Labor is defined as the onset of rhythmic contractions and the relaxation of

the uterine smooth muscles which results in effacement or progressive thinning of the cervix, and dilation or widening of the cervix. This process culminates with the expulsion of the fetus and expulsion of the other products of conception (placenta and membranes) from the uterus.

TRUE LABOR VS FALSE LABOR

Many women often experience "false labor" before "true labor" actually begins. False contractions may begin as early as three or four weeks before the termination pregnancy. Contractions, show, the cervix, and fetal movement all are vital in distinguishing between true and false labor FACTOR a.

Contractions.

(1) True labor. The contractions of true labor produce progressive dilatation and enfacement of the cervix. These contractions occur regularly and increase in frequency, duration, and intensity. The discomfort of true labor contractions usually starts in the back and radiates around to the abdomen and is not relieved by walking. (2) False labor. False labor contractions are referred to as Braxton Hicks contractions. They do not produce progressive cervical effacement and dilatation. They are irregular and do not increase in frequency, duration, and intensity. Discomfort is located chiefly in the lower abdomen and groin area. Walking often offers relief. b. Show. This is another sign of impending labor. After the discharge of the mucous plug that has filled the cervical canal during pregnancy, the pressure of the descending presenting part of the fetus causes the minute capillaries in the cervix to rupture. This blood is mixed with mucus and therefore has a pink tinge. (1) True labor. Show is usually present in true labor. There will be pinkish mucus or a bloody discharge. This mucus or discharge may also be from the mucous plug from the cervix. (2) False labor. Show is not present in false labor. However, the mother may have an old, brownish discharge especially if she had a vaginal exam within the last 48 hours. c.

Cervix.

(1) True labor. In true labor, the cervix becomes effaced and dilates progressively. This change can be identified within an hour or two. (2) False labor. In false labor, the cervix is usually un-effaced and closed. There is no change identified if the cervix is rechecked in an hour or two.

d.

Fetal Movement.

(1) True labor. There is no significant change in fetal movement even though the fetal continues to move. (2) False labor. Fetal movement may intensify for a short period or it may remain the same.

OVERVIEW OF THE LABOR PROCESSFOUR STAGES 1.First Stage of Labor

a. The first stage of labor is referred to as the "dilating" stage. It is the period from the first true labor contractions to complete dilatation of the cervix (10cm) (see figure 2-2). The forces involved are uterine contractions. The first stage of labor is divided into three phases: a. Latent or Prodromal Phase (Early). In this phase, the mother feels slow, rhythmic contractions radiating from the lumbar region to the anterior portion of her abdomen. The contractions last from 30 to 45 seconds with the intensity gradually increasing. The frequency of contractions is from 5 to 20 minutes. There is some cervical effacement. Dilation is from 0 to 3 cm. "Bloody show" is usually present. The mother is usually able to walk, talk, or laugh some during this phase. Diversion is usually welcomed during this time. This phase may not be included as part of the first stage of labor since it is before the onset of true labor. True labor is considered to be at 4 cm. Duration of this phase varies, sometimes as long as 24 hours and is referred to as the "prolonged latent" phase. The mother may sometimes make some progress dilating from 1 to 2 cm and will then stop. She is usually not admitted to the hospital at this point unless the membranes are ruptured. b. Active or Accelerated Phase. In this phase, the contractions become stronger and last longer, usually 45 to 60 seconds. The frequency is from 3 to 5

minutes. The cervix dilates from 4 to 7 cm. This phase is considered the onset of true labor. The mother is admitted to the hospital at this point. She, then, becomes involved with bodily sensations and tends to withdraw from the surrounding environment. She is not able to walk, but, desires companionship and encouragement. c. Transient or Transitional Phase. In this phase, the contractions are sharp, more intensified, and last from 60 to 90 seconds. The frequency is from 2 to 3 minutes. The cervix dilates from 8 to 10 cm. Completion of this phase marks the end of the first stage of labor. The mother may express feelings of frustration, loss of control, and/or irritability. Her focus becomes internal. She has difficulty comprehending surroundings, events, and instructions. There is an increase in bloody show as a result of the rupture of capillary vessels in the cervix and the lower uterine segment. The mother feels an urge to push or to have a bowel movement. This is considered the most severe and difficult phase for the mother.

NURSING CARE DURING THE FIRST STAGE OF LABOR a. Hospital Admission.

-Initiate the patient's labor chart. -Review the information obtained originally in the exam room, verify and transfer the OB health record to the labor chart per ward policies. You will review the following information: > Obstetric history. 1 Gravida/para. 2 Estimated date of confinement (EDC) or due date. 3 Duration of previous labors. 4 Problems with previous pregnancies/deliveries. >General condition. 1 Rh status. 2 Allergies. 3 History of medical problems. >Current pregnancy. 1 Onset of labor (contractions regular, 5 minutes or less). 2 Frequency, duration, and intensity of contractions. 3 Membranes-ruptured or intact. 4 Amount and character of show or vaginal bleeding. 5 Vital signs.

6 Rate, location of fetal heart tones. 7 Plans to bottle or breast feed. 8 Any problems with this pregnancy.

-Evaluate the patient's current emotional status.

-Evaluate for possible danger signs. (a) Increased pulse or temperature. (b) Excessive vaginal bleeding. (c) Presence of meconium (fetal feces) in the amniotic fluid of a mother with a vertex position. (d) Alteration in fetal heart tones (FHT's) above 160 or below 120. (e) Obvious change in the character of uterine contractions.

b. Perineal Preparation.
Shaving of pubic hair to prevent infection of perineal episiotomy/lacerations is rarely done anymore. There must be a physician's order to perform this task.

c. Cleansing Enema. d. Evaluation of Uterine Contractions

(1) The purpose of this evaluation is to assess the ability of the uterus to dilate the cervix, help in determining the progress of labor, help to detect abnormalities of uterine contractions (such as lack of uterine relaxation), and help to evaluate any signs of fetal distress. (2) This evaluation will help you in identifying the frequency (how often in minutes contractions occur), intensity (strength of contractions when palpitations are identified as mild, moderate, or strong [severe]), and duration (how long the contractions lasts in seconds). (3) When palpating for contractions, place your hand over the fundal area of the patient's uterus. Contractions can be felt by your fingers before the patient actually becomes aware of them. See figure 2-3 for patient experiencing contractions.

e.Monitoring and Recording Color and Amount of Show. As labor progresses, the show
becomes more blood-tinged. A sharp increase in the amount of bloody show coupled with frequent severe contractions may indicate labor is progressing too rapidly. Report this immediately to the Charge Nurse or physician and be prepared for possible delivery.

f. Fetal Vital Signs. Monitor the patient's vital signs.

On admission,Every hour during early labor, Blood pressure (BP), pulse (P), and respiratory rate (R) every 30 minutes during active, transition, and the second stage of labor, to include the temperature every hour.Blood pressure, P, and R every 15 minutes while on Pitocin, to include the temperature every hour. More frequently if complications arise.

g. Vaginal Exams. Only the physician or a trained nurse performs this exam.

It is done to evaluate cervical effacement, cervical dilatation, status of membranes, and station of presenting part. Care must be taken to perform good perineal cleansing before and after the procedure (vaginal exam).

2. Second Stage of Labor

The second stage of labor is referred to as the "delivery or expulsive" stage. This is the period from complete dilatation of the cervix to birth of the baby. The forces involved are uterine contractions plus intra-abdominal pressure. the second
stage of labor begins when the cervix is completely effaced and dilated and ends when the infant is born. Once dilatation and effacement are complete, the patient is instructed to push with each contraction to bring the presenting part down into the pelvis. TRANSFER OF THE LABOR PATIENT TO THE DELIVERY ROOM a. Primigravida patients are transferred when the cervix is completely effaced and dilated and the head or presenting part is crowning.

b. Multipara patients are transferred when the cervix is completely effaced and dilated. The patient usually pushes (i.e., bears down) in the delivery room. She may be transferred prior to complete dilatation (8 to 9 cm) if she is progressing rapidly and the presenting part is descending. These patients are normally not encouraged to push when in the labor room since delivery occurs more rapidly in the multipara patient. NURSING CARE GIVEN WHILE IN THE DELIVERY ROOM -Encourage the patient to rest between contractions and to push with contractions. -Position the patient's legs in the stirrups for the lithotomy position. -Prepare the patient's perineum. Clean with betadine

NORMAL BIRTHING PROCESS

a. Crowning, the appearance of the infant's head on the perineum. b. Delivery of the head. This includes suctioning of the infants nose and mouth with a bulb syringe. A DeLee suction trap is used if meconium is present. c. Delivery of the anterior shoulder and the posterior shoulder. d. Delivery of the trunk and lower body. e. Clamping and cutting of the umbilical cord.

INFORMATION TO BE RECORDED ABOUT THE DELIVERY Record the following information. a. Exact date and time of delivery. b. Sex of the infant. c. Condition of the infant (APGAR) after birth. APGAR is the most widely used method of evaluating the condition of a newborn baby. A value of 0 to 2 is given for each observation (i.e., heart rate, respiratory effort, muscle tone, reflex irritability, and color). The values are added giving a total APGAR score (see table 2-2). A baby in excellent condition would score 9 to 10 and a dead baby would score 0. Most babies score 7 or better. The condition of the infant will be taken at one (1) minute, at five (5) minutes, and at thirty (30) minutes.

Apgar Score

Category Heart Rate Respiratory Effort Muscle Tone Reflex Irritability Color

0 Points Absent Absent Flaccid No Response Blue, pale

1 Point <100 Slow, Irregular Some flexion of extremities Grimace >100

2 Points Good, crying Active motion Vigorous cry

Body pink, extremities Completely pink blue

d. Position of the infant at delivery. e. Type of episiotomy, lacerations. f. Spontaneous or forceps delivery. g. Use of oxygen and suction on the infant. h. Number of vessels in the cord. i. Mother's name. j. Any other pertinent facts about the delivery.

3. Third Stage of Labor

The third stage of labor is referred to as the "placental" stage. This is the period from birth of the baby until delivery of the placenta. The forces involved are uterine contractions and intra-abdominal pressure. third stage of
labor is the period from birth of the baby through delivery of the placenta. This is considered a dangerous time because of the possibility of hemorrhaging. Signs of the placental separation are as follows: a. The uterus becomes globular in shape and firmer. b. The uterus rises in the abdomen. c. The umbilical cord descends three (3) inches or more further out of the vagina. d. Sudden gush of blood.

INFORMATION TO RECORD Record the following information. a. Time the placenta is delivered. b. How delivered (spontaneously or manually removed by the physician). c. Type, amount, time and route of administration of oxytocin. Oxytocin is never administered prior to delivery of the placenta because the strong uterine contractions could harm the fetus. d. If the placenta is delivered complete and intact or in fragments.

4. Fourth Stage of Labor. The fourth stage of labor is

referred to as the "recovery or stabilization" stage. This period begins with the delivery of the placenta and ends when the uterus no longer tends to relax. The forces involved are uterine contractions

-is the period from the delivery of the placenta until the uterus remains firm on its own. In this stabilization
phase, the uterus makes its initial readjustment to the nonpregnant state. The primary goal is to prevent hemorrhage from the uterine atony and the cervical or vaginal lacerations.

NOTE: Atony is the lack of normal muscle tone. Uterine atony is failure of the uterus to contract. NURSING CARE DURING THE FOURTH STAGE OF LABOR a. Transfer the patient from the delivery table. Remove the drapes and soiled linen. Remove both legs from the stirrups at the same time and then lower both legs down at the same time to prevent cramping. Assist the patient to move from the table to the bed. b. Provide care of the perineum. An ice pack may be applied to the perineum to reduce swelling from episiotomy especially if a fourth degree tear has occurred and to reduce swelling from manual manipulation of the perineum during labor from all the exams. Apply a clean perineal pad between the legs. c. Transfer the patient to the recovery room. This will be done after you place a clean gown on the patient, obtained a complete set of vital signs, evaluated the fundal height and firmness, and evaluated the lochia. d. Ensure emergency equipment is available in the recovery room for possible complications. (1) Suction and oxygen in case patient becomes eclamptic. (2) Pitocin is available in the event of hemorrhage. (3) IV remains patent for possible use if complications develop. e. Check the fundus. (1) Ensure the fundus remains firm. (2) Massage the fundus until it is firm if the uterus should relax (4) Chart fundal height. (5) Inform the Charge Nurse or physician if the fundus remains boggy after being massaged. NOTE: A boggy uterus many indicate uterine atony or retained placental fragments. Boggy refers to being inadequately contracted and having a spongy rather than firm feeling. This is descriptive of the postdelivery of the uterus. f. Monitor lochia flow. Lochia is the maternal discharge of blood, mucus, and tissue from the uterus. This may last for several weeks after birth.

Observe patient's urinary bladder for distention. Be able to recognize the difference between a full bladder and a fundus. (1) Characteristics of a full bladder. (a) Bulging of the lower abdomen b) Spongy feeling mass between the fundus and the pubis. (c) Displaced uterus from the midline, usually to the right. (d) Increased lochia flow. Full bladders may actually cause postpartum hemorrhage because it prevents the uterus from contracting appropriately. FACTORS THAT MAY EXTEND OR INFLUENCE THE DURATION OF LABOR--5 Ps

There are five essential factors that affect the process of labor and delivery. They are easily remembered as the five Ps (passenger, passage, powers, placenta, and psychology). a. Passenger (Fetus). (1) Presentation of the fetus (breech, transverse). (2) Position of the fetus (ROP, LOP). (3) Size of the fetus. b. Passage (Birth Canal). (1) Parity of the woman, if she has ever delivered before. (2) Resistance of the soft tissues as the fetus passes through the birth canal. (3) Fetopelvic diameters. c. Powers (Contractions). (1) Force of the uterine contractions. (2) Frequency of the uterine contractions. d. Placenta. (1) Site of implantation. (2) Whether it covers part of the cervical os. e. Psychology (Psychological State of the Woman). (a) Patient extremely anxious. (b) Emotional factors related to the patient. (c) Amount of sedation required for the patient.

COMPLICATION OF PREGNANCY
ECTOPIC PREGNANCY a. Ectopic pregnancy (figures 1-3 and 1-4) is any pregnancy that does not occupy the uterine cavity properly. PLACENTA PREVIA a. Placenta previa is hemorrhage resulting from the low implantation of the placenta on the interior uterine wall. It is common in multiparous mothers.

ABRUPTIO PLACENTAE

a. Abruptio placentae is hemorrhage resulting from the detachment of the placenta. Hypertension
may cause this. It may occur any time during pregnancy. If the placenta becomes detached prior

to the 20th week of gestation it is called a spontaneous abortion b. b. Abruptio placentae may be classified in three types of separation (see 0figure 1-6). (1) Marginal/low separation. This occurs when the separation is low and is not complete; vaginal hemorrhage is evident. (2) Moderate/high separation. This occurs when the separation is high in the uterine segment, causing the fundus of the uterus to rise. The fetus is in grave danger because of lack of oxygen. External hemorrhage will probably not be present here, whereas the amniotic fluid will be a port-wine color. (3) Severe/complete separation. This occurs when the fetus head is present in the cervical os that prevents external hemorrhage. The fetus is in grave danger, and an immediate cesarean section will probably be needed in order to save the baby's and mother's lives.

ABORTION a. Abortion refers to the loss of the fetus before viability (twenty weeks gestation or fetal weight of 400 gr/14 oz) (see figure 1-7). The types of abortion are: PROLAPSED UMBILICAL CORD a. A prolapsed umbilical cord occurs when the umbilical cord precedes the presenting part of the fetus so that the blood circulating inside the cord is clamped off by the passing fetus through the birth canal. This is considered an obstetric emergency. PREMATURE LABOR AND BIRTH b. a. Premature labor and birth refers to a baby born "before its time," that is, before the end of the 37th gestational week. Premature babies are likely to suffer respiratory distress.

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