Labor and Delivery 11/11/2018 06:32 ص Dr/ Hanan Elsayed.

Presentation on theme: "Labor and Delivery 11/11/2018 06:32 ص Dr/ Hanan Elsayed."— Presentation transcript:

1 Labor and Delivery 11/11/ :32 ص Dr/ Hanan Elsayed

2 Definition of LABOR Labor is the process by which the products of conception (the viable fetus, placenta and membranes) are expelled from the uterus via the vagina into the external environment. 11/11/ :32 ص Dr/ Hanan Elsayed

3 Normal Labor Occurs at term (neither premature nor post-mature).
Has a spontaneous onset (not induced). Is completed after 4 hours, and before 24 hours from the time of its onset (neither precipitate nor prolonged). Is achieved without artificial aids (such as forceps). Involves no complications (such as excessive hemorrhage). Has the (single) fetus presenting by the vertex (top of the head), with the occipit in the anterior part of the pelvis. Involves spontaneous delivery of the placenta. 11/11/ :32 ص Dr/ Hanan Elsayed

4 The Factors Affecting Labor: 1- The powers:
Primary power contraction and Retraction of the uterine muscles Secondary power Voluntary muscular efforts of the mother i.e. contraction of the abdominal muscle & the diaphragm during the ‘pushing’ or ‘bearing-down’ phase). 11/11/ :32 ص Dr/ Hanan Elsayed

5 4- Personality & psychological Status : age, parity.
2- The passages: the bony pelvis, cervix, vagina and pelvic floor (muscles). 3- The passengers: mainly the fetus (specifically the fetal head), plus the placenta, membranes and liquor. 4- Personality & psychological Status : age, parity. 11/11/ :32 ص Dr/ Hanan Elsayed

6 Causes of uterine contractions
Hypoxia of the contracted myometrium Compression of nerve ganglia in the cervix and lower uterus. Stretching of the cervix during dilatation. Stretching of the perineum. 11/11/ :32 ص Dr/ Hanan Elsayed

7 Phases of uterine contraction
a) Increment b) Acme c) Decrement 11/11/ :32 ص Dr/ Hanan Elsayed

8 Retraction Retraction is shortening that persists after a contraction. The muscle fibers do not relax completely at the end of a contraction, but retain some of the shortening and thickening. 11/11/ :32 ص Dr/ Hanan Elsayed

9 Pic ( 114 ) Progress of uterine contraction
Secondary powers ‘bearing down’ Pic ( 114 ) Progress of uterine contraction 11/11/ :32 ص Dr/ Hanan Elsayed

10 The Secondary powers (the abdominal muscles and diaphragm) are used in the second stage of labor; They are used during ‘bearing down’ or ‘pushing;’ they are the mother’s voluntary expulsive efforts. 11/11/ :32 ص Dr/ Hanan Elsayed

11 Pelvic inlet 11 cm anteroposteriorly 13.5 cm laterally (side to side)
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12 Pelvic Cavity : The pelvic cavity (between the inlet and the outlet) is circular in shape and curves forwards. Its average measurement is 12 cm in diameter. 11/11/ :32 ص Dr/ Hanan Elsayed

13 Pelvic outlet : The pelvic (obstetric) outlet is bordered by the two ischial tuberosities (spines 11/11/ :32 ص Dr/ Hanan Elsayed

14 Soft Tissues The cervix and vagina
when labor begins, uterine contractions affect the cervix in two ways. Effacement and dilatation Normally, a primiparous woman will experience effacement before dilation. For a multiparous woman, both processes usually occur at the same time. 11/11/ :32 ص Dr/ Hanan Elsayed

15 Cervical dilation and effacement
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16 The fetal skull: Made of 5 main bones Two frontal bones
Two parietal bones One occipital bone 11/11/ :32 ص Dr/ Hanan Elsayed

17 Sutures: The lines of junction between the bones are called sutures. The main ones are: Frontal-between the two frontal bones Coronal-between the frontal and parietal bones Sagittal-between the two parietal bones Lambdoidal-between the parietal bones and the occipital. 11/11/ :32 ص Dr/ Hanan Elsayed

18 Fontanelle The anterior (called the bregma) is the large diamond-shaped (2.5*1.25cm) formed by the junction of the parietal and frontal bones The posterior fontanelle is the smaller, triangular-shaped, junction of the parietal and occipital bones. 11/11/ :32 ص Dr/ Hanan Elsayed

19 11/11/ :32 ص Dr/ Hanan Elsayed

20 Moulding (Slight overlapping, caused gradually by the pressure of the birth canal
Attitude : (Relation ship of the fetus body parts to each other. Flexion, or extension). Lie Relationship of the long axis of the fetus to long axis of the mother. (longitudinal – transverse or oblique ) Position: Relationship between back of the fetus and the anterior abdominal wall of the mother. Presentation : part of the fetus lying in the pelvic prim 11/11/ :32 ص Dr/ Hanan Elsayed

21 11/11/ :32 ص Dr/ Hanan Elsayed

22 Causes of the onset of labor
1- Hormone level changes are probably due to placental aging Progesterone levels fall Oestrogen and prostaglandin levels-rise 2- Fetal pressure 11/11/ :32 ص Dr/ Hanan Elsayed

23 Preliminary signs of labor :
Lightening Greater pressure below False Labor Braxton-hicks contractions, Formation of fore water 11/11/ :32 ص Dr/ Hanan Elsayed

24 Late signs of labour Show Contraction Rupture of membrane
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25 THE STAGES OF LABOR The first stage is the stage of dilatation, starts from the onset of regular contractions until the cervix is fully dilated 11/11/ :32 ص Dr/ Hanan Elsayed

26 2)The second stage: is the stage of expulsion, starts from complete cervical dilatation until the expulsion of the fetus. Pic (111 ) 11/11/ :32 ص Dr/ Hanan Elsayed

27 3) The third stage: is the stage of separation, following delivery of the fetus until the complete expulsion of the placenta. 11/11/ :32 ص Dr/ Hanan Elsayed

28 4) Fourth Stage: The hour or two following the completion of Labor,
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29 The first stage The average duration of the first stage of labor is hours in a primi-gravida, and about 4-6 hours in a multipara. 11/11/ :32 ص Dr/ Hanan Elsayed

30 At the end of the first stage:
* The cervix is fully dilated * The uterus, cervix and vagina form one continuous canal * The membranes rupture (it this has not already happened) * There will be strong uterine contractions usually every 2 to 3 minutes, lasting between 50 and 60 seconds each * The fetal head will have descended into the pelvis. 11/11/ :32 ص Dr/ Hanan Elsayed

31 Duration of Different Stages of labor
Third stage Second stage First stage Duration of labor 10-20 minutes 1-2 hours 12-16 hours Primigravida 10-30 minutes 6-8 hours Multipara 11/11/ :32 ص Dr/ Hanan Elsayed

32 Phases Latent phase: The cervical dilation is less than 3 cm. The uterine contractions are t infrequent, uncomfortable, and irregular, but generate force to cause slow dilation and some effacement of the cervix A prolonged latent phase is greater than 20 hours in the primigravida, and greater than 14 hours in the multipara. 11/11/ :32 ص Dr/ Hanan Elsayed

33 Active phase: The cervix dilates from 3-10 cm.
progressive cervical dilation. A prolonged active phase is see in the primigravida who dilates at less than 1.2 cm/hr, and in the multigravida who dilates at less than 1.5 cm/hr. 11/11/ :32 ص Dr/ Hanan Elsayed

34 Signs and Symptoms of 2nd stage of labor
Strong uterine cont, urge to bear down. Gaping of anus & vulva. Plugging of perineum Flashing of the face full dilatation, complete effacement. Appearance of presenting part from the vulva. Spontaneous rupture of membranes. Changing in woman cry. 11/11/ :32 ص Dr/ Hanan Elsayed

35 THE MECHANISM OF LABOR 2) Descent 1) Engagement 6) extension
The Mechanism of labor is a series of passive adaptive movements of the fetal head in order to accommodate it self to pass through the irregular birth canal . 2) Descent 1) Engagement 6) extension 7) restitution 3) Flexion 8) external rotation 4) Internal rotation 9) Delivery of shoulder (anterior) & body 5) crowning 11/11/ :32 ص Dr/ Hanan Elsayed

36 1) Engagement : Engagement Station 11/11/2018 06:32 ص
11/11/ :32 ص Dr/ Hanan Elsayed

37 THE THIRD STAGE OF LABOR
Following delivery of the baby, the uterus contracts to a twenty week size, causing the detachment of the placenta and expelling the upper vagina. 11/11/ :32 ص Dr/ Hanan Elsayed

38 Signs of placental separation
1-The uterus becomes smaller, harder, higher, more globular and more mobile. 2-Suprapubic bulge appears due to presence of the placenta in the lower uterine segment. 3- The passage of gush of blood per vagina. 4- The umbilical cord outside the vulva increases in length. 5- Loss of pulsation in the cord when pressure is exerted on the funds. 11/11/ :32 ص Dr/ Hanan Elsayed

39 11/11/ :32 ص Dr/ Hanan Elsayed

40 A healthy placenta after delivery.
Pic ( 128 ) Pic ( ) A healthy placenta after delivery. (A). Notice the shiny surface of the fetal side. The umbilical cord is inserted in the center of the fetal surface. (B). The maternal side is rough and divided into segments (cotyledons). 11/11/ :32 ص Dr/ Hanan Elsayed

41 Pic ( ) 11/11/ :32 ص Dr/ Hanan Elsayed

42 Methews Duncan’s Method
Schuitze’s Method 20% of cases 80% of cases Percentage More liability for bleeding Less liability for bleeding Bleeding Start in periphery as a button and button hole Start in the center as an inverted umbrella Separation Presented by maternal surface Presented by fetal surface Mode 11/11/ :32 ص Dr/ Hanan Elsayed

43 MANAGEMENT OF LABOR The expertise to management of normal labor begins well before the onset of labor, enabling proper preparation of the mother for the birth. This primarily involves education about what happens at each stage and in addition, a variety of methods which enable the mother to control pain to some degree and to regulate expulsive efforts during the second stage. 11/11/ :32 ص Dr/ Hanan Elsayed

44 In the Egypt today most of women are confined to hospital because obstetric emergencies like
fetal hypoxia and postpartum haemorrhage can spontaneously occur in apparently normal deliveries and the facilities are readily at hand, a long with deal with these here. 11/11/ :32 ص Dr/ Hanan Elsayed

45 No labor is normal until the fourth stage is safely concluded and since danger can arise at anytime to the mother and the fetus. 11/11/ :32 ص Dr/ Hanan Elsayed

46 1- complete history taking:
Personal, gynecological &obstetrics, medical &surgical etc 2- Full examination: Temperature, pulse, BP, respiratory rate, state of hydration are all stated. Check urine for ketones, protein and glucose. 11/11/ :32 ص Dr/ Hanan Elsayed

47 3- Abdominal/obstetric examination:
Inspection, palpation, auscultation to determine fetal lie, position and the state of the presenting part. It will also show the frequency and strength of uterine contractions. The fetal heart rate is checked and any abnormalities of the rate and rhythm is noted. 11/11/ :32 ص Dr/ Hanan Elsayed

48 4- Vaginal examination:
This should be performed after cleansing the vulva and introitus and using an aseptic technique. It will show: Degree of dilatation of the cervix, consistency and effacement. Whether the membranes are intact or ruptured. The nature and position of the presenting part and fetal head. Assessment of the bony pelvis, particularly the pelvic outlet. 11/11/ :32 ص Dr/ Hanan Elsayed

49 5- Examination of the vulva: Inspect for gaping of introitus.
Observe colour and odour of liquor amnii, and presence of meconium or blood. Offensive odour indicates infection. Check for oedema of the vulva. If present, it indicates pre-eclampsia. 11/11/ :32 ص Dr/ Hanan Elsayed

50 During labor the woman should always be informed about the dilatation of the cervix, and the condition of her baby, if the fetal hear rates monitored, you must explain the purpose of the fetal heart rate monitor to the mother too. The reason for any intervention should also be discussed with the mother and her partner fully. 11/11/ :32 ص Dr/ Hanan Elsayed

51 Therefore the general principles of management are:
Observations and intervention if the labor becomes abnormal. Pain relief and emotional support for the mother. Adequate hydration throughout labor. 11/11/ :32 ص Dr/ Hanan Elsayed

52 Heart Rate (Beats per minute)
FETAL HEART RATES Table 1 Fetal heart rate definitions Heart Rate (Beats per minute) Definition ( ) ( ) >180 ( ) <100 Normal Tachycardia - moderate - severe Bradycardia - moderate - severe 11/11/ :32 ص Dr/ Hanan Elsayed Table ( 7 )

53 5-Signs of maternal distress:
Increased pulse rates over 100 b/min. Elevated temperature, more than 37.5 c0 Decreased blood pressure. Sweating and pale face. Signs of dehydration. Dark vomitus. Ketone bodies in urine Irritability and restlessness. Anxious expression. 11/11/ :32 ص Dr/ Hanan Elsayed

54 11/11/ :32 ص Dr/ Hanan Elsayed

55 Nursing diagnosis: Alteration in comfort: acute pain related to uterine contraction. Anxiety related to impending labor and delivery. Rest is important in the first stage of labor to reserve energy, prevent and anxiety, and maintain mental equilibrium. 11/11/ :32 ص Dr/ Hanan Elsayed

56 6-Signs of fetal distress:
Increase or decrease of fetal heart rate . Excessive fetal movements. Excessive moulding of the fetal head. Passage of meconium in cephalic presentation Excessive formation of caput succedanum. Propulsive: from full dilatation to the presenting part reaching the pelvic floor. 11/11/ :32 ص Dr/ Hanan Elsayed

57 Nursing Diagnosis: Pain related to descent of the fetus and stretching of vagina and perineum. Fatigue related to inability to rest and pushing efforts. Anxiety related to unknown outcome of labor process. High risk for infection. Risk for Trauma related to pushing techniques and positioning for delivery 11/11/ :32 ص Dr/ Hanan Elsayed

58 The advantages of this position are:
Voluntary efforts are better brought up. Change of position is not needed to check FHS and to conduct 3rd stage of labor. Draping woman and preserving aseptic techniques are easy. Left lateral position: Woman lies on left side, her thighs are partly flexed and her knees are held apart by the help of another person. 11/11/ :32 ص Dr/ Hanan Elsayed

59 The advantages of this position are:
Decrease liability of perineal laceration. Easy removal of feces. Easy manipulation of shoulders. Woman feel more comfort 11/11/ :32 ص Dr/ Hanan Elsayed

60 1-Preparations: A- Preparation of the delivery room:
Delivery room should always be ready for the conduction of labor. Delivery trolley and emergency drug tray should be ready. The delivery room should be warm enough for the baby. 11/11/ :32 ص Dr/ Hanan Elsayed

61 Enough privacy should be provided.
All equipment needed for baby's care, and resuscitation trolley should be ready for use at all times. Safety of woman should be ensured. She should be transferred between contractions, and supported adequately. Enough privacy should be provided. Strict aseptic technique should be maintained.\ 11/11/ :32 ص Dr/ Hanan Elsayed

62 B- Preparation of the woman:
Place the woman on the delivery table and put her legs in leg holders. The legs and thighs should be dressed with sterile leggings. Sterile towels should be laid over abdomen and under buttocks, leaving only vulva and perineum exposed. Empty the bladder. Swab external genitalia and apply sterile pad. 11/11/ :32 ص Dr/ Hanan Elsayed

63 C-Preparation of the attendant:
The attendant should put on cap and mask, wash and scrub hands, and put on a sterile gown and gloves. The attendant starts to scrub up for primigravida when head is seen at the vulva during contractions, and for multipara-towards the end of the first stage. 11/11/ :32 ص Dr/ Hanan Elsayed

64 2-Promotion of comfort:
Encourage the woman to rest and to let all muscles relax between contractions, e.g. breathing exercises. Give few sips of water to provide moisture, and relieve dryness of mouth. Sponge the face and hands with cool water. Keep the woman informed of her progress. 11/11/ :32 ص Dr/ Hanan Elsayed

65 3-Bearing down: Prop up the woman with additional pillows to assume semi-recumbent position. Encourage her to push during contractions, and to relax between contractions. Teach the woman how to bear down .She takes a deep breath, holds it, closes her lips and glottis, and bears down. The woman must not cry out or make any sound because much of the expulsive force will be wasted. 11/11/ :32 ص Dr/ Hanan Elsayed

66 4-Observations: Close and frequent observation is very important for both the woman and fetus. The fetal heart should be checked after 2-3 contractions. If fetal distress is suspected, check it after each contraction. The maternal pulse should be taken every 10 minutes. The strength and frequency of the contractions, and whether the uterus is relaxed between them must be closely watched. 11/11/ :32 ص Dr/ Hanan Elsayed

67 5-Protection of perineum:
Obtain the woman's co-operation. She should only push when instructed, and must desist while the head is actually being born. Maintain flexion, and control too rapid extension of the head. Deliver the head between contractions. 11/11/ :32 ص Dr/ Hanan Elsayed

68 6-After delivery of the head:
Wipe the eyelids with separate swabs of sterile cotton. Wipe any mucus from the mouth and nostrils with a gauze swab. If the umbilical cord is looped round the baby's neck, slip it over the head if it is loose, or clamp and cut it, if it is tight. Give the woman IM syntometrine, 1 ml after delivery of the baby's anterior shoulder, or after expulsion of placenta, to stimulate uterine contractions and prevent bleeding. Note and record the time of birth. 11/11/ :32 ص Dr/ Hanan Elsayed

69 Evaluation (expected outcomes):
The woman is able to push effectively. She gains support and comfort from the nursing personnel. Her physiological and psychological status has been maintained. The baby is born without difficulty. 11/11/ :32 ص Dr/ Hanan Elsayed

70 EPISIOTOMY The decision to perform an episiotomy requires considerable experience and judgment. The aim of this procedure is to deliver the fetal head but minimize perineal tears. However not all women experience a severe tear and certainly most multi-gravidae will be able to deliver with an intact perineum. Primi-gravidae may also be able to avoid an episiotomy. 11/11/ :32 ص Dr/ Hanan Elsayed

71 AIM: To enlarge the outlet in order to
Hasten delivery of a distressed baby. For instrumental or breech delivery. To protect a premature head. 11/11/ :32 ص Dr/ Hanan Elsayed

72 COMPLICATIONS OF EPISIOTOMY
1.Bleeding 2.Infection and breakdown. 3. Haematoma formation. 4. Superficial dyspareunia. 5.Incorrect repair leading to change in size of introitus. 11/11/ :32 ص Dr/ Hanan Elsayed

73 Management of third stage of labor
Assessment: Assess uterine contractions. Observe maternal vital signs. 11/11/ :32 ص Dr/ Hanan Elsayed

74 Nursing Diagnosis: Fatigue related to inability to rest and pushing efforts during labor. Alteration of comfort, pain related to episiotomy, perineal distension, and muscle strain during labor. Alteration of fluid less than body requirements. Knowledge deficit related to physiological changes of normal labor, new-born care, and self care. High risk for infection secondary to episiotomy during delivery. 11/11/ :32 ص Dr/ Hanan Elsayed

75 Immediate care of the newborn
ABCW principles of delivery: Remember the following ABCW principles of delivery to ensure adequate resuscitation of the baby: Airway. Breathing. Circulation. Warmth. 11/11/ :32 ص Dr/ Hanan Elsayed

76 Objectives of immediate care of the newborn:
To establish and maintain respiratory function. To provide warmth and prevent hypothermia. To provide safety from injury and infection. To identify actual and potential problems that might require immediate action. 11/11/ :32 ص Dr/ Hanan Elsayed

77 Assessment of the baby's condition:
The airway: to clear the airway, hold the baby upside down for few seconds and perform gentle suction to establish breathing, and improve baby's colour. The APGAR Score: APGAR score involves consideration of 5 signs, and the degree to which they are present or absent. It is recorded at 1 and 5 minutes after birth. 11/11/ :32 ص Dr/ Hanan Elsayed

78 Body pink and extremities blue Blue and pale Colour
2 1 Sign Fast above 140 Slow below 100 absent Heart rate Good crying Weak crying Respiration Active flexion Some flexion Limp or flaccid Muscle tone Good response Grimace No response Reflex irritability Completely pink Body pink and extremities blue Blue and pale Colour Total Score = Normal = Mild asphyxia= Severe asphyxia = 0 - 3 11/11/ :32 ص Dr/ Hanan Elsayed

79 3-Wamth: It is very important to keep the baby warm at birth because he will lose heat rapidly through evaporation . So, labor room should be arm and the baby should be dried gently, and wrapped in a warm dry towel to avoid exposure. 4-Umbilical cord: Use sterile plastic clamp at 3-5 cm from umbilicus to prevent strangulation, and a congenital umbilical hernia. Then cut away from the clamp about 1cm. Nowadays, alcohol gauze and bandage are not applied to the stump. 11/11/ :32 ص Dr/ Hanan Elsayed

80 5-Weight and measurements:
Weigh the baby after birth. The normal weight is 2.5 – 3.5 kg. Measure its length. The average length is 50 cm. Pic ( 139 ) 11/11/ :32 ص Dr/ Hanan Elsayed Pic ( 140 )

81 6-Measure its circumferences
6-Measure its circumferences. The head and chest circumferences are 13 inches. Care of eyes: The eyes are washed with sterile warm water. Erythromycin ointment is the drug of choice now. 7-Vitamin K should be given to prevent bleeding. 11/11/ :32 ص Dr/ Hanan Elsayed

82 8-Identification: It is very important to label the baby by its sex, and its mother's name. Identity bracelet is placed around wrist or ankle. Neck strand of lead, or footprint, may be used. 11/11/ :32 ص Dr/ Hanan Elsayed

83 Fourth stage of labor Definition: Duration:
The Fourth stage of labor involves the very close observation of mother and infant after the delivery of the placenta. It begin with the delivery of the placenta and ends after one hour postpartum. Duration: One to two hours after the delivery of the placenta 11/11/ :32 ص Dr/ Hanan Elsayed

84 Care during the fourth stage of labor:
Note & record vital signs & blood pressure. Observe and record the amount of vaginal blood loss every 15 minutes or more often if necessary. Make sure that the uterus is hard and well contracted. Massage the uterus gently and frequently to maintain firm contraction. 11/11/ :32 ص Dr/ Hanan Elsayed