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Normal Birth 9 Read Holistic Midwifery vol. 2 pages 366 – 411. How do you assess the strength and duration of labor? Is the woman even in labor? What begins the process? These and other questions will be examined in this assignment. After reading and taking notes answer the questions below. 1. How do you know if the labor has actually started? What are the definitive signs and symptoms? Regular uterine contractions that are progressing in intensity, duration and frequency and are accompanied by cervical changes. Contractions alter the shape of the uterus. Contractions are felt low in the suprapubic area 2. As the midwife, what should you be looking for while observing the progress of labor? Watch the mother's reactions. Listen to the mother's description of contractions. Pay attention to how she is coping. Make sure everything is within normal 3. How can you distinguish early/prodromal labor? What are the signs and symptoms? Regular contractions that are increasing in frequency and intensity. Contractions last 15-40 seconds. 15-30 minutes apart. Mother is still active (cleaning, talking, eating). Bloody show. Mother reaches 3-4 cm dilation 4. What is active labor? Describe the difference in this and early labor. Covers dilation from 4-8 cm typically. Possible flush on their cheekbones at 4 cm signals Active Labor. Mother gives focused attention to contractions. Talking takes more effort. Contractions last 1 minute. 4-5 minutes apart. Dilation happens readily. Pressure in pelvis. Backache, cramping in lower back or down low in the front. Stretching in the pelvis. Early Labor: more of the effacement happens in this stage, dilation doesn't happen as readily, mom can multitask and focus on other activities besides labor, contractions are shorter and further apart. 5. What is hard labor? What are the signs and symptoms? Dilation from 7-9 cm Slow and deliberate movements (like swaying). Less modesty. Contractions intensify and her body might also tense up. The pain may feel deeper or higher. More fetal movement as the baby tries to descend. her nipples may darken, and her breasts may fill. Variety of positions. Working harder. Moving away from or into the sensations of labor. Near 8 cm mom may feel hot, cold, shaky, cranky. Pain without contractions. Desire to urinate. Intense Pelvic Pressure. Deep and soft voice 6. Define transition. How long can it last and what should you be looking for? Active labor from 8/9 cm through complete dilation. A turning point in labor. Can last between 5-20 contractions. More intense for mom. No inhibitions (no modesty, harsh language, yelling at others). Lots of sweating. Hot or Cold flashes. Feels like giving up. Flushed cheeks. Nausea, vomiting, and Shakes or tremors, especially in the legs and jaw. Increased pressure in pelvis. ROM. Low back discomfort. Another bloody show at 8 cm. Slight labial swelling 7. Discuss the various techniques used in abdominal examinations during labor. Ensure you cover both early and established labor. You should spend time discussing uterine changes and activity, palpitations, and using both your hands and instruments. This will likely be a longer answer than most other questions. During early labor, the uterus will be more rounded than at any other point during labor. The baby’s head will be sitting up higher. If the baby’s head has not engaged yet, it will probably be floating and mobile near the pubic bone. With progressive labor you can watch the contractions become more intense. The uterus will be tense, rise up, become slightly narrower along its sides, and lean forward as the contraction peaks, and then settle back down and soften again as the contraction subsides. Visibility can depend on the woman’s body and how she is carrying the baby. The uterus will also lengthen as the baby’s spine stretches out during the descent. You will probably feel the baby’s back rotate toward the mother’s anterior midline or spine. You can also assess the contractions and note frequency, duration, resting time, and strength. In the beginning they may last 15-20 seconds and come about 20-30 minutes apart. As birth becomes closer, the contractions will come more frequently and be longer and stronger. You can expect each one to last 60-90 seconds and come 2-3 minutes apart. As labor progresses, each contraction causes the uterus to elongate which allows the baby to straighten its spine 5-10cm which also helps to facilitate dilation. The descent of the head can also be gauged in “fifths” with its relation to pelvic brim. The width of all your 5 fingers held together parallel to the border (width-wise) of the pelvic bone. The width of each finger represents one-fifth. Descent can also be monitored with a fetoscope by the location of the loudest fetal heart sounds. This point will descend and move across the mother’s abdomen as the baby moves down and rotates - arriving at a midline position as transition nears. This will be more difficult if the placenta is on the anterior wall of the uterus or if the baby’s back is posterior. Doppler can be used for heart tones however, it amplifies the sound making it difficult to locate the point of maximum intensity. You can also check descent at the pubic bone because often prior to +1 station, there is a slight bulging to the area just above the pubic bone. Keep in mind, a full bladder can also cause a slight bulge so make sure the bladder is not full when you do this. 8. What is bloody show? Why does it matter? A discharge of mucus that's tinged pink or brown with blood. It means the blood vessels in the cervix are rupturing as it begins to efface and dilate . This matters because it shows that significant cervical changes are being made. 9. When doing an internal exam during labor, what would you be looking for? Give 5 findings that tell you important information. Why do these 5 things matter? Effacement: the thinning of the cervix lets the midwife know you are progressing Dilation: this lets you know how the labor is progressing and when you are ready to push Presenting Part: this helps you know what to expect in delivery. If there is a face presentation or breech this is important to know and labor can be much more complicated. Position: this will help the midwife know what kind of labor the mom will have. For example, if the baby is posterior the midwife will know that labor may be harder and more painful and there are specific positions she can suggest. Cord Prolapse: this is a complication that the midwife needs to be aware of in order to make a plan to deliver the baby quickly or transport. 10. Which of these is considered “normal”, with the rest falling outside normal: vasa previa, cord prolapse, caput, compound presentation, shoulder presentation. Caput 11. What is vasa previa? Membranes that contain blood vessels connecting the umbilical cord and placenta are lying across or near the opening of the cervix, which can cause them to be severed during childbirth and the baby will lose its blood supply. 12. What is cord prolapse? The umbilical cord drops (prolapses) through the open cervix into the vagina ahead of the baby. The cord can then become trapped against the baby's body during delivery. 13. How can you determine a caput in an exam? A soft, swollen feel. It makes palpating features underneath it very difficult It will pit as you press on it 14. What is a compound presentation? When a fetal extremity (hand or foot) lies alongside the head in the pelvis. This can happen with a small fetus or a roomy pelvis. 15. How can you identify a shoulder presentation? Labor has been going on for an abnormal amount of time with no progress. Palpate the shoulder The shoulder will be more round than a knee, heel, or elbow Shoulder has 3 bony ridges instead of two 16. Why is it good for the amniotic sac to remain intact in labor as long as possible? The amniotic sac is a barrier that will protect the fetus from organisms that may enter the uterus from the vagina or cervix. The forewaters cushion the presenting part, protect the head from stress, minimize caput formation, and protect against cord prolapse if the head is not engaged. The amniotic fluid also provides support and cushioning, which minimizes compression. 17. What typically happens in labor once the membranes rupture? Contractions get stronger and labor progresses 18. What are the 5 colors of amniotic fluid and what does each tell you? Clear: healthy fluid Brown: old meconium staining. Possibly old blood or sign that baby died before labor Green: recent meconium staining. Possibly hemolyzed blood Red: concealed abruption. Possibly ruptured umbilical vessel Yellow/Gold: light meconium staining. Possibly fetal bilirubin.
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