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Obstetric & Gynecology Nursing: Topic-Physiological Changes During Labour
Obstetric & Gynecology Nursing: Topic-Physiological Changes During Labour
cervical dilatation and full cervical effacement. During this time, patient
may be exhausted and withdrawn or aggressive and restless. Patient’s
urge to push is noticeable.
Stages cont….
Physiological events in the first stage of labor
are –
1. The first stage of labour is chiefly concerned with the
preparation of the birth canal so as to facilitate the expulsion of
the fetus in the second stage of labour. Physiological events in the
first stage of labor –
Contraction & retraction uterine muscles
Formation of upper & lower uterine segment
Development of retraction ring
Taking up or effacement of the cervix
Dilatation of the cervix
Show presentation
Formation of bag of water
General fluid pressure
Rupture of membranes
Fetal Axis pressure
I. UTERINE FACTORS
1. UTERINE CONTACTION IN LABOR: - Uterine contractions are involuntary movements, which are
recurring with rhythmic & irregular intervals.
Nature of uterine contraction
1. Pain full uterine contraction
2. Fundal dominance
3. Raised intra amniotic pressure
4. Retraction
5. polarity
1. Painfull uterine contraction: - the contractions are intermittent and regular intervals which
are pain full. During contractions are not within the control of the patient & confines even
when the patient is unconscious sedation.
Frequency: - contractions occur intermittently throughout labour. They begin at 20- 30 min.
apart & become closer together until, at height of the expulsive efforts, they are as frequent
as every 2 - 3 min. in 2nd stage.
Regularity:- contractions occur more & more regularly as becomes well established.
Duration: the length of the time a contraction lasts increase from 30 sec. to between 60-90
sec. near full dilation of the cervix. Then the duration becomes about 60sec. until delivery
of the fetus is accomplished.
Intensity: the strength of the contraction also increase as labour progress, from weak
Maintain the advancement of presenting part & help in expulsion of the fetus.
Help to reduce the surface area of the uterus favoring separation of placenta
microorganisms.
It is also important in retaining the fetus in the uterus.
Stretching of the cervix is resisted due to its high content of connective tissue,
bind together.
The changes associated with cervical ripening are independent of myometrial
contractions.
Increases in oestrogens relative to progesterone and increases in relaxin levels
promote collagen degradation.
Once the cervix is prepared physiologically and structurally, labuor can begin.
5. EFFECMENT: -
takeoff & reduce or thinning out & shortening of cervical
canal length & merge with the isthmus of uterus.
During pregnancy, your cervix has been closed and
protected by a plug of mucus. When the cervix effaces, the
mucus plug comes loose and passes out of the vagina. The
mucus may be tinged with blood. Passing the mucus plug is
called "show" or " bloody show." You may notice when the
mucus plug passes. But you might not.
Effacement and dilatation allow a baby to be born through
the birth canal. Effacement means that the cervix stretches
and gets thinner. Dilatation means that the cervix opens.
6. DILATATION: -
Most of the time, the cervix is a small, tightly closed
hole. It prevents anything from getting into or out of
the uterus, which helps to protect the baby. After the
cervix begins to efface, it will also start to open. This is
called cervical dilatation.
Dilation cont…
rupture of membranes.
If the membranes rupture before 37 weeks
myometrial tissue.
Increase calcium levels in mayometrial cells.
As mentioned previously, prostaglandins also have a role in softening the cervix, enabling
Oxytocin-
Another hormone essential for labor is oxytocin.
Oxytocin is released into the systemic circulation from the posterior pituitary in response to tactile
PULSE RATE: during maternal pushing effort. Elevated throughout the 2nd
stage with a definite tachycardia reaching a peak at the time of delivery.
TEMPERATURE: the highest elevation is at the time of delivery &
immediately thereafter. An increase of 0.5 to 1 degree celsius is considered
normal.
GASTRO INTESTINAL CHANGES: there is a reduction in gastric
motility & absorption continues through the 2nd stage. Usually nausea &
vomiting subside during this stage but may persist some women.
RENAL & HEMATOLOGICAL CHANGES: there is increased filtration
& reabsorbtion because increase CO2, decreased renal vascular resistance,
plasma volume expansion, decrease viscosity of the blood, & other
endocrine changes.
Hemodynamic changes include increase in Glomerulus filtration rate,
renal plasma flow (RPF), excretion of amino acids, & elimination of water
soluble vitamins.
THE MECHANISM OF LABOUR
These are changes in the position of the fetus and movement
done by the fetus to navigate the birth canal. It is the relation
of the head and body of the fetus the maternal pelvis during
parturition. The mechanism comprises of
•Engagement
•Descent
•Flexion
•Internal rotation
•Extension
•Restitution
•External rotation
•Delivery of the shoulder and fetal body
THE MECHANISM OF LABOUR
ENGAGEMENT
the head of the baby enters into the mid pelvic cavity by passing through the
transverse pelvic diameter of the upper pelvic passage. Engagement happens
when the largest part of the presenting part (the part of the fetus occupying the
lowest portion of the uterus) has successfully passed through the upper pelvic
opening (inlet). Normally when this occurs only 2/5 of the fetal head is palpable
on abdominal examination.
DESCENT
this happens before the head is flexed in the mid cavity. Descent is usually
secondary to uterine contractions and also by pushing (valsalva manoeuvre).
FLEXION
As the fetal head descends into the narrow mid cavity it begins to flex due to
pressure by surrounding structures.
INTERNAL ROTATION
At this point the fetal chin is in contact with the chest, the face is turned to the
left. When internal rotation occurs the fetal head is turned to face forward with
the face intended to make its way out facing the gluteal region (buttocks). This is
so that the widest diameter or the fetal head passes the widest diameter of the
lower pelvic opening (pelvic outlet). This is also known as 'face to pubes'.
EXTENSION
As the fetal head makes its way through the vagina it begins to
extend in order to give room for the shoulders to make their way
through the bid cavity. The fetal head then distends the vulvar. This
is known as crowning.
RESTITUTION
As the head is delivered it relines itself with the shoulder. This
slight rotation is known as restitution.
EXTERNAL ROTATION
In order to be delivered, the shoulders have to be rotate into the
plane of the pelvic outlet. When this occurs the head rotates 1/8th of
a circle.
DELIVERY OF THE SHOULDER AND FETAL HEAD
when restitution and external rotation happen the shoulder would be
ready to be delivered. This process happens without assistance
sometimes traction may be needed. After this the rest of the body is
delivered with ease.
STAGE 3 / placental stage
Third Stage of Labor or the placental stage starts
from birth of infant to delivery of placenta. It is divided
into two separate phases: placental separation and
placental expulsion. Five minutes after delivery of
baby, the uterus begins to contract again, and placenta
starts to separate from the contracting wall. Blood loss
of 300-500 mL occurs as a normal consequence of
placental separation. Placenta sinks to the lower uterine
segment or upper vagina. The placenta is then expelled
using gentle traction on the cord. finally its expulsion
with the membranes.
PHYSIOLOGICAL CHANGES DURING 3RD STAGE OF
LABOUR:
The expulsion of placenta & fetal membranes by
mother additional efforts or manipulative methods.
The plane of separation runs through deep spongy layer
of decidua basalis.
Two types of placental separation –
1). Central separation (Schultze):-
The third stage of labor can be managed actively with several standard procedures,
or it can be managed expectantly, the latter allowing the placenta to be expelled
without medical assistance.
A retained placenta is a placenta that doesn't undergo expulsion within a normal
time limit. Risks of retained placenta include hemorrhage and infection. If the
placenta fails to deliver in 30 minutes in a hospital environment, manual extraction
may be required if heavy ongoing bleeding occurs, and very rarely a curettage is
necessary to ensure that no remnants of the placenta remain (in rare conditions
with very adherent placenta, placenta accreta).
However, in birth centers and attended home birth environments, it is common for
licensed care providers to wait for the placenta's birth up to 2 hours in some
instances.
Active management
Methods of active management include
1. Umbilical cord clamping
2. Stimulation of uterine contraction
3. Cord traction.
4. Manual placenta removal
1. Umbilical cord clamping:-
Active management routinely involves clamping of the
umbilical cord, often within seconds or minutes of
birth.
2. Uterine contraction
Uterine contraction assists in delivering the placenta.
Uterine contraction reduces the placental surface area,
often forming a temporary hematoma at their former
interface. Myometrial contractions can be induced with
medication, usually oxytocin via intramuscular
injection. The use of ergometrine, on the other hand, is
associated with nausea or vomiting and hypertension.
Breastfeeding soon after birth stimulates oxytocin
which increases uterine tone, and through physical
mechanisms uterine massage (the fundus) also causes
uterine contractions.
3. Cord traction
Controlled cord traction (CCT) consists of pulling on the
umbilical cord while applying counter pressure to help deliver
the placenta. It may be uncomfortable for the mother. Its
performance requires specific training. Premature cord
traction can pull the placenta before it has naturally detached
from the uterine wall, resulting in hemorrhage. Controlled
cord traction requires the immediate clamping of the
umbilical cord.
4. Manual placenta removal