THE LABOR PROCESSThe woman in labor

Theories of Labor Onset• Uterine Stretch Theory – any hollow body

organ when stretched to capacity will necessarily contract and empty

• Oxytocin Theory – Labor being considered a stressful event, stimulates the hypophysis to produce oxytocin from the posterior pituitary gland. It causes the contraction of the smooth muscles of the body

• Progesterone Deprivation Theory – proesterone being the hormone designed to promote pregnancy is believed to inhibit uterine motility.

• Prostaglandin Theory – Initiation of labor is said to result from the release of arachidonic acid produced by steroid action on lipid precursors. Arachidonic acid is said to increase prostaglandin synthesis which in turn causes uterine contractions.

• Theory of Aging Placenta – because of the decrease in blood supply the uterus contracts.

Labor is influenced by a combination of Factors from the mother and Fetus:• Uterine muscle stretching which results

in prostaglandin release• Pressure on the cervix, which stimulates

the release of oxytocin from the posterior pituitary

• Oxytocin stimulation, which works together with prostaglandin to initiate contractions

• Change in the ratio of estrogen and progesterone

• Placental age which triggers contraction at a set point

• Rising fetal cortisol levels, which reduce progesterone formation and increase prostaglandin formation

• Fetal membrane production of prostaglandin, which stimulates contraction

PRELIMINARY SIGNS OF LABOR• LIGHTENING – the settling of the fetal

head into the pelvic brim. In PRIMIs, it occurs 2 weeks before EDC; in MULTIS it occurs on or before labor onset.

• It should not be confused with engagement, engagement occurs when the presenting part has descended into the pelvic inlet.

Lightening results in:• Increase in urinary frequency

• Relief of abdominal tightness and diaphragmatic pressure

• Shooting pain down the legs because of pressure on the sciatic nerve

• Increase in the amount of vaginal discharges

• Increased Activity Level – due to increased epinephrine secreted to prepare the body for the coming “work” ahead. Advise the pregnant woman not to use this increased energy for doing household chores

• Loss of weight – about 2-3 lbs, 1 to 2 days before labor onset; due to decrease in progesterone production leading to decrease in fluid retention

• BRAXTON HICKS CONTRACTIONS – pain less irregular practice contractions

• RIPENING OF THE CERVIX - an internal sign seen only on pelvic examination. At term, the cervix becomes still softer and can be described as buttersoft, and it tips forward.

• SHOW – as the cervix softens and ripens the mucus plug that filled the cervical canal during pregnancy is expelled. The blood, mixed with mucus, takes on a pinked tinge.

RUPTURE OF THE MEMBRANES• It is important to remember that once

membranes have ruptured:1. Labor is inevitable. It will occur within 4

hours2. The integrity of the uterus has been

destroyed. Infection can easily set in. That is why once membrane have ruptured:

1. Aseptic techniques should be observed in all procedures

2. Less obstetric manipulation (e.g. IE)

3. Enema is no longer ordered

4. Temperature should be taken regularly so that fever a sing of infection can be detected

UMBILICAL CORD COMPRESSION/ CORD PROLAPSE CAN OCCUR

• A woman in labor seeking admission to the hospital and saying that her BOW has ruptured should be put to bed immediately and the fetal heart tones taken consequently

• If a woman in the labor Room says that her membranes have ruptured, the initial nursing action is to take the fetal heart tones

• If a woman in labor says that she feels a loop of the cord coming out of the vagina (cord prolapse), the first nursing action is to put her on Trendelenburg position in order to reduce pressure on the cord ( REMEMBER: ONLY 5 MINUTES OF CORD COMPRESSION CAN ALREADY LEAD TO IRREVERSIBLE BRAIN DAMAGE OR EVEN DEATH)

• Apply a warm saline-saturated OS on the prolapsed cord to prevent drying

TRUE AND FALSE LABOR CONTRACTIONS

• FALSE CONTRACTIONS– BEGIN AND REMAIN IRREGULAR– REMAIN CONFINED TO ABDOMEN AND

GROIN– DISAPPEARS WITH AMBULATION AND

SLEEP– NO INCREASE IN DURATION FERQUENCY

OR INTENSITY– DO NOT ACHIEVE CERVICAL DILATION

TRUE LABOR PAINS• MAY BEGIN IRREGULAR BUT BECOME

REGULAR AND PREDICTABLE• FELT FIRST IN THE LOWER BACK AND

SWEEP AROUND TO THE ABDOMEN IN A GIRDLE-LIKE FASHION

• INCREASE IN DURATION, FREQUENCY AND INTENSITY

• CONTINUE NO MATTER WHAT THE WOMAN’S LEVEL OF ACTIVITY

• ACHIEVE CERVICAL DILATION

SIGNS OF TRUE LABOR• UTERINE contractions – the surest sign that

labor has begun is the initiation of effective, productive uterine contractions

• Pain in uterine contractions results from:

• Contraction of uterine muscles when in an ischemic state

• Pressure on nerve ganglia in the cervix and lower uterine segments

• Stretching of ligaments adjacent to the uterus and in the pelvic joints

• Stretching and displacement of the tissues of the vulva and perineum

PHASES OF UTERINE CONTRACTIONS

• INCREMENT – FIRST PHASE DURING WHICH THE INTENSITY OF CONTRACTION INCREASES; ALSO KNOWN AS CRESENDO

• ACME – THE HEIGHT OF UTERINE CONTRACTION ALSO KNOWN AS APEX

• DECREMENT – LAST PHASE DURING WHICH INTENSITY OF CONTRACTION DECREASES; ALSO KNOW AS DECRESENDO

• EFFACEMENT – shortening and thinning of the cervical canal as distinct from the uterus. It is expressed in percentage

• DILATION – enlargement of the external cervical os up to 10 cm primarily as a result of uterine contractions and secondarily as a result of pressure of the presenting part and the BOW

UTERINE CHANGES• The uterus is gradually differentiated into two

distinct portions

• UPPER UTERINE SEGMENT – becomes thick and active to expel out fetus

• LOWER UTERINE SEGMENT – becomes thin walled, supple and passive so that fetus can be pushed out easily

PHYSIOLOICAL RETRACTION RING

• Formed at the boundary of the upper and lower uterine segments.

• In difficult labor when the fetus is larger than the birth canal, the round ligaments of the uterus become tense during dilation and expulsion, causing an abdominal indentation called BANDL’S pathological retraction ring, adanger sign of labor signifying impending rupture of the uterus.

COMPONENTS OF LABOR• The womans pelvis (PASSAGE) is of

adequate size and contour

• The PASSENGER (fetus) is of appropriate size and in an advantageous position and presentation

• The POWERS of labor (uterine factors) are adequate

• The woman’s PSYCHE

PASSAGE• The route the fetus must travel from the

uterus through the cervix and vagina to the external perineum.

• For the fetus to pass through the pelvis, the pelvis must be of adequate size.

• DIAGONAL CONJUGATE = the anterior-posterior diameter of the inlet

• TRANSVERSE DIAMETER of the outlet

PASSENGER• The passenger is the fetus

• The body part of the fetus that has the widest diameter is the head

• STRUCTURE OF THE FETAL SKULL:

• CRANIUM – upper most portion of the skull, comprises of 8 bones

• Important bones in childbirth: Frontal, 2 parietal and the occipital bone

• Frontal bone is referred to as the sinciput

• Occipital bone is referred to as the occiput

• The bone of the skull meet at suture lines

• Sagittal suture, Coronal suture, Lambdoid suture

• The suture lines are important in birth because they allow the cranial bones to move and overlap = MOLDING

• Significant membrane-covered spaces called the fontanelles are found at the junction of the main suture line

• Anterior Fontanelle (Bregma) lies at the junction of coronal and sagittal sutures. Diamond in shape. AP diameter is 3 – 4 cm. Transverse Diameter 2 – 3 cm.

• Posterior Fontanelle lies at the junction of Lambdoidal and sagittal sutures

• VERTEX the space between the two fontanelles

Diameters of the Fetal Skull• Wider in its anterior posterior diameter than

in its transverse diameter

• To fit through the birth canal, the fetus must present the smaller diameter to the smaller diameter of the maternal pelvis

• SUBOCCIPITOBREGMATIC DIAMETER – the narrowest diameter (9.5 cm), measured from the inferior aspect of the occiput to the center of anterior fontanelle

• OCCIPITOFRONTAL DIAMETER – measured from the bridge of the nose to the occipital prominence (12cm)

• OCCIPITOMENTAL DIAMETER – widest anteroposterior diameter, measured from the chin to the posterior fontanelle.(13.5 cm)

• BIPARIETAL DIAMETER (9.25 cm) – the narrowest diameter

• In full flexion, the head flexes so sharply that the chin rest on the thorax, the smallest anteroposterior diameter will be presented to the birth canal. (suboccipitobhregmatic)

• Moderate flexion, Occipitofrontal diameter will be presented

• Poor Flexion, head is hyperextended, the largest diameter (occipitomental) will be presented

• The anteroposterior diameter of the fetal head must fit through the transverse diameter of the pelvic inlet, (12.4 to 13.5 cm) and at the outlet through the anteroposterior diameter of the pelvis (9.5 to 11.5 cm)

• MOLDING – the change in shape of the fetal skull produced by the force of uterine contractions pressing the vertex against the not yet dilated cervix.

Fetal Presentation and Position• ATTITUDE – the degree of flexion the fetus

assumes during labor or the relation of the fetal parts to each other.

• A fetus in good attitude is in complete flexion: spinal column is bowed forward, head is flexed forward so much that the chin touches the sternum, the arms are flexed and folded on the chest, the thighs are flexed onto the abdomen the calves are pressed aginst the posterior aspect of the thighs

• A fetus is in moderate flexion if the chin is not touching the chest but is in an alert or military position. Occipital diameter present to the birth canal

• Partial extension presents the brow of the head to the birth canal.

• If a fetus is in poor flexion, the back is arched, the neck is extended and the fetus is in complete extension, presenting the occipitomental diameter of the head to the birth canal.

• ENGAGEMENT – refers to the settling of the presenting part of the fetus far enough into the pelvis to be at the level of the ischial spines, a midpoint of the pelvis.

• A presenting part that is not engaged is said to be floating

• One that is descending but has not yet reached the iliac spines can be said to be dipping

• The degree of engagement is assessed by vaginal and cervical examination.

Station• Refers to the relationship of the presenting

part of the fetus to the level of the ischial spines

• Presenting part is at the level of ischial spines, it is at a 0 station.

• Above the spines, the distance is measured and described as minus station (-1cm to – 4 cm)

• Below the spines = plus stations (+1cm to +4cm)

FETAL LIE• Lie is the relationship between the long axis

of the fetal body and the long axis of the woman's body

• Longitudinal lie ( with their long axis parallel with the long axis of the woman)

• Horizontal or transverse lie

Types of fetal Presentation• Denotes the body part that will first contact

the cervix or deliver first• CEPHALIC PRESENTATION – the head is

the body part that first contacts the cervix• Four types of cephalic presentation (vertex,

brow, face and mentum)• BREECH PRESENTATION – means that

either the buttocks or feet are the first body parts to contact the cervix (complete, Frank, and footling)

SHOULDER PRESENTATION• Fetus is lying horizontally in the pelvis so that

its long axis is perpendicular to that of the mother.

• Presenting part may be the acromion of shoulder, iliac crest, a hand, or elbow.

• Caused by grand multiparity, placenta previa, pelvic contractions

Types of Fetal Position• POSITION is the relationship of the

presenting part to a specific quadrant of the woman’s pelvis

• 4 quadrant of the pelvis: Right anterior, Left anterior, Right posterior, Left posterior

• Landmarks: Vertex: occiput, Face: Chin or Mentum, Breech: Sacrum, Shoulder: Scapula or acromion

• Position is marked by abbreviation of 3 letters. The middle letters denotes the fetal landmark( O for occiput, M for Mentum, Sa for sacrum, A for acromion process)

• The 1st letter defines whether the landmark is pointing to the mothers right or left.

• The last letter defines whether the landmark is pointing Anteriorly, posteriorly or transveresely.

• LOA most common fetal position; ROA 2nd most frequent position

FOUR METHODS ARE USED TO DETERMINE FETAL POSITION

PRESENTATION AND LIE• Combined abdominal inspection and

palpation

• Vaginal examination

• Auscultation of FHT

• Sonography

CARDINAL MOVEMENTS OF LABOR

• DESCENT – downward movement of the biparietal diameter of the fetal head to within the pelvic inlet

• Occurs when the fetal head extrudes beyond the dilated cervix and touches the posterior vaginal wall

• Occurs because of pressure on the fetus by the uterine fundus aided by abdominal muscle contractions.

• FLEXION

• Pressure from the pelvic floor causes the fetal head to bend forward onto the chest

• The smallest anteroposterior diameter is the one presented to the birth canal in this flexed position

• Flexion is aided by abdominal muscle contraction during pushing

INTERNAL ROTATION• The occiput rotates until it is superior, or just

below the symphysis pubis, bringing the head into the best diameter for the outlet of the pelvis.

• This movement brings the shoulders, into the optimal position to enter the inlet or puts the widest diameter of the shoulders in line with the wide transverse diameter of the inlet.

EXTENSION

• As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. The head thus extends, and the foremost parts of the head, the face and the chin are born.

EXTERNAL ROTATION• Almost immediately after the head of the

infant is born, the head rotates back to the diagonal position or transverse position of the early part of labor.

Expulsion• Once the shoulders are born, the rest of the

baby is born easily and smoothly because of its smaller size.

• This is the end of pelvic division of labor

Powers of Labor• Supplied by the fundus of the uterus, a process that

causes cervical dilatation and then expulsion of the fetus from the uterus.

• Uterine contractions, labor contractions begin at a pacemaker point located in the myometrium near one of the uterotubal junctions.

• Each contraction begins at that point and then sweeps down over the uterus as a wave.

• In some women, contractions appear to originate in the lower uterine segment rather than in the fundus.

• Reverse, ineffective contractions, cause tightening rather than dilation of the cervix.

Phases of Contraction• INCREMENT – when the intensity of

contractions increases

• ACME – when the contraction is at its strongest

• DECREMENT – when the intensity decreases

• Between contractions the uterus relaxes

• Relaxation intervals decreases from 10 minutes early in labor to - 3 minutes.

• The duration of contractions also changes, increasing from 20 – 30 seconds to a range of 60 to 90 seconds.

PHYSIOLOGIC RETRACTION RINGS

• As labor contractions progress and become regular and strong, the uterus gradually differentiates itself into two distinct functioning areas.

• The upper portion becomes thicker and active.

• Lower segments become thin walled, supple, and passive, so the fetus can be pushed out of the uterus easily.

PATHOLOGIC RETRACTION RING OR

BANDL’S RING• It is a danger sign that signifies impending

rupture of the lower uterine segment if the obstruction to labor is not relieved.

CERVICAL CHANGES

• EFFACEMENT – shortening and thinning of the cervical canal.

• In primiparas, effacement is accomplished before dilation begins

• In multiparas, dilation may proceed before effacement is complete

DILATATION• ENLARGEMENT OF THE CERVICAL

CANAL FROM AN OPENING A FEW MILLIMETERS WIDE TO ONE LARGE ENOUGH TO PERMIT PASSAGE OF THE FETUS.

• As dilation begins, there is an increase in the amount of vaginal secretions (SHOW), because it is dislodge.

• Minute capillaries in the cervix ruptures.

PSYCHE• Psychological state or feelings that women

bring into labor with them.

• A feeling of apprehension or fright.

• For many it includes a sense of excitement or awe

• Women who manage best in labor typically are those who have a strong sense of self estem and a meaningful support person.

STAGES OF LABOR

FIRST STAGE• Divided into three phases: LATENT,

ACTIVE, AND TRANSITION PHASE

• Latent Phase – or preparatory phase begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilation begins.

• Contractions are mild and short, lasting 0 – 40 seconds.

LATENT PHASE• CERVIX DILATES FROM 0 TO 3 CM

• LAST FOR 6 HOURS IN A NULLIPARA

• 4.5 HOURS IN A MULTIPARA

• MOTHER IS EXCITED WITH SOME DEGREE OF APPREHENSION BUT STILL WITH ABILITY TO COMMUNICATE

NURSING CARE

• ENCOURAGE WALKING

• ENCOURAGE TO VOID EVERY 2 – 3 HOURS

• BREATHING EXERCISES

ACTIVE PHASE• Cervical dilation reaches 4-8cm

• Rapid increase in duration, frequency and intensity or contractions

• Mother fears losing control of himself

• Contractions are stronger lasting 40-60 seconds and occuring every 3-5minutes.

• Last for 3 hours in NULLIPARA and 2 hours in a multipara

NURSING CARE• MONITORING AND EVALUATING

IMPORTANT ASPECT

• Uterine contractions – DURATION – from the beginning of one

contraction to the end of the same contraction.– INTERVAL – from the end of one contraction to

the beginning of the next contraction (early in labor 40 – 45 minutes, late in labor 2 – 3 minutes)

• INTENSITY – The strength of a contraction, maybe mild moderate or strong

• FREQUENCY – from the beginning of one contraction to the beginning of the next contraction

BLOOD PRESSURE• Should not be taken during a contraction as

it tend to increase

• BP reading should be taken at least every half hour during active labor

• When a woman in labor complains of a headache, the first nursing action is to take the BP.

FETAL HEART RATE

• Should not be mistaken with uterine souuffle• Normally 120 – 160 per minute

• Should not be taken during a uterine contraction because it tends to decrease. Compression of the fetal head when the uterus contracts stimulates the vagal reflex which, in turn, causes bradycardia.

• Should be taken every hour during the latent phase of labor, every half of an hour during active phase.

• Every 15 minutes during the transition phase

• For any abnormality in FHR, the initial nursing action is to change the mothers position

SIGNS OF FETAL DISTRESS

• BRADYCARDIA (FHR less than 100/minute or tachycardia (FHR more than 180/minute)

• Meconium-stained amniotic fluid in non-breech presentation

• Fetal – thrashing – hyperactivity of the fetus as it struggles for more oxygen

• Emotional support is provided for the woman in labor by keeping her constantly informed of the progress of labor

• Health Teachings:

• Bath – is advisable if contractions are tolerable or not too close to one another. Will make the mother more comfortable

• AMBULATION – helps shorten the first stage of labor

• Solid or liquid foods are to be avoided because:

• Digestion is delayed during labor

• A full stomach interferes with proper bearing down

• May vomit and cause aspiration

• Enema– Purpose: A full bowel hinders the progress of

labor

– Expulsion of feces during second stage of labor predisposes the mother and baby to infection

– Full bowel predisposes to postpartum discomfort

• Contraindications to enema in labor– Vaginal bleeding– Premature labor– Abnormal fetal presentation or position– Ruptured membranes– crowning

• Encourage the mother to void every -3 hours by offering the bedpan because–A full bladder retards fetal descent–Urinary stasis can lead to urinary

tract infection–A full bladder can be traumatized

during delivery

• Perineal prep – done aseptically. Use no. 7 method, always from front to back

• Perineal shave – not a routine procedure; maybe done to provide a clean area for delivery. Muscles at the symphysis pubis should be kept taut and razor moved along the direction of hair growth

SIMS POSITION• Favors anterior rotation of the fetal head

• Promotes relaxation between contractions

• Prevents continual pressure of the gravid uterus on the inferior venacava

• Women in labor should not be allowed to push or bear down unecessarily during contractions of the first stage because it leads to unnecessary exhaustion

• ABDOMINAL BREATHING – advised for contractions during the first stage in order to reduce tension and prevent hyperventilation

TRANSITION PERIOD• When the mood of the woman suddenly

changes and the nature of the contractions intensify

• Characteristics– If membranes are still intact, this period is

marked by a sudden gush of amniotic fluid as fetus is pushed into the birth canal

– Show becomes more prominent

• There is an uncontrollable urge to push with contractions, a sign of impending second stage of labor. Profuse perspirations and distention of the neck veins are seen.

• Nausea and vomiting is a reflexreaction due to decreased gastric motility and absorption

• In primis, baby is delivered within 20 contractions (40 minutes); in multis, after 10 contractions (20 minutes)

Comfort measures• Sacral pressure

• Proper bearing down techniques: push with contractions

• Controlled chest breathing during contractions

• Emotional support

SECOND STAGE• Stage of expulsion

• Begins with complete dilatation of the cervix and ends with the delivery of the baby

• Overwhelming, uncontrollable urge to push or bear down with contractions as if she had to move her bowels

NURSING CARE• When positioning legs on lithotomy, put them

up at the same time to prevent injury to the uterine segments

• As soon as the fetal head crowns instruct the mother not to push, but to pant. If panting is deep and rapid, called hyperventilation, patient will experience lightheadedness and tingling sensation of the fingers leading to carpopedal spasms because of respiratory alkalosis.

• Assist in episiotomy – incision made in the perineum primarily to prevent lacerations

• Prevent prolonged and severe stretching of muscles supporting the bladder or rectum

• Enlarge outlet

• Reduce duration of second stage

Types of Episiotomy• MEDIAN – from middle portion of the lower

vaginal border directed toward the anus

• MEDIOLATERAL – Begun in the midline but directed laterally away from the anus

• Natural anesthesia is used in episiotomy because pressure of fetal presenting part against the perineum is so intense that nerve endings for pain are momentarily deadened.

MODIFIED RITGEN’S MANEUVER• Cover the anus with sterile towel and exert

upward and forward pressure on the fetal chin, while exerting gentle pressure with two fingers on the head to control emerging head.

• This will not only support the perineum, thus preventing lacerations, but will also favor flexion so that the smallest diameter of the fetal head is presented.

• Immediately after delivery, the newborb should be held below the level of the mothers vulva for a few minutes to encourage flow of blood from the placenta to the baby

• The infant is held with his head in a dependent position to allow for drainage of secretions. Never stimulate the baby to cry unless you have drained the secretions

• Wrap the baby in a sterile towel to keep him warm. Chilling increases the body’s need for oxygen

• Put the baby on the mothers abdomen. The weight of the baby will help contract the uterus

• Cutting of the cord is postponed until the pulsations have stopped because it is believed tha 50 – 100 ml of blood is flowing from the palcenta to the baby at this time

THIRD STAGE/ PLACENTAL STAGE

• SIGN OF PLACENTAL SEPARATION

• Uterus becoming round and firm again, rising high to the level of the umbilicus (calkin’s sign) – earliest sign of placental separation

• Sudden gush of blood from the vagina

• Lengthening of the cord

TYPES OF PLACENTAL DELIVERY

• SCHULTZ – If placenta separates first at its center and last at its edges, it tends to fold back on itsefl like an umbrella and presents the fetal surface which is shiny (shiny for schultz) 80 % of placenta separate inthis manner

• DUNCAN – if placenta separates first at its edges, it slides along the uterine surface and presents with the maternal surface which is raw, red, beefy, irregular and dirty (dirty for duncan). Only about 20 % of placenta separates this way.

NURSING CARE• Do not hurry the expulsion of the placenta by

forcefully pulling out the cord or doing vigorous fundal push as this can cause uterine eversion, just watch for the sign of placental separation

• Tract the cord slowly, winding it around the clamp until the placenta spontaneously comes out, slowly rotating it so that no membranes are left inside the uterus = BRANDT ANDREWS MANEUVER

• Take note of the time of placental delivery. It should be delivered within 20 minutes after the delivery of the baby.

• Inspect for the completeness of cotyledons; any placental fragments retained can cause severe bleeding in the mother

• Palpate the uterus to determine degree of contraction. If relaxed boggy or non-contracted, first nursing action is to massage gently and properly. An ice cap over the abdomen will also help contract the uterus.

• Inject OXYTOCIN (Methergin = 0.2 mg/ml or syntocinon = 10 U/ml) IM to maintain uterine contractions, thus prevent hemorrhage. NOTE: oxytocin are not given before placental delivery

• inspect the perineum for laceration=bright red vaginal bleeding

Categories of lacerations• First Degree – involves the vaginal mucous

membranes and perineal skin• Second Degree – involves not only the muscles,

vaginal mucous membranes and skin, but also the muscles

• Third degree – involves not only the vaginal mucous membranes and skin, but also the external sphincter of the rectum

• Fourth Degree – involves not only the external sphincter of the rectum, the muscles, vaginal mucous membranes and skin, but also the mucous membrane of the rectum.

• Assist the doctor in doing episiorrhapy (repair of the episiotomy or laceration). In vaginal episiorrhapy, packing is done to maintain pressure on the suture line, thus prevent further bleeding. Vaginal packs have to be removed after 24 – 48 hours

• Make mother comfortable by perineal care and applying clean sanitary napkin snugly to prevent the moving forward from the anus to the vaginal opening. Soiled napkin should be removed from front to back

• Position the newly delivered mother flat on bed without pillows to prevent dizziness due to decrease in intraabdominal pressure

• The newly delivered mother may suddenly complains of chills due to decreased blood pressure, fatigue or cold temperature in the delivery room.

• Give initial nourishment: milk, tea

• Allow patient to sleep in order to regain lost energy

Fourth stage• First 1 – 2 hours after delivery which is said

to be the most critical stage for the mother because of unstable VS

• Assessment:• FUNDUS – should be checked every 15

minutes for 1 hour then every 30 minutes for the next 4 hours. Fundus should be firm in the midline and during the first 12 hours postpartum, is a little above the umbilicus

LOCHIA• Should be moderate in amount. Immediately

after delivery, a perineal pad can be completely saturated after 30 minutes. If saturated in 15 minutes or earlier, amy mean hemorrhage

• Uterine discharges consisting of blood, decidua,WBC, mucus and some bacteria

PATTERN• RUBRA – first 3 days postpartum, red and

moderate in amount

• SEROSA – next 4 – 9 days; pink or brownish and decreased in amount

• ALBA – from 10th day up to 3 – 6 weeks postpartum; colorless and minimal in amount

CHARACTERISTICS OF LOCHIA• Pattern should not reverse• Should not have any offensive odor; foul

smelling, may mean either poor hygiene or infection

• It should not contain large clots• It should never be absent, regrdless of

method of delivery• Increases with activity and decreases with

breastfeeding

BLADDER

• A full bladder is evidenced by a fundus which is to the right of the midline and dark red bleeding with some clots. Will prevent adequate uterine contraction

PERINEUM• Is normally tender, discolored and

edematous. It should be clean with intact sutures

• Blood pressure and pulse rate may be slightly increased from excitement and effort of delivery, but normalize within one hour

Puerperium• Postpartum – refers to the six weeks period

after delivery of the baby of the baby

• Involution – return of the reproductive organs to their pre pregnant state.

• Principles of postpartum care:– Promote healing and return to normal of different

parts of the body

Vascular Changes• The 30 – 50 % increase in total cardiac

volume during pregnancy will be reabsorbed into the general circulation within 5 – 10 minutes after placental delivery.

• Implications: the first 5 – 10 minutes after placental delivery is crucial to gravidocardiacs because the weak heart may not be able to handle such workload

• WBC count increases to 20,000 – 30,000

• Implication: The WBC count therefore, cannot be used as an indication or sign of postpartum infection

• There is an extensive activation of the clotting factors, which encourage thromboembolization.

This is the reason why:• Ambulation is done early – 4 – 8 hours after

normal vaginal delivery• Recommended exercises:

– Kegels and abdominal breathing on postpartum day 1

– Chin to chest on PPD2 to tighten and firm up abdominal muscles

– Knee to abdomen when perineum has healed, to strenghten the abdominal muscles and gluteal muscles.

• All blood values are back to prenatal levels by the 3rd or 4th week postpartum

• Genital changes – uterine involution is assessed by measuring the fundus or fingerbreadth.

• On PPD 1 fundus is 1 fingerbreadth below the umbilicus

• On PPD2 fundus is 2 fingerbreadths below and until PPD10.

• To encourage the return of the uterus to its usual anteflexed position, prone and knee chest position are advised

• Afterpains/ afterbirth pains – normal and rarely last for more than 3 days

• Management:– Never apply heat on the abdomen

– Give analgesics as ordered

Pain in the Perineal region may be relieved by:

• Sim’s Position – minimizes strain on the suture line

• Perineal heat lamp or warm Sitz baths twice a day

• Application of topical analgesics or administration of mild oral analgesics as ordered

Sexual Activity

• Maybe resumed by the third or 4 th week postpartum if bleeding has stopped and episiorrhapy has healed.

• Decreased physiologic reactions to sexual stimulation are expected for the first 3 months postpartum because of hormonal changes and emotional factors

MENSTRUATION• If not breast feeding return of menstrual flow

is expected within 8 weeks after delivery.

• If breastfeeding, menstrual return is expected in 3 – 4 months

• In some women no menstruation occurs during the entire lactation period

• Postpartum check – up – should be done after the 6th week postpartum to assess involution

• Gastrointestinal Changes – delayed bowel evacuation postpartally may be due to:– Decrease muscle tone– Lack of food or enema during labor– Dehydration– Fear of pain from perineal tenderness

URINARY CHANGES

• MARKED DIURESIS within 12 hours postpartum to eliminate excess tissue fluid accumulation during pregnancy

Vital Signs• Temperature may increase because of the

dehydrating effects of labor• Implications: any increase in body

temperature during the first 24 hours postpartum is not necessarily a sign of postpartum infection

• Bradycardia is common for 6 – 8 days postpartum

• No change in the respiratory rate

WEIGHT

• There is an immediate weight loss of 10 – 12 pounds

• Further weight loss will occur during the next days due to diaphoresis

Psychological phases during postpartum period are:

• Taking-in-phase – first 1 – 2 days postpartum when mother is passive and relies on others to care for her and her newborn

• She keep on verbalizing her feelings regarding the recent delivery for her to be able to integrate the experience into herself

Taking-hold phase• Begins to initiate action and make decision

• Postpartum blues (an overwhelming feeling of sadness that cannot be accounted for)

• Could be due to hormonal changes, fatgue or feelings of inadequacy in taking care of a new baby.

• Management: explain that it is normal; crying is therapeutic

• 7 days and above, interdependent phase

• Redifine roles and set new goals as parent

• Extends until the child grows

Letting Go phase

• Prevent Postpartum complications– HEMORRHAGE

– INFECTION

RISK CONDITION• INFECTIONS

• Syphilis– causes: Treponema Pallidum- a spirochete

which enters the body during coitus or through cuts and breaks in the skin or mucous membrane

– Treatment: 2.4 – 4.8 million units of Penicillin will usually prevent congenital syphilis in the newborn because it readily crosses the placenta

• If untreated syphilis can cause midtrimester abortion, CNS lesions in the newborn or even death

• The Newborn with congenital syphilis– jaundice at 2 weeks of life – first sign of the

disease– Anemia and Hepatosplenomegaly– Snuffles (persistent rhinorrhea), coppery rashes

on palms and soles; mucous patches; pseudoparalysis d/t bone inflammation

RUBELLA/GERMAN MEASLES• Incidence:

– Mother: the earlier the mother contracted the disease, the greater the likehood that the baby will be affected. Rubella virus slows down division of infected cells dring organogenesis, thus causing congenital defects

– Newborn: can carry and transmit the virus for as long as 12 – 24 months after birth

SIGNS AND SYMPTOMS• Low birth weight; jaundice;

petechiae;anemia;thrombocytopenia;hepatosplenomegaly

• Classic sequelae:– Eyes:cataract, glaucoma– Heart: PDA, Stenosis, Coarctations– Ear: Nerve deafness– Dental and facial clefts

POSTPARTUM INFECTIONS

• SOURCES:– Endogenous (primary) source – bacteria in the

normalflora become virulent when tissues are traumatized and general resistance is lowered

– Exogenous Sources – pathogens introduced from external sources (streptococci)

Common exogenous sources• Hospital personnel

• Excessive obstetric manipulation

• Break in aseptic technique – faulty handwashing, unsterile equipments and supply

• Coitus in late prenancy

• Premature rupture in the membrane

General symptoms:• Malaise

• Anorexia

• Fever

• Chills

• Headache

General Management

• Complete bed rest

• Proper nutrition

• Increased fluid intake

• Analgesics

• Antipyretics and antibiotics as ordered

• If untreated can progress to deformed bones, teeth, nose joints and CNS syphilis

• Management: Penicillin IM for 10 days or one long acting penicillin

Types of Infection• Infection of the Perineum

• Specific symptoms:

• Pain, heat and feeling of pressure in the perineum

• Inflammation of the suture line with 1 or 2 stitches sloughed off

• With or without elevated temperature

• Specific Management– Doctor remove sutures to drain area and

resutures

– Hot sitz bath or warm compress

ENDOMETRITIS• Inflammation or infection of the lining of the

uterus

• Specific symptoms:

• Abdominal Tenderness

• Uterus not contracted and painful to touch

• Dark brown foul smelling lochia

• Specific Management

• Oxytocin administration

• Fowlers position to drain out lochia and prevent pooling infected discharges

THROMBOPHLEBITIS• Infection of the lining of a blood vessel

formation of clots; usually an extension of endometritis

• Specific symptoms:• Pain, stiffness and redness in the affected

part of the leg• Legs begins to swell below the lesion

because venous circulation has been blocked

• Skin is stretched to a point of shiny whiteness, called milk leg or phlegmasia alba dolens

• Positive Homan’s sign – pain in the calf when the foot is dorsiflexed

Management• Bed rest with affected legs elevated

• Anticoagulants to prevent furthe clotformation or extension of a thrombus

• MASTITIS – inflammation of breast tissues

BLEEDING HEMORRHAGE• Bleeding in Pregnancy

• First Trimester Bleeding:

• ABORTION– Spontaneous( Threatened/Imminent) = Complete

& incomplete– Induced– Missed

ECTOPIC PREGNANCY• Tubal• Cervical• OvarianII. SECOND TRIMESTER BLEEDING

a. Hydatidiform Moleb. Incompetent Cervical Os

III. THIRD TRIMESTER BLEEDINGa. Placenta Previab. Abruptio Placenta