LABOUR AND BIRTH PROCESS IN MORDERN HOSPITALS.pptx

Labour and Birth process in mordern day hospitals in Nigeria

1. LABOUR AND BIRTH PROCESS DR OKE, R.O. (RN,RM,RPHN, RME, BNSc, PGDE, MSc, MEd, PhD)

2. Learning Objectives Upon completion of the lesson, the students will be able to: Outline premonitory signs of labour. Compare and contrast true versus false labour. Categorize the critical factors affecting labour and birth. Analyse the cardinal movements of labour. Identify the maternal and foetal responses to labour and birth. Classify the stages of labour and the critical events in each stage. Explain the normal physiologic/psychological changes occurring during all four stages of labour. Formulate the concept of pain as it relates to the woman in labour

3. Introduction The process of labour and birth involves more than the birth of a new-born. Numerous physiologic and psychological events occur that ultimately result in the birth of a new-born and the creation or expansion of the family Initiation of Labour Labour is a complex, multifaceted interaction between the mother and foetus. It is a series of processes by which the foetus is expelled from the uterus. It is difficult to determine exactly why labour begins and what initiates it. Although several theories have been proposed to explain the onset and maintenance of labour, none of these has been proved scientifically.

4. Definition of Labour Labour is described as the process by which the foetus , placenta and membrane are expelled through the birth canal . Normal labour occurs at term and is spontaneous in onset with the foetus presenting by the vertex. The process should be completed with acceptable time with in 24 hours vaginally. With no complications arise . Cause of the Onset Of Labour Hormonal , Biochemical and M echanical charges that occur around term may trigger labour.

5. Hormonal release of oxytocin Altered Oestrogen progesterone ratio Biochemicial Prostaglandin Mechanical Pressure from the presenting part Over stretched uterus

6. Differentiation between true and false labour contractions False Labour contractions True Labour Contractions Begin and remain irregular Begin irregularly but becomes regular and predictable usually 4-6 min apart, lasting 30-60 seconds First felt abdominally and remain confined to the abdomen First felt in lower back and sweep around to the abdomen in a wave Often disappears with ambulation i.e. contractions may stop or slow down with ambulation Continue no matter what the women’s level of activity Do not increase in duration, frequency or intensity Increase in duration, frequency, and intensity Do not achieve cervical dilatation Achieve cervical dilatation Labour is said to be established with regular painful uterine contraction occurs and effacement of cervix with 2 cm dilated.

7. Factors Affecting the Labour Process Traditionally, the critical factors that affect the process of labour and birth are outlined as the “five Ps:” 1 . Passageway (birth canal) 2 . Passenger ( foetus and placenta) 3 . Powers (contractions) 4 . Position (maternal) 5 . Psychological response Other additional factors are: 1. Philosophy (low tech, high touch) 2 . Partners (support caregivers) 3 . Patience (natural timing) 4 . Patient (client) preparation (childbirth knowledge base) 5 . Pain management (comfort measures) These five additional Ps are helpful in planning care for the labouring family.

8. Passageway The birth passageway is the route through which the foetus must travel to be born vaginally. The passageway consists of the maternal pelvis and soft tissues. As the pregnancy progresses, the hormones relaxin and oestrogen cause the connective tissues to become more relaxed and elastic and cause the joints to become more flexible to prepare the mother’s pelvis for birth. The true pelvis is the bony passageway through which the foetus must travel. It is made up of three planes: the inlet, the cavity, and the outlet . The pelvic inlet allows entrance to the true pelvis. It is bounded by the sacral prominence in the back , the ilium on the sides , and the superior aspect of the symphysis pubis in the front The pelvic inlet is wider in the transverse aspect (sideways) than it is from front to back.

9. The mid-pelvis (cavity) occupies the space between the inlet and outlet. It is through this snug, curved space that the foetus must travel to reach the outside. As the foetus passes through this small area its chest is compressed, causing lung fluid and mucus to be expelled. This expulsion removes the space-occupying fluid so that air can enter the lungs with the newborn’s first breath. The pelvic outlet is bound by the 2 ischial tuberosity, the lower rim of the symphysis pubis, and the tip of the coccyx. In comparison with the pelvic inlet, the outlet is wider from front to back. For the foetus to pass through the pelvis, the outlet must be large enough . The shape of a woman’s pelvis is a determining factor for a vaginal birth. The gynecoid pelvis is considered the true female pelvis, occurring in about 40% of all women

10. The soft tissues of the passageway consist of the cervix, the pelvic floor muscles, and the vagina. Through effacement, the cervix effaces (thins) to allow the presenting foetal part to descend into the vagina. Passenger The foetus (with placenta) is the passenger. The foetal head (size and presence of moulding); foetal attitude (degree of body flexion), foetal lie (relationship of body parts), foetal presentation (first body part), foetal position (relationship to maternal pelvis), foetal station, and foetal engagement are all important factors that have an impact on the ultimate outcome in the birthing process

11. The foetal head is the largest foetal structure, making it an important factor in relation to labour and birth . Foetal attitude is another important consideration related to the passenger. Foetal attitude refers to the posturing (flexion or extension) of the joints and the relationship of foetal parts to one another . Foetal lie refers to the relationship of the long axis (spine) of the foetus to the long axis (spine) of the mother. There are three possible lies: longitudinal (which is the most common), transverse and oblique . Foetal presentation refers to the body part of the foetus that enters the pelvic inlet first (the “presenting part”). This is the foetal part that lies over the inlet of the pelvis or the cervical os Foetal position describes the relationship of a given point on the presenting part of the foetus to a designated point of the maternal pelvis Foetal station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Foetal engagement signifies the entrance of the largest diameter of the foetal presenting part (usually the foetal head) into the smallest diameter of the maternal pelvis

12. Power The primary stimulus powering labour is uterine contraction. Contractions cause complete dilation and effacement of the cervix during the first stage of labour. The secondary powers in labour involve the use of intra-abdominal pressure (voluntary muscle contractions) exerted by the woman as she pushes and bears down during the second stage of labour. Uterine contractions are involuntary and therefore cannot be controlled by the woman experiencing them, regardless of whether they are spontaneous or induced. Uterine contractions are rhythmic and intermittent, with a period of relaxation between contractions. This pause allows the woman and the uterine muscles to rest . In addition, this pause restores blood flow to the uterus and placenta, which is temporarily reduced during each uterine contraction . Uterine contractions are responsible for thinning and dilating the cervix, then thrusting the presenting part toward the lower uterine segment.

13. The cervical canal reduces in length from 2 cm to a paper-thin entity and is described in terms of percentages from 0% to 100%. In primigravidas, effacement typically starts before the onset of labour and usually begins before dilation; in multiparas, however, neither effacement nor dilation may start until labour ensues. On clinical examination the following may be assessed: Cervical canal 2 cm in length would be described as 0% effaced. Cervical canal 1 cm in length would be described as 50% effaced. Cervical canal 0 cm in length would be described as 100% effaced

14. Cervical effacement and dilation. Cervical dilation is expressed in centimetres. A. Shows cervix not effaced or dilated. B. 50% effaced. C. 100% effaced. D. Fully dilated at 10 centimetres.

15. During early labour , uterine contractions are described as mild, they last about 30 seconds, and they occur about every 5 to 7 minutes. As labour progresses, contractions last longer (60 seconds), occur more frequently (2 to 3 minutes apart), and are described as being moderate to high in intensity. Each contraction has three phases: increment ( build-up of the contraction), acme (peak or highest intensity), and decrement (descent or relaxation of the uterine muscle fibres Uterine contractions are monitored and assessed according to three parameters: frequency, duration, and intensity

16. The three phases of a uterine contraction

17. Position (Maternal) Although many labour and birthing facilities claim that all women are allowed to adopt any position of comfort during their labouring experience, many women spend their time on their backs during labour and birth. Women should be encouraged to assume any position of comfort for them Changing positions and moving around during labour and birth offer several benefits. Maternal position can influence pelvic size and contours. Changing position and walking affect the pelvis joints, which may facilitate foetal descent and rotation. Squatting enlarges the pelvic inlet and outlet diameters, whereas a kneeling position removes pressure on the maternal vena cava and helps to rotate the foetus from a posterior position to an anterior one to facilitate birth

18. Psychological Response Childbearing can be one of the most life-altering experiences for a woman. The experience of childbirth goes beyond the physiologic aspects: it influences a woman’s self-confidence, self-esteem, and view of life, relationships, and children. Her state of mind (psyche) throughout the entire process is critical to bring about a positive outcome for her and her family. Factors promoting a positive birth experience include: clear information about procedures support; not being alone sense of mastery, self-confidence trust in staff caring for her positive reaction to the pregnancy personal control over breathing preparation for the childbirth experience

19. Philosophy Not everyone views childbirth in the same way. A philosophical continuum exists that extends from viewing labour as a disease process to a normal process. One philosophy assumes that women cannot manage the birth experience adequately and therefore need constant expert monitoring and management. The other philosophy assumes that women are capable and reasoning individuals who can actively participate in their birth experience . Midwives empower women within the birthing environment by subscribing to a normal birth process where the woman uses her own instincts and bodily signs during labour No matter what philosophy is held, it is ideal if everyone involved in the particular birth process from the health care provider to the mother shares the same philosophy toward the birth process.

20. Partners Women desire support and attentive care during labour and birth . The presence of the mother’s significant other at the birth provides special emotional support, a partner can be anyone who is present to support the woman throughout the experience. For many women, the essential ingredients for a safe and satisfying birth include a sense of empowerment and success in coping with or transcending the experience, in addition to having solid, positive encouragement from a support companion.

21. Patience The birth process takes time. If more time were allowed for women to labour naturally without intervention, the caesarean birth rate would most likely be reduced . Patient (Client) Basic prenatal education can help women manage their labour process and feel in control of their birthing experience . Prenatal education teaches the woman about the childbirth experience and increases her sense of control . She is then able to work as an active participant during the labour and birth experience Pain Management Labour and birth, although a normal physiologic process, can produce significant pain. Pain during labour is a nearly universal experience. Controlling the uterine discomfort without harm to the foetus or labour process is the major focus of pain management during childbirth.

22. Physiologic Responses to Labour Maternal Responses As the woman progresses through childbirth, numerous physiologic responses occur that assist her to adapt to the labour process. The labour process stresses several of the woman’s body systems, which react through numerous compensatory mechanisms. Maternal physiologic responses include : Heart rate increases by 10 to 20 bpm. Cardiac output increases by 12% to 31% during the first stage of labour and by 50% during the second stage of labour . Blood pressure increases by up to 35 mm Hg during uterine contractions in all labour stages. The white blood cell count increases to 25,000 to 30,000 cells/mm3, perhaps as a result of tissue trauma.

23. Respiratory rate increases and more oxygen is consumed related to the increase in metabolism. Gastric motility and food absorption decrease, which may increase the risk of nausea and vomiting during the transition stage of labour . Gastric emptying and gastric pH decrease, increasing the risk of vomiting with aspiration. Temperature rises slightly, possibly due to an increase in muscle activity. Muscular aches/cramps occur as a result of the stressed musculoskeletal system. Basal metabolic rate increases and blood glucose levels decrease because of the stress of labour

24. Foetal Response Although the focus during labour may be on assessing the mother’s adaptations, several physiologic adaptations occur in the foetus as well. The foetus is experiencing labour along with the mother. If the foetus is healthy, the stress of labour usually has no adverse effects. The nurse needs to be alert to any abnormalities in the foetus’s adaptation to labour . Foetal responses to labour include: Periodic foetal heart rate accelerations and slight decelerations related to foetal movement, fundal pressure, and uterine contractions Decrease in circulation and perfusion to the foetus secondary to uterine contractions (a healthy foetus is able to compensate for this drop) Increase in arterial carbon dioxide pressure (PCO2 ) Decrease in foetal breathing movements throughout labour Decrease in foetal oxygen pressure with a decrease in the partial pressure of oxygen (PO2 )

25. Stages of Labour Labour is typically divided into three stages : dilation, expulsive and placental & membrane The first stage is the longest: it begins with the first true contraction and ends with full dilation (opening) of the cervix. Because this stage lasts so long, it is divided into three phases, each corresponding to the progressive dilation of the cervix. Stage two of labour , or the expulsive stage, begins when the cervix is completely dilated and ends with the birth of the newborn . The expulsive stage can last from minutes to hours. The contractions typically occur every 2 to 3 minutes, lasting 60 to 90 seconds and are strong by palpation. The woman is usually intent on the work of pushing during this stage. The third stage, or placental & membrane expulsion , starts after the newborn is born and ends with the separation and birth of the placenta. Continued uterine contractions typically cause the placenta & membrane to be expelled within 5 to 30 minutes. If the newborn is stable, bonding of infant and mother takes place during this stage through touching, holding, and skin-to-skin contact

26. First Stage of Labour During the first stage of labour , the fundamental change underlying the process is progressive dilation of the cervix. Cervical dilation is gauged subjectively by vaginal examination and is expressed in centimetres . The first stage ends when the cervix is dilated to 10 cm in diameter and is large enough to permit the passage of a foetal head of average size. The foetal membranes, or bag of waters, usually rupture during the first stage, but they may have burst earlier or may even remain intact until birth. For the primigravida , the first stage of labour lasts about 12 hours. However, this time can vary widely; for the multiparous woman, it is usually only half of that . The first stage is divided into three phases: latent or early phase, active phase, and transition phase.

27. Latent Phase The latent or early phase gives rise to the familiar signs and symptoms of labour . This phase begins with the start of regular contractions and ends when rapid cervical dilation begins. Cervical effacement occurs during this phase, and the cervix dilates from 0 to 3 cm. Contractions usually occur every 5 to 10 minutes, last 30 to 45 seconds, and are described as mild by palpation by the nurse Active Phase The active phase of labour encompasses the time from an increase in the rate of cervical dilation (end of latent phase of labour ) until completion of cervical dilation. Cervical dilation begins to occur more rapidly during the active phase. The cervix usually dilates from 4 to 7 cm, with 40% to 80% effacement taking place. This phase can last up to 6 hours for the nulliparous woman and 4.5 hours for the multiparous woman

28. Transition Phase The transition phase is the last phase of the first stage of labour . During this phase, dilation slows, progressing from 8 to 10 cm, with effacement from 80% to 100%. The transition phase is the most difficult and, fortunately, the shortest phase for the woman, lasting approximately 1 hour in the first birth and perhaps 15 to 30 minutes in successive births During transition, the contractions are stronger (hard by palpation), more painful, more frequent (every 1 to 2 minutes), and they last longer (60 to 90 seconds)

29. Second Stage The second stage of labour begins with complete cervical dilation (10 cm) and effacement and ends with the birth of the newborn . This stage involves movement of the foetus through the birth canal and out of the body. The cardinal movements of labour occur during the early phase of passive descent in the second stage of labour. Contractions occur every 2 to 3 minutes, last 60 to 90 seconds, and are described as strong by palpation. The average length of the second stage of labour in a nullipara is approximately 1 hour and less than half that time for the multipara. During this expulsive stage, the mother usually feels more in control and less irritable and agitated. The woman is focused on the work of pushing. The maternal urge to push is generally felt when there is direct contact of the foetus to the pelvic floor

30. Third Stage The third stage of labour begins with the birth of the newborn and ends with the separation and birth of the placenta. It consists of two phases: placental separation and placental expulsion. Worldwide , approximately 800 women die each day from preventable causes related to childbirth. The single most common cause is severe bleeding, which can kill a woman within hours if care is delayed. Prompt and effective management is paramount to saving the lives of these women and prevention measures can be initiated in the third stage of labour. Controversy continues about active verses physiological management of the third stage of labour

31. Placental Separation After the infant is born, the uterus continues to contract strongly and can now retract, decreasing markedly in size. These contractions cause the placenta to pull away from the uterine wall. The following signs of separation indicate that the placenta is ready to deliver: The uterus rises upward. The umbilical cord lengthens. A sudden trickle of blood is released from the vaginal opening. The uterus changes its shape to globular . Spontaneous birth of the placenta occurs in one of two ways: the foetal side (shiny gray side) presenting first (called Schultz’s mechanism or more commonly called “shiny Schultz’s”) or the maternal side (red raw side) presenting first (termed Duncan’s mechanism or “dirty Duncan”).

32. Placental Expulsion After separation of the placenta from the uterine wall, continued uterine contractions cause the placenta to be expelled within 2 to 30 minutes unless there is gentle external traction to assist. After the placenta is expelled, the uterus is massaged briefly by the attending physician or midwife until it is firm so that uterine blood vessels constrict, minimizing the possibility of haemorrhage . Normal blood loss is approximately 500 mL for a vaginal birth and 1,000 mL for a caesarean birth. Blood loss of over 1,000 mL is considered severe If the placenta does not spontaneously deliver, the health care provider assists with its removal by manual extraction. On expulsion, the placenta is inspected for its intactness by the health care provider and the nurse to make sure all sections are present. If any piece is still attached to the uterine wall, it places the woman at risk for postpartum haemorrhage because it becomes a space-occupying object that interferes with the ability of the uterus to contract fully and effectively

33. After labour, The mother usually feels a sense of peace and excitement, is wide awake, and is very talkative initially. The attachment process begins with her inspecting her newborn and desiring to cuddle and breast-feed him or her. The mother’s fundus should be firm and well contracted. Typically it is located at the midline between the umbilicus and the symphysis, but it then slowly rises to the level of the umbilicus during the first hour after birth If the uterus becomes boggy, it is massaged to keep it firm. The lochia (vaginal discharge) is red, mixed with small clots, and of moderate flow. If the woman has had an episiotomy during the second stage of labour , it should be intact, with the edges approximated and clean and no redness or oedema present.