Maternal & Child Nursing Care

Sixth Edition

Chapter 15

Processes and Stages

of Labor and Birth

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Learning Outcomes (1 of 2)
15.1 Compare methods of childbirth preparation.
15.2 Describe the five critical factors that influence labor in
the assessment of an expectant woman's and fetus's
progress in labor and birth.
15.3 Examine an expectant woman's and fetus's response
to labor based on the physiologic processes that occur
during labor.
15.4 Assess for the premonitory signs of labor when caring
for the expectant woman.
15.5 Differentiate between false and true labor
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Learning Outcomes (2 of 2)
15.6 Describe the physiologic and psychologic changes
occurring in an expectant woman during each stage of
labor in the nursing care management of the expectant
woman.
15.7 Explain the maternal systemic response to labor in
the nursing care of the expectant woman.
15.8 Examine fetal responses to labor.

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Childbirth Preparation Methods (1 of 3)
• Lamaze (psychoprophylactic): Dissociative relaxation,
controlled muscle relaxation, and specific breathing
patterns are used to promote birth as a normal process.
• Kitzinger (sensory-memory): Women use chest
breathing, abdominal breathing, and their sensory
memory to help work through the birthing process.

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Childbirth Preparation Methods (2 of 3)
• Bradley (partner-coached childbirth): Consists of a
12-week session in which the woman works on
controlled breathing and deep abdominopelvic
breathing with a focus on achieving a natural birth.

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Childbirth Preparation Methods (3 of 3)
• HypnoBirthing: Breathing and relaxation techniques help
prepare the body to work in neuromuscular harmony to
make the birth process easier, safer, and more
comfortable.

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Methods of Childbirth Preparation
• Body conditioning exercises
• Relaxation exercises
• Breathing techniques
• Support individuality

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Factors Affecting Labor Progress
• The birth passageway (birth canal)
• The passenger (fetus)
• The physiologic forces of labor
• The position of the mother
• The woman's psychosocial considerations

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Passageway
• True pelvis
– Inlet, midpelvis, outlet
• Four types
– Gynecoid
– Android
– Anthropoid
– Platypelloid

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Figure 15-1 Comparison of Caldwell
Moloy Pelvic Types

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Fetus (1 of 2)
• Fetal head
– Two frontal bones, two parietal bones, and occipital
bone
• Molding
• Sutures
• Fontanelles

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Figure 15-2 Superior View of the Fetal
Skull

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Fetus (2 of 2)
• Landmarks—mentum, sinciput, bregma, vertex, posterior
fontanelle, occiput

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Figure 15-3 Lateral View of the Fetal Skull

This figure identifies the landmarks that have significance during birth.

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Fetal Attitude
• The relation of the fetal body parts to one another
• Normal attitude is flexion.

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Figure 15-5 Fetal Attitude

The attitude (or relationship of body parts) of this fetus is normal. The head is flexed
forward, with the chin almost resting on the chest. The arms and legs are flexed.

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Fetal Lie
• The relationship of spinal column of the fetus to that of
the mother
• Longitudinal or transverse

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Fetal Presentation (1 of 2)
• Presenting part
– Cephalic, breech, shoulder
– Vertex
– Sinciput
– Brow
– Face
• Engagement

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Figure 15-7 Process of Engagement in
Cephalic Presentation (1 of 3)

A, Floating. The fetal head is directed down toward the pelvis but can still easily move
away from the inlet.
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Figure 15-7 Process of Engagement in
Cephalic Presentation (2 of 3)

B, Dipping. The fetal head dips into the inlet but can be moved away by exerting pressure
on the fetus.
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Figure 15-7 Process of Engagement in
Cephalic Presentation (3 of 3)

C, Engaged. The biparietal diameter (BPD) of the fetal head is in the inlet of the pelvis. In
most instances the presenting part (occiput) is at the level of the ischial spines (zero
station).
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Fetal Presentation (2 of 2)
• Station
– Relationship of the presenting part to the ischial
spines
– Ischial spines are zero station
– If presenting part above the ischial spine—negative
number
– If presenting part below the ischial spine—positive
number

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Figure 15-8 Measuring the Station of the Fetal Head
While It Is Descending. In This View the Station Is −2 / −3 St ar t FractionNegative2Ove
r Nega
t ive3EndFrac
t ion

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Fetal Position
• Right (R) or left (L) side of the maternal pelvis
• Landmark: occiput (O), mentum (M), sacrum (S), or
acromion (scapula[Sc]) process (A)
• Anterior (A), posterior (P), or transverse (T)

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Physiologic Forces of Labor
• Primary forces-uterine muscular contractions
– Contraction phases-increment, acme, decrement
– Described with frequency, duration, and intensity
• Secondary forces-abdominal muscles used in pushing

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Figure 15-10 Characteristics of Uterine
Contractions

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Cause of Labor Unclear
• Between 38th and 42nd week
• Progesterone relaxes smooth muscle.
• Estrogen stimulates uterine muscle contractions.
• Connective tissue loosens to permit opening of cervix.
• Research on possible causes
– Fetal membranes, deciduas
– Progesterone withdrawal, prostaglandin
– Corticotropin-releasing hormone.

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Uterine and Cervical Changes
• Physiologic retraction ring
• Upper uterine segment thickens and pulls up.
• Lower segment expands and thins out.
• Effacement

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Figure 15-11 Effacement of the Cervix in the
Primigravida (1 of 4)
A

A, Beginning of labor. There is no cervical effacement or dilatation. The fetal head is

cushioned by amniotic fluid.
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Figure 15-11 Effacement of the Cervix in the
Primigravida (2 of 4)
B

B, Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid
collects below the fetal head.
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Figure 15-11 Effacement of the Cervix in the
Primigravida (3 of 4)
C

C, Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic
fluid exerts hydrostatic pressure.
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Figure 15-11 Effacement of the Cervix in the
Primigravida (4 of 4)
D

D, Complete effacement and dilatation.

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Premonitory Signs of Labor (1 of 2)
• Lightening
• Braxton Hicks contractions
• Cervical changes
• Bloody show
• Rupture of membranes (ROM)
• Sudden burst of energy
• Weight loss

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Causes of Uterine Changes
• Estrogen
– Stimulates uterine muscle contractions
• Collagen fibers in the cervix are broken down.
• Increase in the water content of the cervix

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Premonitory Signs of Labor (2 of 2)
• Indigestion
• Nausea and vomiting
• Diarrhea

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True Labor
• Progressive dilatation and effacement
• Regular contractions increasing in frequency, duration,
and intensity
• Pain usually starts in the back and radiates to the
abdomen.
• Pain is not relieved by ambulation or by resting.

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False Labor
• Lack of cervical effacement and dilatation
• Irregular contractions do not increase in frequency,
duration, and intensity.
• Contractions occur mainly in the lower abdomen and
groin.
• Pain may be relieved by ambulation, changes of position,
resting, or a hot bath or shower.

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Physiologic Stages of Labor (1 of 2)

• First stage
– Latent phase
– Active phase
– Transition phase
• Second stage
– Begins with complete cervical dilation and ends with
birth of baby
– Sometimes subdivided into latent and passive fetal
descent phases

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Maternal Psychosocial Response to the
Latent Phase
• Woman feels able to cope with discomfort of mild
contractions.
• May be relieved labor has begun
• Able to express feelings of anxiety
• Often talkative and smiling
• High excitement

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Maternal Psychosocial Response to the
Active Phase
• Anxiety
• Need for energy and focus
• Fear of loss of control
• Use of various coping mechanisms
– Sense of purpose and need for regrouping
– Helplessness and decreased coping ability
– Support person involvement may increase
satisfaction and decrease anxiety

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Maternal Psychosocial Response to the
Transition Phase (1 of 2)
• Awareness of the need for energy and focus
• Significant anxiety or loss of control
• Restlessness
• Inner directed and often tired

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Maternal Psychosocial Response to the
Transition Phase (2 of 2)
• May not want to be left alone
• Support person may need a break
• Nursing interventions
– Reassure the woman that she will not be left alone.
– Remain available as relief support.
– Inform woman of whereabouts of her labor support
people.

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Maternal Psychosocial Response to
Progressive Dilatation of Transition Stage

• Intense pressure may cause fear.

– Nurse should provide reassurance that sensations
are normal in this stage of labor.
• May become apprehensive, irritable, and withdrawn
• Desire for verbal and physical support may vary.

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Maternal Psychosocial Response to
Second Stage
• May feel some relief
– Transition phase is over.
– Birth is near
– Able to push

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Second Stage of Labor-Nursing
Interventions
• Encourage woman to focus on pushing.
• Encourage rest when possible.
• Provide leg support.
• Offer ice chips.
• Cooling techniques
• Verbal encouragement
• Assist support person.

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Physiologic Stages of Labor (2 of 2)

• Third stage
– Placental separation
– Placental delivery
• Fourth stage

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Systemic Responses to Labor (1 of 2)

• Changes in cardiac output

• Diaphoresis
• Hyperventilation
• Changes in acid‒base balance

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Systemic Responses to Labor (2 of 2)

• Impaired blood and lymph drainage from base of bladder

• Reduced gastric motility
• Increased white blood cells (W BCs)
• Decreased maternal blood glucose
• Pain

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Fetal Adaptations
• Fetal heart rate decelerations due to intracranial
pressure
• Quiet and awake state
• Aware of pressure sensations

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