Labor and Delivery
Normal Labor and Delivery Processes
Signs Preceding Labor (Does not imply labor has started!)
Lightening
Urinary Frequency
Backache
Stronger Braxton Hicks Contractions
Flu-like symptoms or fatigue
Surge of energy (nesting)
Slight weight loss
Bloody show
Cervical ripening
Loss of mucous plug
Couple of other terms to know
Braxton Hicks contractions – short usually not painful, tightening or contractions of uterus.
Should have less than 6 in an hour – goes away with change in activity
ROM (Date/time, color, amount, odor) We need to know this for all pregnant or laboring patient.
If their bag of waters (or membranes) are intact (BOWI or I) or ruptured and if ruptured for how
long = can indicate risk factors.
Document always!!
Standard Protocols
Typically:
If ROM – she will remain in the hospital
If in labor will be on the monitor
Most of the time if admitted, she will have IV, labs (CBC with platelets, Type and screen, UA at
minimum - may have a lot of prenatal labs completed at this time if no previous prenatal care)
May be NPO or ice chips/Clear Liquids
While on monitor -document: FHR, variability, accels/decels, contraction pattern (frequency,
duration, intensity or absence of….)
A word about Group Beta Strep (GBS)
ACOG, AAP and CDC recommend all women get tested (vaginal and rectal swab) at 34-37 weeks)
If positive: woman is treated in labor (unless C/S is planned and her membranes are still intact)
Causes Of Labor (Therories)
The first 5 Ps of Labor
We don’t know what causes it – but know what affects it.
The Passenger (Fetus and placenta)
The Passage (birth canal: soft tissues and boney pelvis)
The Powers (contractions)
Position (maternal)
The Psyche (psychological response)
The Passenger Sutures and Fontanelles :
Allow molding of the fetal head (caput succedaneum, cephalohematoma)
Serve as landmarks to assess fetal attitude and position
Vertex:The smallest diameter of the fetal head (suboccipitobregmatic) should move through the
, pelvis.
Feto-pelvic Relationship s We’ll talk more about these in a minute
Fetal presentation
Fetal attitude
Fetal lie
Fetal Position
Passenger Fetal Presentation: (All pictures are in your text)
The part of the fetal body that enters the pelvis first and leads through the birth canal.
Cephalic (95%)
Breech (3%)
Shoulder (2%) `
Passenger Fetal Attitude: The relationship of fetal parts to each other
The relationship of the fetal parts to each other:
Vertex (flexed) (A)
Military (extended) (B)
Brow or Face (extended) (C&D)
Passenger Fetal Lie: The relationship of the fetal spine to the maternal spine
Vertical lie - cephalic or breech
Horizontal or transverse lie
Passenger Fetal Position : The relationship of the presenting part to the maternal pelvis
OA: Occiput Anterior - optimal position for labor
OP: Occiput Posterior - prolongs first and second stage labor; typically causes “back labor”
OT: Occiput Transverse - causes arrest of descent at the ischial spines
Passenger Fetal Station (engagement)
Floating (ballotable) = - 4 -3 -2 -1 0 +1 +2 +3 +4 = Crowning
0 = At Ischial Spines
The Passageway
The bony pelvis - joints are softened by the hormone relaxin
(4 types: gynecoid, android, anthropoid, platypelloid)
The soft tissues - cervix, vagina, perineum - estradiol, progesterone, relaxin, and prostaglandins
increase tissue size and elasticity
The Powers
Uterine contractions cause effacement and dilation
You DON’T have to check dilation every hour!!
Hydrostatic force of the membranes and amniotic fluid facilitate effacement and dilation
Secondary - bearing down efforts (pushing) in the second stage facilitates expulsion. These have
no effect on dilation, but help with expulsion.
The Position
Affects maternal and uteroplacental perfusion
Affects maternal perception of pain
Basic physics - Affects fetal position and rotation in the pelvis
, Effects of Recumbent Position
Aortocaval compression leading to maternal hypotension and fetal distress
Narrower birth canal
Loss of pelvic mobility
Loss of gravity
Less efficient contractions
Greater discomfort and pain
Slower progress of labor
Supine Hypotension
Benefits of Lateral Recumbent Position
Provides rest
Corrects aortocaval compression
Can be used to facilitate rotation of baby
Facilitates interventions - Monitoring, regional anesthesia
Benefits of Upright Positions in Labor
Utilize gravity to speed labor progress
Provide more maternal control
Decrease pain and discomfort
Facilitate rotation of fetus through the pelvis
Allow more interaction with labor support persons
Upright Positions for labor
Semi-reclining
Sitting (chair or rocking chair)
Standing
Walking
Lunges
Squatting
The Psyche
“You can do it!”
Every woman wants to know that she is doing well, that the baby is doing well, and that she can
handle labor.
Stages of Labor
Stages and Phases
1st Stage – Closed cervix to 10cm dilated
1st Stage Phases:
Latent or early phase
Active Phase
Transition
nd
2 Stage – Pushing and birth of baby
rd
3 Stage – Delivery of Placenta
4th Stage - Recovery
The First Stage
From onset regular contractions to completely dilated
Normal Labor and Delivery Processes
Signs Preceding Labor (Does not imply labor has started!)
Lightening
Urinary Frequency
Backache
Stronger Braxton Hicks Contractions
Flu-like symptoms or fatigue
Surge of energy (nesting)
Slight weight loss
Bloody show
Cervical ripening
Loss of mucous plug
Couple of other terms to know
Braxton Hicks contractions – short usually not painful, tightening or contractions of uterus.
Should have less than 6 in an hour – goes away with change in activity
ROM (Date/time, color, amount, odor) We need to know this for all pregnant or laboring patient.
If their bag of waters (or membranes) are intact (BOWI or I) or ruptured and if ruptured for how
long = can indicate risk factors.
Document always!!
Standard Protocols
Typically:
If ROM – she will remain in the hospital
If in labor will be on the monitor
Most of the time if admitted, she will have IV, labs (CBC with platelets, Type and screen, UA at
minimum - may have a lot of prenatal labs completed at this time if no previous prenatal care)
May be NPO or ice chips/Clear Liquids
While on monitor -document: FHR, variability, accels/decels, contraction pattern (frequency,
duration, intensity or absence of….)
A word about Group Beta Strep (GBS)
ACOG, AAP and CDC recommend all women get tested (vaginal and rectal swab) at 34-37 weeks)
If positive: woman is treated in labor (unless C/S is planned and her membranes are still intact)
Causes Of Labor (Therories)
The first 5 Ps of Labor
We don’t know what causes it – but know what affects it.
The Passenger (Fetus and placenta)
The Passage (birth canal: soft tissues and boney pelvis)
The Powers (contractions)
Position (maternal)
The Psyche (psychological response)
The Passenger Sutures and Fontanelles :
Allow molding of the fetal head (caput succedaneum, cephalohematoma)
Serve as landmarks to assess fetal attitude and position
Vertex:The smallest diameter of the fetal head (suboccipitobregmatic) should move through the
, pelvis.
Feto-pelvic Relationship s We’ll talk more about these in a minute
Fetal presentation
Fetal attitude
Fetal lie
Fetal Position
Passenger Fetal Presentation: (All pictures are in your text)
The part of the fetal body that enters the pelvis first and leads through the birth canal.
Cephalic (95%)
Breech (3%)
Shoulder (2%) `
Passenger Fetal Attitude: The relationship of fetal parts to each other
The relationship of the fetal parts to each other:
Vertex (flexed) (A)
Military (extended) (B)
Brow or Face (extended) (C&D)
Passenger Fetal Lie: The relationship of the fetal spine to the maternal spine
Vertical lie - cephalic or breech
Horizontal or transverse lie
Passenger Fetal Position : The relationship of the presenting part to the maternal pelvis
OA: Occiput Anterior - optimal position for labor
OP: Occiput Posterior - prolongs first and second stage labor; typically causes “back labor”
OT: Occiput Transverse - causes arrest of descent at the ischial spines
Passenger Fetal Station (engagement)
Floating (ballotable) = - 4 -3 -2 -1 0 +1 +2 +3 +4 = Crowning
0 = At Ischial Spines
The Passageway
The bony pelvis - joints are softened by the hormone relaxin
(4 types: gynecoid, android, anthropoid, platypelloid)
The soft tissues - cervix, vagina, perineum - estradiol, progesterone, relaxin, and prostaglandins
increase tissue size and elasticity
The Powers
Uterine contractions cause effacement and dilation
You DON’T have to check dilation every hour!!
Hydrostatic force of the membranes and amniotic fluid facilitate effacement and dilation
Secondary - bearing down efforts (pushing) in the second stage facilitates expulsion. These have
no effect on dilation, but help with expulsion.
The Position
Affects maternal and uteroplacental perfusion
Affects maternal perception of pain
Basic physics - Affects fetal position and rotation in the pelvis
, Effects of Recumbent Position
Aortocaval compression leading to maternal hypotension and fetal distress
Narrower birth canal
Loss of pelvic mobility
Loss of gravity
Less efficient contractions
Greater discomfort and pain
Slower progress of labor
Supine Hypotension
Benefits of Lateral Recumbent Position
Provides rest
Corrects aortocaval compression
Can be used to facilitate rotation of baby
Facilitates interventions - Monitoring, regional anesthesia
Benefits of Upright Positions in Labor
Utilize gravity to speed labor progress
Provide more maternal control
Decrease pain and discomfort
Facilitate rotation of fetus through the pelvis
Allow more interaction with labor support persons
Upright Positions for labor
Semi-reclining
Sitting (chair or rocking chair)
Standing
Walking
Lunges
Squatting
The Psyche
“You can do it!”
Every woman wants to know that she is doing well, that the baby is doing well, and that she can
handle labor.
Stages of Labor
Stages and Phases
1st Stage – Closed cervix to 10cm dilated
1st Stage Phases:
Latent or early phase
Active Phase
Transition
nd
2 Stage – Pushing and birth of baby
rd
3 Stage – Delivery of Placenta
4th Stage - Recovery
The First Stage
From onset regular contractions to completely dilated
