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Labor and Vaginal Birth of a Woman:Nursing Case Study

Friday, 7 March 2014

Labor is a physiologic process in which a fetus, after an 40-week habitus in utero, is expelled. There are four stages of labor. The first stage can be further divided into the latent, active, and transition phases. Prelabor is an amorphous stage that occurs several weeks before true labor and results in increased uterine activity, which serves to ready the cervix for its eventual effacement and dilation.

First‑stage labor is characterized by cervical effacement and dilation, readying for passage of the fetal head. Second‑stage labor results in expulsion of the fetus. Third‑stage labor results in placental separation and expulsion. Fourth‑stage labor is the 1 to 4 hours after placental delivery, in which the contracting uterus controls bleeding. During this period, the mother is at risk for hemorrhage and complications associated with uterine atony, anesthesia induction, and metabolic disorders.
wikipedia.common: c-section delivery
This care plan assumes delivery is in the occiput or vertex presentation, which accounts for 95% to 97% of all births. The positional changes necessary to accommodate the fetal head to the maternal pelvis include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. Between 5 and 30 minutes after expulsion, placental separation usually occurs, and placental delivery is enacted either spontaneously or manually.

Pathophysiology
The labor process is hypothesized to result from oxytocin release by the neurohypophysis, estrogen stimulation, progesterone withdrawal, increased maternal prostaglandin and fetal cortisol levels, increased uterine size, calcium release from the sarcoplasmic reticulum, pressure of the presenting part on the cervix and lower uterine segment, or placental aging.

Signs of impending labor include lightening, false labor, and bloody show. Lightening is a decrease in fundal height, reshaping and enlarging of the lower abdomen, flattening of the costal region, and a subjective maternal feeling of fetal "dropping" that occur with the descent of the fetus to the pelvic inlet. This phenomenon occurs several weeks before true labor and is more pronounced in primigravid patients. False labor is brief, irregular uterine contractions of the lower abdomen and groin that don't progress and don't result in cervical dilation. These contractions, which are more common in patients of high parity and late in pregnancy, should be considered harbingers of true labor and be monitored closely. Bloody show is the vaginal discharge of the blood‑tinged mucus plug of the cervical canal. It indicates the approach of labor but may occur hours to days before actual labor. It should be differentiated from frank bleeding.

Complications
■ Uterine rupture
■ Abruptio placentae
■ Fetal distress
■ Cesarean birth

Assessment
Health perception and management
■ Prenatal care and education

Cognition and perception
■ Pain related to labor contractions

Self-perception and self-concept
■ Anxiety

Roles and relationships
■ Presence of significant other

Physical Examination
Reproductive

■ Stage 1: Latent phase
– Cervical dilation: 0 to 3 cm
– Cervical effacement in primiparous patient (usually complete before dilation); occurs with dilation in multiparous patient
– Duration of latent phase: 8 to 10 hours
– Uterine contractions: Mild, 5 to 30 minutes apart, and last 10 to 30 seconds
– Membranes ruptured or intact
– Scant brown or pink vaginal discharge or mucus plug
– Station: Primiparous patient, usually 0; multiparous patient, 0 to –2
– Fetal heart tones (FHTs): clearest at level of or below umbilicus, depending on fetal position

■ Stage 1: Active phase
– Cervical dilation: 4 to 7 cm
– Duration of active phase: About 6 hours
– Uterine contractions: Moderate, 3 to 5 minutes apart, and last 30 to 45 seconds
– Scant to moderate bloody mucus
– Station: 0 to +1
– FHTs: Heard slightly below umbilicus or lower abdomen

■ Stage 1: Transition phase
– Cervical dilation: 8 to 10 cm (cervical dilation is complete at 10 cm at the end of stage 1)
– Duration of transition phase: 1 to 2 hours
– Uterine contractions: Strong, 2 to 3 minutes apart, and last 45 to 60 seconds
– Copious bloody mucus
– Station: +2 to +3
– FHTs: Clearest directly above symphysis pubis

■ Stage 2: Expulsion of fetus
– Cervical effacement 100%
– Duration of stage 2: 20 to 50 minutes
– Uterine contractions: Strong, 2 to 3 minutes apart, and last 60 to 90 seconds; fetal bradycardia may occur during contractions
– Possible membrane rupture
– Copious bloody mucus
– Station: Fetal descent continues at a rate of 1 cm/hour in primiparous patient and 2 cm or more in multiparous patient until perineal floor is reached
– Urge to push begins
– Perineum bulges, flattens
– Crowning occurs
– Infant is born

■ Stage 3: Expulsion of placenta
– Duration of stage 3: Usually within 5 to 30 minutes of delivery
– Uterine shape globular, usually firmer; fundus rises
– Dark vaginal bleeding, gushing, or trickling
– Further protrusion of umbilical cord from introitus
– Placenta intact: Shiny presentation of fetal side of placental separation occurs from inner to outer margins (Schultze mechanism); rough presentation of maternal side of placental separation occurs from outer margins inward (Duncan mechanism)
– Placenta, membranes, and umbilical cord intact and free from anomalies

■ Stage 4
– Fundus firm or becomes firm when massaged, midline at level of umbilicus
– Moderate lochia rubra
– Episiotomy and laceration repair clean without ecchymosis or discharge; minimal edema; tenderness commensurate with analgesia, usually mild; edges well approximated
– Hemorrhoids possibly extruded

Diagnostic Tests
■ Fern test identifies integrity of membranes. A crystalline frondlike or fern pattern (arborization) indicates amniotic fluid. Urine, blood, and vaginal secretions don't elicit this configuration.

Teaching checklist
■ Stages of labor
■ Procedures and equipment used for monitoring or treatment during labor and delivery
■ Signs of healthy fetal functioning
■ Comfort measures to reduce labor pain
■ Medications used for pain, their effects, and potential adverse effects
■ Infection control procedures to decrease the risk of maternal and fetal infection
■ Positioning for comfort and fetal oxygenation
■ Results of diagnostic tests
■ Use of distraction to cope with pain and anxiety
■ Neonatal characteristics at birth, particularly period of alertness for bonding
■ Physical and emotional findings in the early postpartum period
■ Basic care of the neonate


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