process of Normal labor (1).ppt

Normal Labour
By
Captain Ala’a ababneh RN, MSc

Normal labor
The process by which the fetus,placenta,
and amniotic membranes are expelled
from the uterus is called LABOR.

Characteristics of the normal labor
Occurs spontaneously at term
Fetus vertex presentation
Completed spontaneously within 18 hours
No complication

Causes of the onset of the labour
unknown
Other causes :
Maternal cause.
Fetal cause.
Placental cause.

Maternal cause
Psychological cause
Releasing the oxytocin from the maternal
posterior pituitary gland  stimulate the
prostaglandin lead to enhance the uterine
contraction and decreased the production
of progesterone and increased the
production of estrogen (changing
estrogen ratio)

process of Normal labor (1).ppt

Increasing estrogen level can lead to
increasing realising prostaglandin from
the decidua. (prostaglandin increase
uterine contractions and increase cervical
dilatation).
Over stretching of the uterine muscles
increasing irritability and causing 
contraction of the uterine muscles

Fetal causes
Fetal hypothalamus produce releasing
factors which stimulate pituitary gland to
produce ACTH stimulate fetal adrenal
glands secret cortisol which causes
changes in placental hormone levels
decreased progesterone and increasing
estrogen.

Events before the onset of the labour:
 lightening: 2-3 wks before the onset of the
labour the fetus begins to settle in the maternal
pelvic and descends toward the pelvic out let
 The physical changes that occurs are
 1- easier breathing
 2- increasing urination
 3- leg cramps
 4- venous congestion
 5- oedema

 2- Vaginal discharge (bloody show)
cervical mucous stained with blood result
from the rupture of the superficial blood
vessels as a result of cervical dilatation.

 Energy spurt :
 Some women experience a sudden high level of
energy from 1-2 weeks before the onset of the
labour (unknown).
 Advice the women conserve this energy for the
labour process.
 false labour ( Braxton hicks contraction)
 False contraction painless , irregular , no
effect on the cervix , abdomen pain , duration
from 30-40 sec, disappeared when the woman is
walking.
 Loss of 0.2 to1.5Kg weight, result from water
loss.

 Possible SROM
 The bag of water broke at full term.
 The process of the labour must be begins within
24hours.
 If not occurs  induced labour because the risk
of infection
 ARM a minotomy.
 The danger of the rupture of membrane  cord
prolapsed if the head not engaged.
 Nitrazine swab to test the PH of the A.F, slightly
alkaline.
 Speculum test

4 factors are significant in the labour
process
 Major variables in the birth process (4 P.S)
pelvic, passenger, power, psychological state.
 Pelvic ( passageway) : size and shape bony
pelvic.
 Adequate diameter  X-Ray , pelvimetry,
Diagonal congegate.
 Soft tissue: lower uterine segment, cervix,
vagina, pelvic floor muscle, introitius.


Passenger ( fetus, placenta) :
The way the passenger moves through the
birth canal is determined by several
interacting factors: size of the fetal head,
fetal presentation, lie, attitudes, position.
Fetal head  descent
Fetal bony skull thin and poorly
ossified overlap (molding).

Certain critical diameter of the fetal
head are:-
1-biparietal diameter:-(9.25)cm is the largest
transverse diameter well flexed cephalic
presentation .
2:-the anteroposterior diameters:-
suboccipitobregmatic diameter:-9.5 cm at term the
head is in complete flexion, this the smallest
diameter allow the fetal head to pass easily
through the pelvis.
As the head is more extended, the anteroposterior
diameter widens, the head may not be able to
enter the pelvis.

Critical diameter of the fetal head

fetal attitude : the relation of the fetal
parts to one another  (flexion) normally
fetal lie : relation of the longitudinal axis of
the fetus to the longitudinal axis of the
mother (long) , Less common transverse ,
oblique

 Fetal presentation : the lowest fetal part of the
fetus in the mother pelvis (cephalic) 95% , less
common breech 3% , shoulder , face  1%
 fetal position: is the relation of some
designated point on the four quadrants of the
maternal pelvis,
 A anterior, P posterior , Lleft,R right
side, O. occiput, M mentum, S sacrum.
 Station: relationship of the presenting part of the
fetus to the ischial spines of the maternal pelvis
 measured in (cm) above or below ischial
spines , at the level of the ischial spines 
engaged (0 level) above (-) floating of the level
of the inlet , below (+) at level out let. ( how far
the presenting part has descended into the
mother pelvis).

Example of fatal vertex in relation to front, back or side of
maternal pelvis

Engagement : the widest biparietal
diameter of the baby’s head has entered in
inlet. (when lightening occurs engagement
has occurred).
Lightning: the movement of the
presenting part down ward toward the
outlet of the pelvis( descend into true
pelvis).
Crowing : when the fetal head is forced
against the pelvic floor and can be seen at
the vaginal opening during contractions.

Characteristics of the labour
Power : uterine contraction (effective or
not, mild, moderate to sever). Start from the
fundus and spread throughout the uterus
Powers are primary or secondary.
Characterized by: frequency , duration ,
intensity.

 Assessment of the labour contractions
 produce cervix effacement and
dilatation.
 causes the fetus to engage and rotate.
 causes the fetus and the placenta to be
delivered .

Characteristics of labour contraction
Frequency : time between the beginning
of one contraction and the beginning of the
next one.
start every 20/min then increase 2-3 min
at the end of the labour.
If occur less than 1/min (with out rest time)
lead to rupture uterus.

 Duration : time between the onset of the
contraction to it’s end
1st stage every 15-45 sec
2nd stage every 60-90 sec
 90 sec  fetal hypoxia.
 Intensity : strength of the contraction,
determined by the uterus firm.

Palpation of uterine contraction
Mild- slightly tense fundus feels like
touching finger to tip of nose.
Moderate- firm fundus feels like touching
finger to chin.
Strong- rigid, broad like fundus, feels like
touching finger to forehead.

Phase of the contractions
Increment.
Acme.
Decrement.

Cervical changes :
 Effacement : shortening and thinning out
of the cervix (2.5cm)
 complete disappear of the cervix 100%
effaced. (taking up of the cx ) occurs as a
result of the pressure of the presenting part
(lightening) .
In the primi gravida the effacement occurs
before the dilatation of the cervix.

Dilatation : enlargement of the cervical
opening (OS) from 0-10cm
4cm dilatation significant to beginning
the active labour process occurs as a
result of uterine contraction , pressure of
the presenting part and bag of membrane
Effacement and dilatation measured by
P.V

 There are a relation ship between the
maternal position and uterine contractions.
 Back position  contraction more frequent and
low intensity.
 Lateral position  less frequent and more
intensity .
 Side-lying position  improves the fetal
oxygenation at the labour process
 Upright position: Facilitate birth and fetal
decent, Reduce the duration of the 2nd stage
of labor, Reduce the need for episiotomy,
forceps, or vacuum extractor.

 All of these characteristics should be recorded
by nurse every 1 hr during the beginning and
increasing within the process (used) to evaluate
the labor programs.
 Psyche : the anxiety and fear decreased the
ability to cope with pain in labor and maternal
catecholamine release when the women anxious
or feared, this lead to  inhibit the uterine
contraction and decreased placental blood flow,
teach to prevent hyperventilation.

Mechanisms of labor (cardinal movement)
Reflect changes in the fetal posture to
adapt with the birth canal (2nd stage)
Depend on the pelvic diameter , maternal
soft tissues , fetal size , strength of the
contraction
 decent : the head move toward the pelvic
inlet (floating) , when the biparietal of the
head pass through the inlet (engaged)
complete flexion .

 internal rotation : fetal head rotates from
transverse to anterior posterior , aligning it
self with A.P diameter.
 extension : the occipit appears at the
vaginal opening (crowing) followed by the
fore head , nose , mouth , chin 
complete when the head is born.
 External rotation (restitution) after the
delivery of the head , remains in the A.P
position for short time then outer the
shoulder (external rotation of the head and
internal rotation of the shoulder)

5. Expulsion: down ward then up ward to the
anterior and posterior shoulder.
6. Placental expulsion: occurs within 5-20 mins.
 Sign of placental separation:
1. Globular and firm uterus.
2. Lengthening of the cord.
3. Sudden gush of the blood.
4. Rise of the abdomen.

Methods of placental separation:
Schultz mechanism: clean, shiny,
method, fetal side.
Duncan’s mechanism: dirty method,
maternal side.( increased risk for PPH)
Controlled cord traction.

Stages of labor
1st stage: in primi 8-20 hrs.
 in multi5-14hrs.
Divided into three phases;
Latent phase: 1-3cm dilatation. Regular
contractions, stable and mild contractions,
occur every 10-15min, lasting to 15-20
sec. the woman is able to cope with
discomfort, teach relaxation techniques.

Active phase: cervical dilatation 4-7 cm,
contraction every 5 mints strong, duration
30-45 sec. breathing and relaxation
techniques.
Transition phase: cervical dilatation 8-
10cm, every 2-3 mints last for 60-90 sec,
strong, decrease the ability to cope.

2nd stage: the woman feels urge to bear
down, contractions every 2-3 mints, last
for 60-90 sec.
Last from 20-50 min up to 2 hours.
Episiotomy: may be done to decrease the
duration of the second stage.

3rd stage: placental separation.
Last up to 30min average 5-10 min.
Clamp the cord.
Lean the infant mouth and the nose.
Oxytocin may be given.
4th stage of labor: recovery stage, 1-4
hours after delivery, or until stable v/s.
Close monitor v/s.

Care of the mother
Feel thirsty and hungry.
Shivering.
Discomfort from trauma.
Encourage bonding relationship.

Stages of labor
duration 1st stage 2nd stage 3rd stage
Primi 12-16 hrs 1-2 hr
10-20
mints
Multi 6-8 hrs
10-30
mints
10-20
mints

Nursing management of the 1st stage of
labor
 Admission procedure.
1. The nurse should welcome and greet the woman.
2. Orientation
3. Take v/s.
4. Take full history.
5. Provide information, health education.
6. Assess uterine contractions.
7. Fetal heart rate120-160 beat/min.
8. Asses labor progress
9. Give fluids as order.
10. Check for lab test CBC, urine analysis, Rh.
11. Bladder care every 1.5-2hrs.

Vaginal examination: protect from
infection. (effacement and dilatation, and
the descent of the fetus, station,
membrane intact or bulging or rupture)
Position.
assessment of rupture membrane and
amniotic fluid (color, viscosity, odor,
amount).

Ambulation and position
-freedom of maternal movement and choice of
position is beneficial for women.
-allowed to choose to walk or not walk.
-ambulation should be encouraged if the
women not received medication for pain .
- encouraged the women to squat during
contraction increase pelvic diameter, and
allowing the head to rotate to more anterior
position .
-hand and knee position help in rotation of the
fetal occiput.

Care 2nd stage of labor
 Prepare the instruments.
 Monitor fetal heart rate after each uterine contractions.
 Assess uterine contractions.
 Psychological support.
 Observe vaginal bleeding.
 Assess the pain.
 Observe v/s.
 Empty bladder.
 Suggest an upright position to encourage progression of
decent.
 Encourage bearing down effort with urge to push.

Care during the 3rd stage
Assess uterine condition.
Observe the amount of bleeding.
Monitor v/s.
Assess infant condition, apger score.
Skin to skin contact helps the mother
maintain the baby’s body heat.
Assess perineal area.
Begin breastfeeding.

Care during the 4th stage
Promote rest
Observe bleeding
Change position.
Rooming in.

Assessment of FHTs and FHR pattern
 PMI of FHTs is the location where on maternal
abdomen at which FHTs are the loudest.
 It’s usually directly over fetal back.
 It aids in determining fetal presentation and
position.
 In vertex, it’s usually below mother’s umbilicus
in either right or left lower quadrant of the
abdomen.
 In breech, FHTs are heard above umbilicus.
 In ROA, it’s at midline above symphisis pubis.

Assessment of FHTs and FHR pattern
Must be assessed:
 Immediately after ROM.
 After any change in contraction pattern and or
maternal status.
 Before and after medication or any procedure.

Electronic fetal monitoring
( EFM) is a useful tool for visualizing
FHR pattern on a monitor screen or
printed tracing.

Electronic fetal monitoring
Electronic fetal monitoring is
associated with increased rates
of surgical intervention and
decreased perinatal mortality due
to fetal hypoxia.
( Intrapartum electronic fetal heart rate monitoring versus intermittent auscultation.
2007 )

Reassuring FHR pattern
Baseline FHR in normal range of 110-
160bpm, with no periodic changes and
moderate baseline variability.
Acceleration with fetal movement.

Nonreassuring FHR pattern
Progressive decrease or increase in
baseline rate.
Tachycardia of more than 160bpm or
more.
Progressive decrease in baseline
variability.

Non reassuring FHR pattern
 Sever variable decelerations FHR less than 60
bp/m lasting more than 30-60secondswith slow
return to baseline or decreased variability.
 Late decelerations especially repetitive and
uncorrectable.
 Absent or undetected FHR variability.
 Prolonged deceleration more than 60-90
seconds.
 Severe bradycardia.

Recommended practice AWHONN
(2003).
First stage:
Latent phase: every 1 hour.
Active phase: every 30 min.
 Transitional phase: every 15 min
Second stage: after each contraction.

Base line FHR
Is the average rate during a 10 minute
segment that exclude periodic or episodic
changes, periods of marked variability,
and segments of base line that differ by
more than 25bpm.

Variability
Can be described as irregular fluctuations
in the baseline of FHR.
It’s a characteristic of baseline FHR and
doesn’t include accelerations or
decelerations.

Variability
 Variability in fetal heart rate was significantly and
positively associated with child developmental
performance during the third year of life.
 Significant positive associations between fetal
heart rate variability and developmental
outcomes began at 28 weeks gestation for the
developmental assessment scores and at 32
weeks for the language composite.
Fetal Heart Rate and Variability: Stability and Prediction
toDevelopmental Outcomes in Early Childhood.2oo7

Bradycardia
Is a baseline FHR less than 110 bpm. For
a duration of 10 minutes or more.
It can be considered a later sign of fetal
hypoxia and is known to occur before fetal
death.

Decelerations
May be benign or nonreassuring.
Are described by their relation to onset of
contraction and shape.

Decelerations
Decelerations are:
Early
Late
Variable

Early decelerations
 Starts before the peak of contraction and returns
to baseline when contraction returns to it’s
baseline.
May occur:
 During contraction
 During vaginal examination
 Fundul pressure
 Placement of internal monitor
 Pushing

Late decelerations
Begins after contraction had started, the
lowest point of deceleration after the peak
of contraction
Usually doesn’t return to base line the
contraction is over.

Late decelerations
Caused by uteroplacental insufficiency.
 Hyperstimulation
 Gestational hypertension
 Post date
 Amnionitis or SGA
 DM
 Previa or abruption
 Anesthetics and maternal anemia

Late decelerations
It’s associated with fetal hypoxemia
associated with acidosis.

Variable decelerations
A visual abrupt decrease in FHR below
the baseline by 15bpm or more, lasting at
least 15 seconds and return to normal
base line within less than 2 minutes.
Occurs any time during contraction.
Is caused by umbilical cord compression.

Variable decelerations
Have U or V shape.
Followed or preceded by acceleration
called shouldering.

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