety related to situational crisis, unmet needs, stress

 Risk for ineffective coping (individual / couple) related to situational
crises / personal vulnerability / use of ineffective coping mechanism /
inadequate support system / pain

 Risk for decreased cardiac output related to decreased venous return /
hypovolemia / changes in systemic vascular resistance

 Deficient knowledge regarding progression of labour and available
options related to lack of exposure / recall / information
misinterpretation / evidenced by questions / statement of
misinterpretation / inadequate follow through of instructions


NURSING MANAGEMENT IN I STAGE OF LABOR
1) Latent phase :

21
•Complete admission procedures
•Physical examination
•Monitor maternal vital signs
•Monitor FHR
•Status of amniotic fluid
•Status of membrane
•Observe voiding
•Assess coping ability
•Encourage walking
•Encourage visiting , watching TV
•Encourage relaxation
•Change position every ½ hours
•Effleurage

•Monitor Cervicogram
Mata Sahib Kaur College of Nursing, Mohali, Punjab
8/25/2012 •Monitor Partogram

2) Active phase
22

•Continue monitor maternal vital signs
•Status of amniotic fluid
•Encourage voiding every 1 hour
•Observe for full bladder
•Asses progress of labor
•Provide comfort measures
•Moist lips or give ice chips
•Apply cool , damp cloth to woman’s face
•Keep bed linens dry
•Effleurage

Cont . . .
23

•Sacral support
•Oral hygiene
•Inform the progress
•Administer medication if necessary
•Explain electronic fetal monitor
•Encourage breathing and relaxation technique
•Frequent perineal care
•Protect from aspiration and injury


3) Transition phase
24

•Continue the active phase management
•Do not allow alone
•Accept the behaviour of the mother
•Change chux ( pad ) frequently
•Keep bed linen dry
•Get blanket if cold


SECOND STAGE OF LABOUR /
PUSHING STAGE / PELVIC STAGE


DEFINITION
26

It begins with full cervical dilatation (10cm) till the
birth of the baby.

DURATION :
 Primi gravida - 2 hours.
 Multi gravida - 30 minutes.


RECOGNITION OF COMMENCEMENT
27
OF II STAGE OF LABOUR

 Expulsive uterine contraction
 Rupture of the fore waters
 Dilatation and gaping of anus
 Appearance of present part
 Congestion of the vulva
 Show


PHASES OF SECOND STAGE OF
28
LABOUR

Have 3 phases

* Latent phases / Propulsive phase
* Active phases / Expulsive phase
*Transition phases / Compulsive phase


Cont. . .
29

 LATENT PHASES / PROPULSIVE PHASE :
Descend of the fetus 2 cm below from the os to the pelvic
floor .

 ACTIVE PHASES / EXPULSIVE PHASE :
Descend of the fetus from the os 2cm below to the vaginal
outlet ( Crowning )

Ferguson reflux : Pressure exerted by the presenting
part over the cervix causing involuntary
uterine contraction

 TRANSITION PHASES / COMPULSIVE PHASE :
Birth of the baby from the vaginal outlet till extension .

PHYSIOLOGY OF II STAGE OF LABOUR
30

I Uterine action
 Contraction becomes stronger, longer but less frequent.
 Membranes rupture spontaneously.
 Consequent drainage of liquor allows the hard, round
fetal head to be directly applied to the vaginal tissues
and aid distension.
 Fetal axis pressure increasing the flexion of the head
which results in smaller presenting diameter ,more rapid
progress and less trauma to both mother and fetus.
 Expulsive contraction.
 Compulsive contraction
 Involuntary uterine contraction.

Cont . . .
31

II Soft tissue displacement :
 As the hard fetal head descend, the soft tissue of the
pelvis become displace.
 Anteriorly the bladder is pushed upwards into the
abdomen which cause stretching and thinning of the
urethra.
 Posterioly the rectum becomes flattened into the
sacral curve and the pressure of the advancing head
expels any residual faecal matter.
 Laterly the Levator ani Muscles dilate and thins out
and perineal body is flattened ,displaced ,stretched
and thinned. 8/25/2012

MECHANISM OF NORMAL LABOUR /
32
CARDINAL MOVEMENTS OF LABOUR
DEFINITION
As the fetus descends, soft tissue and bony structures exert pressures which
force the fetus to negotiate the birth canal by a series of passive movements
collectively known as Mechanism of labor.

PRINCIPLES

 Descent takes place throughout the labor.
 Whichever part leads and first meets resistance of the pelvic floor
will rotate forwards until it comes under the symphysis pubis.
 Whatever emerges from the pelvis will pivot around the public
bone.

CHARECTERISTICS
Lie is longitudinal
33


 Attitude is one of good flexion
 Presentation is cephalic presentation
 Position is right or left occipito anterior
 Denominator is the occiput
 Presenting part is the posterior part of the anterior
parietal bone
 Occiput pointing left / right ileo pectinal eminence
 Sagital sutures lies on right / left oblique diameter
 Presenting diameter is suboccipito frontal 10cm

CARDINAL MOVEMENTS
34

1) Descend
2) Flexion
3) Internal rotation of the head
4) Extension of the head
5) Restitution
6) Internal rotation of the shoulder
7) External rotation of the head
8)Lateral flexion of the body


Cont . . .
35
1) Descend:
 In primi gravida it occurs during latter weeks of pregnancy

 It will be aided by

 Forces of uterine contraction and retraction
 Rupture of fore waters
 Full cervical dilatation
 Maternal efforts speeds progress
 Slope of the pelvic floor muscle

2) Flexion:
 This increases throughout the labor

 Because of uterine contraction, fetal axis pressure will be exerted more on
the occiput than the sinciput causing good flexion
 Because of flexion the suboccipito frontal 10cm is reduced into suboccipito
bregmatic 9.5cm
 The occiput is the leading part

Cont . . .
36
3) Internal rotation of the head:
 Because of gutter – shaped and slope of pelvic floor gives resistance

 The slope of the pelvic floor determines the direction of rotation

 The second principle applied. The occiput is the leading part and meets
the pelvic floor resistance and it will rotate 1/8 of the circle forward until
it comes under the symphysis pubis.
 Because of internal rotation there is a twist at the neck.

 The sagital suture move from right or left oblique to Antero – posterior
diameter

4) Crowning:
 The occiput slips beneath the sub-pubic arch and crowning take place

 The presenting part engages the vaginal outlet and it will not recede
backward.
 The sub-occipito bregmatic diameter 9.5cm distends the vaginal outlet.


Cont . . .
37

5) Extension of the head:
 Once crowning occur fetal head can extend

 Third principle applied

 The fetal head pivot around the the pubic bone

 This releases sinciput, face and chin sweeps the perineum and born by a
movement of extension.
 The suboccipito frontal diameter 10cm distends the vaginal outlet

6) Restitution:
 The occiput moves one-eighth of a circle towards the side from it started

 Because of this the twist in the neck of the fetus which resulted from
internal rotation is now corrected by a slight un twisted movement


38

7) Internal rotation of the shoulder:
 Now the shoulder is the leading part which meets the pelvic floor
resistance
 Again second principle applied

 So from oblique diameter it will turn to Antero – posterior diameter

8) External rotation of the head:
 The head rotate in same direction as restitution and the occiput of the
fetal head now lies laterally

9) Lateral flexion:
 Anterior shoulder deliver by downwards and backward movement
and posterior shoulder deliver by upward and forward movement
 Body will be delivered by lateral flexion


NURSING DIAGNOSES IN THE SECOND STAGE OF
LABOUR
41

 Acute pain related to contraction – related hypoxia,
dilatation of tissues and pressure on adjacent
structures as evidenced by verbal reports,
restlessness, muscle tension and narrowed focus
 Risk for impaired fetal gas exchange related to
mechanical compression of head or cord / maternal
position / prolonged labour affecting placental
perfusion / effects of maternal anaesthesia /
hyperventilation
 Risk for impaired skin / tissue integrity related to
untoward stretching / laceration
8/25/2012 Mata Sahib Kaur College of Nursing, Mohali, Punjab

Cont . . .
42

 Risk for fatigue related to anxiety / environmental
humidity
 Risk for deficient fluid volume related to lack of intake
or excessive vascular loss
 Risk for infection related to broken or traumatized
tissue / increased environmental exposure / rupture
of amniotic membrane
 Risk for fetal injury related to descent / pressure
changes / compromised circulation / environmental
exposure

NURSING MANAGEMENT OF II STAGE
43
OF LABOR
 Assess FHR
 Assess uterine contraction
 Assess the progress of labor
 Arrange the delivery room
 Follow a sterile technique
 Clean vulva and perineal region using downward strokes
 Support woman
 Provide necessary materials and equipment
 Provide equipment for episiotomy
 Provide perineal support
 Give immediate care
 Assess the APGAR score for 1st , 5th , 15th minutes
 Assess for haemorrhage Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012

III STAGE /

PLACENTAL STAGE


DEFINITION
45

It starts with separation of placenta till
expulsion of placenta .

DURATION :
 Primi gravida :15 minutes
 Multi gravida : 5 – 15 minutes

PHYSIOLOGY OF III STAGE OF LABOR
46

I) MECHANICAL FACTORS

II) HAEMOSTASIS

1) Retractionring / Living ligature
2) Presence of Vigorous uterine contraction
3) Achievement of haemostasis


NURSING DIAGNOSES IN THE THIRD
47
STAGE OF LABOUR
 Acute pain related to tissue trauma / psychological
response following delivery as evidenced by
verbalization / changes in muscle tone / restlessness
 Risk for deficient fluid volume / Bleeding related to lack
or restriction of oral intake, vomiting, diaphoresis,
increased insensible water loss, uterine atony,
lacerations of birth canal, retained placental fragments
 Risk for maternal injury related to positioning during
delivery and transfers / difficulty with placental
separation / abnormal blood profile
 Risk for impaired attachment related to physical barriers,
separation, anxiety associated with the parent role

NURSING MANAGEMENT
48

 Assess the maternal vital signs
 Assess for excessive bleeding
 Provide material for episiotomy repair
 Take to recovery room and provide comfortable
position
 Prevention and measures for heamorrhage


IV STAGE /

RECOVERY STAGE


DEFINITION
50

1 to 4 hours after the expulsion of placenta .


NURSING DIAGNOSES IN THE FOURTH
51
STAGE OF LABOUR
 Acute pain related effects of hormones & medications /
mechanical trauma/ tissue edema/physical &
psychological exhaustion/ anxiety as evidenced by reports
of cramping/ muscle tremors/ guarding or distraction
behavior/ facial mask
 Fatigue related to increased physical exertion, sleep
deprivation, stress, environmental stimuli, hormonal
changes evidenced by verbalization of overwhelming lack
of energy, compromised concentration, listlessness
 Risk for bleeding related to myometrial fatigue / failure of
hemostatic mechanism
 Risk for impaired attachment related to maternal
fatigue/physical barrier/separation / lack of privacy/
anxiety associated with the parent role

NURSING MANAGEMENT OF IV
52
STAGE OF LABOR

 Assess
 Fundal location and consistency
 Lochia amount , color , consistency , odour
 Vital signs
 Perineal or episiotomy care
 Status of hydration
 Bladder observation and distension
 Fatigue and exhaustion

MATERNAL SYSTEMIC
RESPONSE TO
LABOUR


I CARDIO VASCULAR SYSTEM
54

 Increased BP in first and second stage of labor
with a return to pre labor level during the third
stage of labor
 Other factors which increases BP are anxiety
apprehension and pain
 Increased Heart rate during second stage
 Clinical manifestation of hypotension and
increased pulse rate results from Supine vena
caval syndrome

II RESPIRATORY SYSTEM
55

 Oxygen consumption during labor is equal to
that of moderate to strenuous exercise

 Increased in ventilation until respiratory center
is not depressed by medication

 May quickly develop hypoxia or acidosis

 Hyperventilation cause decreased Carbon-
dioxide in blood 8/25/2012

III RENAL SYSTEM
56

 Muscle breakdown during labor results proteinuria.
If it is more pre eclampsia results

 Distended bladder may cause prolonged labor and
urinary stasis which results risk of infection

 Supine position may compress the ureters by
distended uterine results decreased urinary flow


V GASTRO INTESTINAL TRACT
57
SYSTEM
 Decreased gastro intestinal peristaltic movement
results from decreased absorption and decreased
solid intake , because it can take 12 hrs to digest a
meal

 Risk of aspiration of vomitus because of eating

 GI absorption of liquid is not changed

 Ice chips frequently can be given

IV FLUID AND ELECTROLYTE
58

 Muscle activity increases BMR, body temperature,
Sweating and fluid evaporation from the skin

 Increased Perspiration

 Increased respiratory rate

 Hyper ventilation results from Labor alter the
electrolyte balance

 Adequate hydration and IV Fluid administration is
necessary Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012

Labour

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