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Mechanism of Labour

Mechanism of Labour (LOA & ROA)

Definition

Mechanism of labour is the series of passive movements of the fetus during its passage
through the maternal pelvis during labour.

Principles of Mechanism of Labour

1. Descent takes place through out labour


2. Whichever part leads and first meets the resistence of the pelvic floor will rotate forward
until it comes under the symphysis pubis
3. Whatever emerges from the pelvis will pivot around the pubic bone.

LEFT OCCIPITO ANTERIOR (LOA)

Lie : Longitudinal
Presentation : Vertex
Position : LOA
Attitude : Flexion
Denominator : Occiput
Presenting part : Posterior part of the right parietal bone.

Descent
Descent takes place due to forceful uterine contraction and retraction, rupture of membranes,
complete cervical dilatation and maternal efforts.

Flexion
Flexion is increased throughout labour. When the head meets the resistance of the pelvic floor
flexion is increased. The increased flexion will decrease the presenting diameter ie., sub
occipito-frontal (10cm) to a smaller diameter suboccipito-bregmatic (9.5cm). The occiput
becomes the leading part.

Internal rotation of the head


The occiput leads and meets the pelvic floor first and rotates anteriorly 1/8 th of the circle to
come under the symphysis pubis. The anteroposterior diameter of the head now lies in the
anteroposterior diameter of the pelvic outlet.

Crowning
The occiput slips beneath the subpubic arch and crowning occurs when the head no longer
recedes back between the contractions and the widest transverse diameter (biparietal) is born.

Extension of the head


The fetal head pivots around the pubic bone while the sinciput, face and chin sweep the
perineum and head is born by the movement of extension.

Restitution
The twist in the neck of the fetus that resulted from internal rotation is now corrected by a
slight untwisting movement. The occiput moves 1/8 th of the circle towards the side from
which it started.

Internal rotation of the shoulders


The anterior shoulder reaches the pelvic floor first in the left oblique diameter and rotates
forward 1/8th of the circle from right to left and thus the shoulders are now in the AP diameter
of the pelvis.

External rotation of the shoulders


It takes place simultaneously with internal rotation of the shoulders and the occiput of the
fetal head now lies laterally facing mothers right thigh.

Lateral flexion
The anterior shoulder escapes under the symphysis pubis, posterior shoulder sweeps the
perineum and body is born by the movement of lateral flexion.

RIGHT OCCIPITO ANTERIOR (ROA)

Lie : Longitudinal
Presentation : Vertex
Position : ROA
Attitude : Flexion
Denominator : Occiput
Presenting part : Posterior part of the left parietal bone.

Descent
Descent takes place due to forceful uterine contraction and retraction, rupture of membranes,
complete cervical dilatation and maternal efforts.

Flexion
Flexion is increased throughout labour. When the head meets the resistance of the pelvic floor
flexion is increased. The increased flexion will decrease the presenting diameter ie., sub
occipito-frontal (10cm) to a smaller diameter suboccipito-bregmatic (9.5cm). The occiput
becomes the leading part.

Internal rotation of the head


The occiput leads and meets the pelvic floor first and rotates anteriorly 1/8 th of the circle to
come under the symphysis pubis. The anteroposterior diameter of the head now lies in the
anteroposterior diameter of the pelvic outlet.
Crowning
The occiput slips beneath the subpubic arch and crowning occurs when the head no longer
recedes back between the contractions and the widest transverse diameter (biparietal) is born.

Extension of the head


The fetal head pivots around the pubic bone while the sinciput, face and chin sweep the
perineum and head is born by the movement of extension.

Restitution
The twist in the neck of the fetus that resulted from internal rotation is now corrected by a
slight untwisting movement. The occiput moves 1/8 th of the circle towards the side from
which it started.

Internal rotation of the shoulders


The anterior shoulder reaches the pelvic floor first in the right oblique diameter and rotates
forward 1/8th of the circle from left to right and thus the shoulders are now in the AP diameter
of the pelvis.

External rotation of the shoulders


It takes place simultaneously with internal rotation of the shoulders and the occiput of the
fetal head now lies laterally facing mothers left thigh.

Lateral flexion
The anterior shoulder escapes under the symphysis pubis, posterior shoulder sweeps the
perineum and body is born by the movement of lateral flexion.
Posted by Eva Chris at 9:46 am
Systematic supervision of a woman during pregnancy is called antenatal care. The
supervision should be of a regular and periodic nature in accordance with the principles laid
down or more frequently according to the need of the individual. It is the education,
supervision and treatment to a pregnant woman so that her pregnancy and labour will
terminate with delivery of a mature healthy living baby, without injury to the mind or body of
the mother. The objective of Antenatal care is to ensure a normal pregnancy with delivery of a
healthy baby from a healthy mother.

Aims of antenatal care:

1. to monitor the progress of pregnancy in order to ensure maternal health and normal
fetal development.

2. to recognise the deviation from the normal and provide management or treatment as
required.

3. to ensure that the woman reaches the end of her pregnancy physically and emotionally
prepared for her delivery.

4. to identify high risk pregnancy and for their proper management.


5. to reduce or prevent maternal and perinatal mortality and morbidity

6. to help and support the mother in breast feeding and parenting.

7. to offer family welfare advices on parenthood.

Antenatal care comprises of:

1. Registration of pregnancy

2. History taking

3. Antenatal examinations [general and obstetrical]

4. Health education

A. Registration of pregnancy:
The registration of pregnancy must be done in an antenatal clinic within 12 weeks.

B. History taking:
A complete history of the woman including the following is collected in the first visit.

1. Demographic data (Name, age, address, marital status, religion, education, occupation
etc)

2. Menstrual history.

3. Personal history.

4. Past medical and surgical history.

5. Family history.

6. History of present pregnancy (last menstrual period LMP, Expected date of delivery
EDD, etc.
7. Obstetrical history (number of pregnancy, any abnormality in previous pregnancies
and deliveries).

8. Calculation of expected date of delivery (EDD): EDD is calculated by adding nine


calendar months and seven days to the date of first day of the woman s last menstrual
period, provided the woman has a regular 28-day menstrual cycle.

C. Antenatal examination:
A complete general examinations of the body is conducted, including

1. Height: The height is carefully recorded, as patients measuring 5 feet or less is more
likely to have a small pelvis that may cause difficulty during delivery.

2. Weight: Weight should be regularly taken using an accurate weighing machine.


Periodic and regular weight checking helps in detecting abnormalities.

3. Pallor: Colour of conjuctiva, soft palate, tongue, and nail beds are to be noted.
(Paleness indicates anemia)

4. Jaundice: Eyes and mouth are to be observed for yellow discolouration. (yellow
discolouration indicates of jaundice)

5. Tongue, teeth, gums: Observe for signs of infection and malnutrition.

6. Legs: Legs are to be examined for oedema.

7. Breasts: Examination of the breasts is mandatory, to note the presence of pregnancy


charges and condition of the nipples (cracked / depressed / inverted).

8. Abdominal and vaginal examinations: Position of the uterus is noted in abdominal


examination. Unless necessary, vaginal examinations is not routinely done except for
the first time when the woman attends the clinic to confirm pregnancy.

Laboratory investigations:
1. Complete blood count including haemoglobin level,
2. Blood grouping and Rh typing.
3. Blood for VDRL
4. Urine examinations:
5. Urine should be tested for albumin, sugar, pus cells,

One to two doses of tetanus toxoid is given to immunize against tetanus infection iron and
folic acid supplements is given

Subsequent visits:

Up to 28 week -- the antenatal check up should be done at an interval of 4 weeks from


the first visit.

Beyond 28 weeks, the antenatal check up should be done at interval of 2 weeks upto
36 week and

thereafter weekly, till the expected date of delivery.

At each visit, the findings are to be recorded in the same card for better evaluation.

D. Health education:
The antenatal education should include.
Diet
The diet during pregnancy should be adequate to provide for
a. the maintenance of maternal health.
b. the needs of the growing fetus.
c. the strength and vitality required during labour and
d. the successful lactation.
The pregnancy diet should be light, nutritious and easily digestible. It should be rich in
protein, minerals vitamins and fibres and of the required calories. Dietary advice should be
given with due consideration to the socio-economic condition, food habits and taste of the
individual. Supplementary iron therapy is needed for all pregnant mothers from 20 weeks
onwards.

Personal hygiene
1. Rest and sleep: The woman may continue her usual activities throughout pregnancy. Hard
and strenuous work should be avoided. On an average, a patient should have 10 hours of
sleep (8 hours at night and 2 hours at noon)
2. Bowel: As there is a tendency of constipation during pregnancy, regular bowel movement
may be facilitated by regulation of diet taking plenty of fluids, vegetables and
milk.
3. Bathing: Daily baths and preferably twice a day are advised.
4. Clothing: The patient should wear loose but comfortable dresses. High heel shoes are
better avoided.
5. Dental hygiene: The dentist should be consulted at the earliest, if necessary.
6. Care of the breasts: Cleanliness of the breasts is maintained. If anatomical defects are
present advise to seek medical help.
7. Coitus: Contact with the husband to be avoided during the first trimester and last 6 weeks.
8. Travel: Long distance travel better to be avoided. Rail route is preferable.
9. Smoking and alcohol: Smoking and alcohol are to be avoided totally during pregnancy as
both cause variable injuries to the fetus.
10. Drugs: The pregnant women should avoid over-the counter drugs (drugs without medical
prescription). The drugs may have teratogenic effects on the growing fetus especially during
the first trimester (The first three months is the period of organogenesis. Teratogens will
cause gross malformation or defects to the fetus. The common teratogens are drugs caffeine,
exposure to x-rays, alcohol, nicotine, etc).

General advice

The patient should be persuaded to attend for antenatal checkup positively on the scheduled
date of visit. She is instructed to report to the doctor even at an early date and if the following
untoward (warning signs and symptoms) symptoms arise:

intense persistent headache

severe oedema

disturbed sleep with restlessness


low urine output (less than 500 ml per day)

epigastric pain

persistent vomiting

painful uterine contractions

sudden gush of watery fluid per vaginum

AMNIOCENTESIS
Description
Amniocentesis is a procedure needing informed consent, in which amniotic fluid is removed
from the uterine cavity by insertion of a needle through the abdominal and uterine walls and
into the amniotic sac. The procedure, when performed between 16 and 18 weeks gestation, is
used in the prenatal diagnosis of genetic or metabolic diseases. In later pregnancy,
amniocentesis is performed for the assessment of fetal lung maturity and to treat
polyhydramnios. Risks associated with the procedure are very low.

In determination of genetic or metabolic diseases, the procedure is performed between


16 and 18 weeks' gestation. It is useful for women 35 years of age or older, for those
with a family history of metabolic disease, a previous child with a chromosomal
abnormality, a family history of chromosomal abnormality, a patient or husband with
a chromosomal abnormality, or a possible female carrier of an X-linked disease.

In determination of lung maturity, the lecithin/sphingomyelin (L/S) ratio of the


amniotic fluid is analyzed.

o When the L/S ratio is 2:1 or greater, the fetal lung is considered mature and
the incidence of respiratory distress syndrome in the newborn is low.

o Results may be less reliable with maternal diabetes or if the fluid is


contaminated with blood or meconium.

The presence of phosphatidylglycerol (PG), one of the last lung surfactants to


develop, is the most reliable indicator of fetal lung maturity. PG is not present until 36
weeks' gestation and is measured as being present or absent. Unlike the L/S ratio, PG
is not affected by hypoglycemia, hypoxia, or hypothermia.
A Triple Marker Screening (TMS) can also be used for the evaluation of trisomy 18
and 21 and neural tube defects. This test is costly when compared to MS-AFP, thus it
is limited in its use. The TMS evaluates unconjugated estriol and hCG: Down
syndrome shows increased hCG and decreased estriol levels; trisomy 18 shows
decreased hCG and decreased estriol levels. The quadruple screen, which includes a
measurement of the substance Diameric Inhibin-A, provides a more sensitive and
accurate detection of trisomy 21.

In the treatment of polyhydramnios (2,000 mL amniotic fluid or > 25 cm amniotic


fluid index [AFI]), amniocentesis may be performed to drain excess fluid and relieve
pressure. Polyhydramnios can be associated with specific fetal abnormalities, such as
trisomy 18, anencephaly, spina bifida, and esophageal atresia or tracheoesophageal
fistula.

Nurse's Responsibility

Reduce anxiety related to the procedure.

o Reduce the parents' anxiety by determining their understanding of the


procedure and the meaning it holds for them.

o Reexplain the procedure before it begins, and answer any questions they have.
Ensure informed consent is signed.

o Provide explanations during the procedure, correct misinformation they may


have, and make sure they know when the results will be available and how
they may obtain the results as soon as possible.

Reduce pain and discomfort related to the procedure.

o Reduce discomfort by having the mother lie comfortably on her back with her
hands and a pillow under her head. Relaxation breathing may help.

o Ensure adequate time between infiltration of local anesthetic and introduction


of needle into the amniotic sac.
o Start I.V. fluids in accordance with institutional policy. Administer terbutaline
subcutaneously or I.V. or ritodrine I.V. per your facility's policy.

Reduce potential for traumatic injury to fetus, placenta, or maternal structures.

o Have the woman empty her bladder if the fetus is more than 20 weeks'
gestation to avoid injury to the woman's bladder. If the fetus is less than 20
weeks' gestation, the woman's full bladder will hold the uterus steady and out
of the pelvis. The placenta is localized with the use of ultrasound.

o Obtain maternal vital signs and a 20-minute fetal heart rate tracing to serve as
a baseline to evaluate possible complications.

o Monitor the woman during and after the procedure for signs of premature
labor or bleeding.

o Tell the woman to report signs of bleeding, unusual fetal activity or abdominal
pain, cramping, or fever while at home after the procedure.

CHORIONIC VILLUS SAMPLING


Description
CVS involves obtaining samples of chorionic villus (placental tissue [fetal origin]) to test for
genetic disorders of the fetus. CVS is performed between 8 and 12 weeks' gestation.

Using an ultrasound picture, a catheter is passed vaginally into the woman's uterus,
where a sample of chorionic villus tissue is snipped off or obtained by suction.

Results from CVS are available in 1 to 2 weeks.

Complications include rupture of membranes, intrauterine infection, spontaneous


abortion, hematoma, fetal trauma, or maternal tissue contamination.

Incidence of fetal loss is about 2% to 5%.

Nurse's Responsibility

Obtain maternal vital signs.


Instruct the woman to void.

Reduce woman's anxiety as related to the procedure.

Inform the woman that a small amount of spotting is normal, but heavy bleeding or
passing clots or tissue should be reported.

Instruct the woman to rest at home for a few hours after the procedure.

PERCUTANEOUS UMBILICAL BLOOD SAMPLING

Description
PUBS, or cordocentesis, involves a puncture of the umbilical cord for aspiration of fetal
blood under ultrasound guidance.

It is used in the diagnosis of fetal blood disorders, infections, Rh isoimmunization,


metabolic disorders, and karyotyping.

Transfusion to the fetus may be conducted with this procedure.

Using ultrasound picture, the provider inserts a needle (guided by ultrasound) for
insertion into one of the umbilical vessels. A small amount of blood is withdrawn.

Can also be used for fetal therapies, such as RBC and platelet transfusion.

Nurse's Responsibility

Explain the procedure to the woman.

Provide support to the woman during the procedure.

Monitor the woman after the procedure for uterine contractions and the fetal heart rate
for distress.

NONSTRESS TEST
Description
The nonstress test (NST) is used to evaluate FHR accelerations that normally occur in
response to fetal activity in a fetus in good condition. Accelerations are indicative of an intact
central and autonomic nervous system and are a sign of fetal well-being. Absence of FHR
accelerations in response to fetal movements may be associated with hypoxia, acidosis, drugs
(analgesics, barbiturates), fetal sleep, and some fetal anomalies.

Maternal indications include postdates, Rh sensitization, maternal age 35 or older,


chronic renal disease, hypertension, collagen disease, sickle cell disease, diabetes,
premature rupture of membranes, history of stillbirth, trauma, vaginal bleeding in the
second and third trimesters.

There are no contraindications or known adverse effects associated with the NST.

Fetal indications include decreased fetal movement, intrauterine growth restriction,


fetal evaluation after an amniocentesis, oligohydramnios or polyhydramnios.

o Criteria for a reactive NST include two accelerations within 20 minutes, each
lasting at least 15 seconds with a FHR increased by 15 bpm above baseline in
response to fetal activity. The quality of the tracing is an important factor in
the test interpretation.

o In a nonreactive or equivocal NST, the above criteria are not met.

Significance/Management

Reactive NST - suggests < 1% chance of fetal death within 1 week of the NST.

Nonreactive NST - suggests fetus may be compromised and there needs to be further
follow-up with a BPP, Contraction Stress Test (CST), or Oxytocin Challenge Test
(OCT).

Equivocal NST - needs to be repeated in 2 to 3 hours or follow-up with CST, OCT, or


BPP.

Nurse's Responsibility
Explain the procedure and equipment to the woman. Make sure the woman has had
adequate nutrition and fluid intake and, if a smoker, has not been smoking within the
past 2 hours.

Assist the woman to a semi-Fowler's position in bed. Perform Leopold's maneuvers,


and apply the external fetal and uterine monitors.

Event markers do not need to be used unless the fetal movement is not observed on
the fetal monitor. If fetal movement not observed, instruct the woman to make a mark
on the monitor strip each time fetal movement is felt. The nurse will do this if the
woman cannot.

Evaluate the response of the FHR immediately after fetal activity.

Monitor the woman's blood pressure and uterine activity for deviations during the
procedure.

FETAL ACOUSTIC STIMULATION TEST AND VIBROACOUSTIC STIMULATION


TEST

Description
Acoustic (sound) and vibroacoustic stimulation (sound plus vibration), involve the use of
handheld battery-operated devices (usually a laryngeal stimulator) placed over the mother's
abdomen near the fetal head. This technique produces a low-frequency vibration and a
buzzing tone intended to induce fetal movement along with associated FHR accelerations.
The sound stimulus lasts for 2 to 5 seconds. The fetal acoustic stimulation test (FAST) and
vibroacoustic stimulation test (VST) are used as an adjunct following a nonreactive NST;
these tests may also be used with fetuses that exhibit decreased FHR variability during labor.
If no FHR accelerations occur in response to the stimulus, it is repeated at 1-minute intervals
up to three times. If the FHR pattern remains nonreactive, further evaluation with BPP or
CST is indicated.

It is not known whether the fetus responds more to the sound or to the vibration.

Both methods of testing are noninvasive, easy to perform, and yield rapid results.
Interpretation depends on individualized institutional guidelines. Usually:

o Reactive - two accelerations meeting 15 15 criteria.

o Nonreactive - no accelerations.

o Equivocal - one acceleration or accelerations not meeting the 15 15


criteria or uninterpretable/unreadable fetal tracing.

Tachycardic rate may result from stimulus and may last > 1 hour. If this occurs,
observe FHR for normal baseline characteristics, other than the tachycardia, until the
FHR returns to the prestimulus rate.

Nurse's Responsibility

Explain procedure, equipment, and purpose to the woman.

Assist the woman to a semi-Fowler's position in bed.

Apply external fetal monitors to the woman.

Demonstrate how the stimulus may feel on the woman's forearm or leg.

Observe for reactivity.

OXYTOCIN CHALLENGE TEST OR CONTRACTION STRESS TEST

Description
This test is used to evaluate the ability of the fetus to withstand the stress of uterine
contractions as would occur during labor.

The test is generally used when a woman has a nonreactive NST or equivocal
FAST/VST, although in many areas, the CST has been replaced by the BPP.
The test is contraindicated in women with third trimester bleeding, multiple gestation,
incompetent cervix, placenta previa, previous classic uterine incision, hydramnios,
history of PTL, or premature rupture of membranes.

Contractions may occur spontaneously (unusual) or they may be induced.

The CST utilizes endogenously produced oxytocin by way of nipple or breast


stimulation.

The OCT utilizes exogenous oxytocin (Pitocin), which is administered by way of I.V.
infiltration.

Nurse's Responsibility

Obtain maternal vital signs, especially blood pressure.

Instruct the woman to void.

Assist the woman to a semi-Fowler's or side-lying position in bed.

Obtain a 20-minute strip of the FHR and uterine activity for baseline data.

For CST:

o Apply warm packs to the breasts for 10 minutes before the CST.

o Instruct the mother on nipple stimulation (four cycles of 2 minutes on


[stimulating] and 2 minutes off [not stimulating]).

If no uterine contractions after four cycles, wait 10 minutes, then


restimulate.

If no uterine contractions after the second four cycles, stop the


stimulation, notify physician, and prepare for OCT or BPP.

o Stop the stimulation if:


Three or more contractions occur within 10 minutes which last > 60
seconds.

Tetanic uterine contractions or hyperstimulation occurs.

For OCT: follow 1 through 4 above. In addition:

o Administer diluted oxytocin through an I.V. infusion pump as indicated until


three contractions occur within 10 minutes and last 40 to 60 seconds. Maintain
mainline I.V. fluids in accordance with facility policy.

o Discontinue the infusion when:

Criteria are met.

Hyperstimulation occurs.

Prolonged deceleration or bradycardia occurs.

Persistent late decelerations are present.

Interpretation of CST/OCT

Negative (normal) - three uterine contractions in 10 minutes without late


decelerations.

Positive (abnormal) - persistent late decelerations or late decelerations with > 50% of
uterine contractions even if frequency is less than three contractions in 10 minutes;
usually associated with hypoxia.

Suspicious (equivocal) - late decelerations with < 50% of uterine contractions or


significant variables.

Unsatisfactory - quality of tracing inadequate to assess or less than three contractions


in 10 minutes.

Hyperstimulation:
o Contractions more frequent than every 2 minutes or lasting > 90 seconds or
hypertonus.

o If no late decelerations with hyperstimulation, it is interpreted as negative.

o If late decelerations with hyperstimulation, it is interpreted as


unsatisfactory and classified as hyperstimulation.

Significance/Management of CST/OCT

Negative - reassuring.

Positive - nonreassuring.

Suspicious - repeat in 24 hours.

Unsatisfactory - repeat in 24 hours.

Hyperstimulation - repeat in 2 hours.

BIOPHYSICAL PROFILE

Description
The BPP uses ultrasonography and NST to assess five biophysical variables in determining
fetal well-being. A BPP is performed during a 30-minute time frame.

Nonstress test - assessing for FHR acceleration in relation to fetal movements.

Amniotic fluid index volume - assessing for one or more pockets of amniotic fluid
measuring inch (2 cm) or more in two perpendicular planes.

Fetal breathing movements - one or more episodes lasting at least 30 seconds.


Gross fetal body movements - three or more body or limb movements, to include
rolling, in 30 minutes.

Fetal muscle tone - one or more episodes of active extension with return to flexion of
spine, hand, or limbs.

For each variable, if the criteria are met, a score of 2 is given. For an abnormal observation, a
score of 0 is given. A score of 8 to 10 is considered normal, 6 is equivocal, and 4 or less is
abnormal.

Nurse's Responsibility

Explain the purpose and procedure to the woman; provide emotional support.

Instruct the woman to empty her bladder.

Assist the woman onto the examination table and help her to assume a position of
comfort.

Remove the lubricant from the woman's abdomen after the procedure.

Assist the woman in rising from the examination table.

active vaginal bleeding, etc.

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