Labor and the Birth Process

The 5 “Ps” of labor

Passenger Passageway Powers Position Psychologic response

Passenger’s Head

Presentation of the Passenger

What is the fetal presentation?› Cephalic (96%)› Breech (3%)› Shoulder (1%)

Fetal lie

Fetal Attitude

Position of the Passenger

Station & Engagement

Passageway

Passageway Continued

Powers-Primary We really do not know what causes the

primary powers

ContractionFrequency,Duration, andIntensityResult in Effacement and Dilatation

Secondary Powers

Positioning

Pelvic muscles/ligaments

A bit of humor found http://www.youtube.com/watch?

v=ppzV6hoPkIc

Pain Management in Labor

Pain Perception & Expression

Pain thresholds are similar in everyone, the perception of pain is not.

Pain is expressed SensoryEmotionallyPhysiologically

How Does Labor Effect Pain Pain experienced

by mother can result in :› Acidosis of the

fetus › Impaired Uterine

Contraction

Non-Pharmacologic Strategies Position changes

› Walking › Rocking› Labor ball

Breathing› May need to breath

with mother Counter-pressure Application of heat or

cold Showering/Tub

Music Aromatherapy Imagery Focal points Effleurage Therapeutic touch Childbirth Education Hypnosis Biofeedback Empty Bladder

regularly

Pharmacologic

Goal maximum relief with minimal risk to mother and fetus

Pain Control Depends: Epidural Spinal/Epidural

Nerve Block Local Pudendal Spinal Epidural Combined

Spinal/Epidural(CSE)

Analgesics 1st Stage Systemic analgesia IM vs IV Narcotics Opioid agonist

› Demerol, Fentanyl, Morphine Opioid agonist-antagonist

› Stadol, Nubain, Narcan Epidural

Naloxone (Narcan) Opiate antagonist Works immediately-may need to be repeated Used to counteract respiratory depression-

Neonatal dose available at every delivery Adult dose: 0.4-2mg IVP Neonatal dose: 0-1mg/kg of 0.4mg/ml

concentration Do not give to patient with narcotic

dependency-triggers immediate withdrawal and possible seizures

Labor Nerve Block MedsMethod Effects Criteria CareLocal-Lido /Polocaine used with epi

Numbs perineum

Episiotomy or repair of laceration

Normal perineal care

Puedendal Numbs lower vaginal/vulva/perineal area

Epis or vacuum delivery anticipated

May need more direction in pushing

Spinal T-6 to feet C-Section Uterine displacement, VS monitored

Epidural Numbs from T10-S5

Labor /C-section Monitoring line, VS, Positioning of pt

Intrathecals 1.5-3 hours Multip who is progessing fast

Same as Epi/Spinal

Pain Pathway

Epidural Coverage

General AnesthesiaOnly used in an emergency prior to infant delivery, if patient has contraindications to a Spinal /Epidural,or demands to be put to sleep.

Kahn Academy

Fetal Circulation Maternal position Uterine Contractions Blood Pressure Umbilical Blood Flow

Fetal Assessment

Continuously or intermittently

Fetal Monitor Tracing

Monitor placement and Lie

Intrauterine Pressure Catheter-IUPC

IUPC use Montevideo Units (MVU)

› Subtract baseline pressure from peak pressure for each contraction in a 10 min period. 100-250 is optimal

Fetal Heart Rate Normal FHR Baseline110-160

› 10 minute segment with no significant periodic changes or change in baseline of >25 BPM

Variability› Absent› Minimal› Moderate› Marked (pg 421)

Fetal Heart Rate Tachycardia >160

› Can be early sign of fetal hypoxia› Maternal or fetal infection› Maternal hyperthyroidism or fetal anemia› Response to some drugs-cocaine, Meth,

terbutaline, Vistaril Bradycardia <110

› Heart Block› Viral infections such as CMV

Periodic & Episodic Changes Periodic-with contractions Episodic-occur without contractions Acceleration 15 x 15 above baseline Deceleration

› Early› Late› Variable

What type of deceleration?

What type of deceleration?

What type of deceleration would this cause

True knot in cord

Variable deceleration

Management of FHR tracing Basic interventions

› Oxygen› Reposition› IV fluid bolus

Specific problem› Correct the problem› If can not…..DELIVER BY CESAREAN

Categories of FHR tracings Category I-normal Category II-requires interventions and

close monitoring Category III-Deliver

Category I Normal FHR:110-160 FHRV: Moderate (6-25beats) Accelerations or Early Decelerations: Absent or

present Late or Variable Decelerations: Absent

Category III FHRV: Absent + Recurrent late decelerations FHRV: Absent + Recurrent variable

decelerations FHRV: Absent + Bradycardia Sinusoidal

Category II Bradycardia without absent FHRV Tachycardia FHRV: Minimal or Marked FHRV: Absent without recurrent decels Absent accelerations after induced fetal stimulation

(this is only diagnostic-not intervention) Recurrent variable decel + FHRV: Min or moderate Prolonged decel > 2min but <10 min Recurrent late decel + FHRV: Moderate Variable decel with other characteristics: Slow

return to baseline, overshoots, or shoulders

Category II Example

Review

Review

Review

Review

Remember the Psychosocial Labor is anxiety provoking Is the baby going to be ok? Was this pregnancy planned? Does the patient have adequate

support both at home and in labor? Will she have help at home when goes

home with infant?

Questions