Process of Labor and birth

Begins with the onset of regular contractions and ends with the expulsion of the placenta

labor: known as the process by which childbirth will occur

Normal process (healthy) not ill

• Uterine stretch
• estrogen increases/Progesterone withdrawl
• increase oxytocin sensitivity
• increase release of prostagladins- hormone sends message for contraction- even the fetus will excrete this. this comes from different place
• increase of relaxin- relax all organs and helps to separate symphis

Each stage of labor has a different nurse intervention

Placental aging triggering initiation of contraction

Prostagladins synthesis by the fetal membrane and the decidua stimulates contractions

fetal cortisol levels produced by the adrenal gland rises and acts on the placenta to reduce progesterone levels and incre prostagladins levels

• backache 
• cervical changes
• lightening- primite 2 wks before multi right before
• incre energy level (nesting)
• bloody show- mucous plug- the cervix is very vascular which causes this show
• contractions- may be irregular (braxton hicks) that eventually progress in strength and regularity 
• spontaneous rupture of membranes- maybe or not
• GI changes- everything slows down this is what moms can't eat cause they will vomit this

• Passageway (birth canal pelvis and soft tissue)
• Passenger (fetus and placenta)
• Powers (contractions)
• Position (maternal)- get moms up and moving
• Psychological response- fear and anxiety can cause them to tighten up

• Maternal bony pelvis
• - imaginary line called the linea terminalis divides the pelvis into true and false portions

• false pelvis (above linea terminalis)
• True pelvis
• - inlet
• - mid pelvis
• - outlet (pelvic measurements)

transverse diameter- from hip to hip

anterior-posterior diameter- this goes from ur pubic bone to your coccoxy (this is the easiest to measure)

a nice gynecoid pelvis is the best for babies to navigate in.

• Cervix- muscle
• - dilation and effacement- 1-10cm 100% effaced
• Pelvic floor muscles
• - the pelvic floor muscles help the fetus to rotate anteriorly as it passes thru the birth canal
• Vagina
• - expands to accommodate the fetus during birth

• effacement- shortening and thinning of the cervix
• - expressed as percentage related to the length of the cervical canal in comparison to a noneffaced cervix

• Dilation: opening or enlargement of the cervix
• - expressed in cm
• - 0cm (closed) to 10cm (fully dilated)
• Cervical softening loss of rigidity- tightness

• u do this bi manual
• it is pretty much subjective
• use of sterile gloves

• Floating
• - above 0 station (above ischial spine) not engaged. at a negative station
• - presenting part hits the ischial spine this is called engagement
• - presenting part is directed towards the pelvis but can be moved out of the inlet
• - considered to be floating
• - ballotable- when u go to check mom vaginally- can get push the baby out..above the ischial spine fetus in negative

station: refers to the relationship of the presenting part to the level of the maternal pelvis ischial spine 

engagement: signifies the entrance of the largest diameter of the fetal presenting part (usually the fetal head) into the smallest diameter of the maternal pelvis. the fetus is engaged when the presenting part reaches 0 station. 

• Fetus with the placenta
• - fetal skull (size and pressence of molding)
• - fetal attitude (degree of body flexion)
• - fetal lie (relationship of body part)
• - fetal presentation (first body part)
• - fetal position ( relationship to maternal pelvis)
• - fetal station
• - fetal engagement

• Molding:
• - elongated shape of the fetal skull at birth as a result of overlapping of cranial bones

• Sutures:
• - composed of strong but flexible connective tissue that fills the spaces that lie between the cranial bones

• fontanels: 
• - membrane filled spaces
• - anterior
• - posterior
• - tells you fetus position- we can tell if the baby is looking up or is the baby looking down?

u want the baby to present with their sub occipital bone

refers to the posturing of the joints (flexion or extension) and the relationship of the fetal parts to one another (is the fetus flexed or extended)

an attitude of extension present the larger fetal skull diameters, which may birth difficult

• Vertex (best)- nice tucked flexed position
• Miltary lay- when the fetus head is not flexed but just straight (moderate) standing at attention trying to come thru the pelvis straight on
• Brow: head up alittle bit. u are touching the forhead. if u are going to reach for the anterior fontanel u may have to reach more for it
• face presentation: face is head (this is a huge diameter). when baby is like this u have to c-section (extended)

fetal lie refers to the relationship to the maternal long axis (spine) to the fetus long axis (spine)

Longitudinal- (parellel lie fetal spine to maternal spine)

transverse lie- fetal spine lies across the maternal abdomen and cross her spine (makes a t). moms pelvis is not fitting in nice

• Fetal presentation 
• cephalic presentation (four types)

Vertex presentation: head fully flexed. occipital bone presenting (sub occipitobregmatic diameter)

Miltary presentation: head presents in a neutral postion. top of head ( occipitalfrontal diameter)

Brow presention: fetal head is partially extending

Face presentation: fetal head is fully extending

fetal buttocks enter the maternal pelvis first 

3 types

Frank presentation- legs go straight up 

complete (full) presentation- indian sitting legs cross, hands cross head tuck

footling presentation- single footling, double footling

• transverse lie 
• u cant see the attitude
• c-section

cephalic advantages- vaginal

breech- c-section- if the next contraction didnt come quick enough the cervix will begin to close and this usually happens around the neck so thats why they prefer to section

fetal position the relationship of the presenting part, preferable the occiput in reference to its directional position as it relates to one of the four quadrants

split into four parts: right anterior, left anterior, right posterior, left posterior

• Fetal presenting part:
• occipital bone- O vertex presentign
• chin (mentum M) face presenting
• buttucks (sacrum S). breech presentation
• scapula (acromion process A) shoulder presentation
• dorsal (D) fetal back in shoulder presentation 

position is indicated by three letter abreviation documentation

• First letter
• is the presenting part towards the left or right of maternal pelvis

• Second letter
• what is the presenting part of the fetus?
• occiput, scarum, acromion process, dorsal

is the presenting part anterior (A) front portion of maternal pelvis or Posterior back portion of maternal pelvis or is the presenting part transverse (side to side)

• Engagement
• Descent
• flexion (once the navigate thru this pelvis then they do)
• Internal rotation (until they get into a nice position)
• extension (now they need to find the vagina)
• external rotation (to get the shoulders out)
• expulsion

every darn fool in rotherdam eats rotten egg roll everyday

• Primary
• - involuntary contractions (once the prostagladins are working that why pre term mom cant have sex cause sperm has prostagladins in it)
• - with each contraction, upper segment of the uterus shorter and thicker (fundus bc of power)
• - lower segment becomes longer and thinner (so the baby can move down in it)
• - responsible for dilation and effacement of cervix
• - facilitate movement of presenting part toward the lower uterine segment

• Intra abdominal pressure (voluntary muscle contractions) exerted by the women has she pushes and bears down
• promotes birth of the fetus and expulsion of the fetal membranes and placenta from the uterus 
• during second stage of labor

• moving around during labor and birth (even with epidural) or
• changing position every two hours- from left to right
• - influences pelvic size and contour
• - facilitate fetal descent and rotation (gravity)
• - reduces the length of labor
• - enhance sense of control
• - increase comfort/reduce requests for pain medication
• - if no epidural they can be up sitting on balls

• psyche women;s state of mind can impact the process
• Positive
• have a strong sense of self confidence and control
• support not being alone
• feel safe and secure trust staff caring for her
• positive reaction to pregnancy
• preparation for childbirth experience
• negative
• fear and anxiety decreases a women's ability to cope due to increase catecholamine excretion (fear hormone) makes their cervix tight
• during this time things that happened in her childhood like sexual abuse may occur..which she may be anxious bc she is being violated

Philosophies two: disease process v normal process (low tech and high touch)

• Partners (supportive)
• supports, massage, conveys laboring women's wishes
• doula
• nursing pressence: positive experience less intervention

Patience (natural timing) or reduced c-section 

• patient preparation (childbirth knowledge based)
• prepares her with knowledge
• increases feeling of control confidence
• active participant
• opportunity to strenthen family by anticipatory guidance

• universal experience
• subjective - interaction
• focus pain relief controlling pain w/out harming baby
• check every hour

usually mom has a birth.