TRUE OR FALSE LABOR

Prodromal labor or false labor is commonly experienced by the expectant mother near labor thinking that labor
has started only to find out that it has not. The mother commonly experiences contractions which make them think that
labor is imminent. These false contractions however are preparatory contractions for true labor. Three characteristics
distinguish true labor from false labor; contractions, discomfort, and cervical changes. The main difference is that
contractions in true labor produce significant cervical changes which result to effacement and dilation.

FALSE LABOR TRUE LABOR

CONTRACTIONS  Inconsistent in frequency, duration, and  Consistent pattern of increasing
intensity, frequency, duration, and intensity
 Does not change or decreases with activity  Increases with ambulation
 Lower back ang gradually sweeps up to
the abdomen
DISCOMFORT  Felt in abdomen and groin  “Back pain”
 Annoying than truly painful  Menstrual cramp pain during early labor
CERVIX  No significant change in effacement and  PROGRESSIVE effacement and dilatation
dilation

TRIAL LABOR

A trial labor is indicated for mothers whose inlet measurement and fetal lie are borderline adequate. The birth
attendant may try this procedure to determine if labor can continue to progress normally. This procedure can continue
so long as the descent of the presenting part and dilatation of the cervix continue to occur. FHR patterns and uterine
contraction should be monitored consistently. The nurse should also let the client void every 2 hours to completely
empty the bladder to allow the fetus to utilize all the available space since inlet measurement is just good enough.
Once membranes rupture, FHR should be monitored to assess for cord compression. If at any time during labor fetal
distress occurs, a cesarean birth would be indicated.

OPERATIVE AND ASSISTIVE DELIVERIES

An Amniotomy is performed by the MD or midwife. Risk associated with this procedure include, umbilical
cord prolapse, infection, and abruption. A disposable plastic hook is used to perforate the sac by snagging the
membrane and if needed, enlarging the opening with a finger. This is contraindicated in non-cephalic presentations
and a high presenting part due to the increased risk of cord prolapse.
A Version is a procedure done to change the fetus’ presentation from a non-cephalic presentation to a
cephalic presentation. External Cephalic Version is done by first administering a tocolytic (terbutaline) and
anesthetizing the mother. The MD then gently rolls the fetus upside-down into the correct presentation. Induction could
be done immediately after version or the mother may wait for a spontaneous labor. Internal version on the other hand
is seldom performed. More commonly being used to change a second twin’s presenting part. It is done by inserting a
hand into the uterine opening and rolling the feus with the other hand on the abdomen. Contraindications for these
procedures are limited room intrauterine, uterine scarring, macrosomia, fetopelvic disproportion, previa, multifetal
gestation, engagement.
 An operative vaginal birth is a term used to signify vaginal births that are performed with assistance from
either forceps or a vacuum. These paraphernalia are used to increase traction to deliver babies whose descent is not
quite at an optimal rate. Forceps delivery has lost favor whereas vacuum extraction has been preferred. A vacuum
extractor uses suction to grasp the fetal head while applying traction. This is contraindicated in non-cephalic
presentations and in fetuses less than 34 week in gestation. This is because the suction is more likely to injure the
head, scalp, and intracranial vessels. Also, most hospital policies only allow 3 reapplications of the suction cup as more
would probably produce more injuries to the head. A forcep is a curved metal instrument that locks to grasp on to the
fetus’ head to apply traction. Foam pads could be used to protect the head from the blades and reduce possible nerve
damage. A special type of forcep, piper forceps are used in vaginal breech birth. These paraphernalia could also be
used in a cesarean birth to aid in the extraction of the baby. These procedures are indicated for those cases wherein
the second stage of labor is preferably shortened. For the well-being of the baby or the mother. Although, if a more
rapid birth is indicated, a cesarean birth would be indicated as this procedure might be too traumatic. Examples would
be heart failure, pulmonary edema, high fetal station, and fetopelvic disproportion. This procedure also produces many
risks such as lacerations to the vaginal wall for the mother, and facial injuries to the fetus such as, ecchymoses, facial
and scalp lacerations, abrasions, facial nerve injury, cephalohematoma, subgaleal hemorrhage, and intracranial
hemorrhage. A temporary chignon – a scalp edema – might also form with the use of a vacuum extractor. When a
mother has a vaginal laceration, she would usually complain of severe and unrelenting pain and the nurse would usually
assess for a discoloration of the labia and perineum. Cold compress for the first 12 hours resolve pain and limit bruising
then hot compress for the next 12 hours resolves edema and bruising.
An Episiotomy is an incision created either median or mediolateral to the vaginal opening to help facilitate
the birth of cases with shoulder dystocia, operative vaginal births, birth of a fetus with an occiput posterior presentation,
or a preterm fetus to reduce pressure on the head. The main risk for episiotomy is infection. Perineal tears can occur
naturally and could also produce pain, but pain associated with episiotomies often last longer due to the possible 3rd
(anal sphincter) or 4th degree (rectal sphincter) laceration. Episiotomies can actually be avoided using positioning and
pushing techniques. An upright squatting position while pushing promotes the gradual stretching of the perineum. To
delay pushing efforts only until the urge is felt also gradually distends soft tissues in the pelvic floor further facilitating
stretching. Open-glottis pushing also promotes gradual stretching rather than prolonged breath holding. Studies have
also shown that daily perineal massage from 36 weeks until birth have shown the ability to reduce perineal trauma. To
promote healing and comfort. Cold compress applications for the first 12 hours and warm compress for the next 12
reduce pain, edema, and bruising.
CESAREAN BIRTH
A Cesarean birth is indicated when a traditional vaginal birth could compromise the mother and the fetus’
health. Contraindications to this procedure are fetal death, a fetus that is too immature to survive, and maternal
coagulation defects. Risked posed by this procedure include the following:
Indications Maternal Risks
 Dystocia  Infection
 Cephalopelvic (fetopelvic) disproportion  Hemorrhage
 Hypertension, if prompt delivery is necessary  Urinary tract trauma or infection
 Maternal diseases such as diabetes, heart  Thrombophlebitis, thromboembolism
disease, or cervical cancer, if labor is not  Paralytic ileus
advisable  Atelectasis
 Active genital herpes  Anesthesia complications
 Some previous uterine surgical procedures
such as a classic cesarean incision or Fetal risks
removal of fibroid tumors  Inadvertent preterm birth
 Persistent Nonreassuring FHR patterns  Transient tachypnea of the newborn caused
 Prolapsed umbilical cord by delayed absorption of lung fluid
 Fetal malpresentations such as breech or  Persistent pulmonary hypertension of the
transverse lie newborn
 Hemorrhagic conditions such as abruptio  Injury such as laceration, bruising, fractures,
placentae or placenta previa or other trauma

The procedure is performed by first anesthetizing the client. Most commonly used is an epidural block but a
combined spinal epidural or even general anesthesia can be ordered for certain reasons. Preoperative medication are
mainly those to control respiratory and gastric secretions such as famotidine and sodium citrate with citric acid.
Positioning the client during this procedure includes placing padding underneath one hip to prevent aortocaval
compression. Prophylactic antibiotics could be give to prevent infections like ley to develop with PROM or a lengthy
labor. An indwelling catheter is established after anesthetizing the client but before surgery to empty the bladder fully
to prevent it from being accidentally injured during surgery. It also helps the healthcare providers monitor properly the
circulatory status of the patient.
Two incisions are done in this procedure. An abdominal incision, and a uterine incision. The abdominal incision
could either be a Pfannensteil incision or a midline vertical incision. Three uterine incisions could be indicated each
with different indications. (1) low transverse is the preferred incision due to its low risk for rupture in subsequent
pregnancies, however it is not suitable for large fetuses since its size is limited due to the presence of the uterine artery
and vein on its sides. If going to be used on a large baby however, a vertical incision could be added to extend the size
of the opening. Less blood loss and less adhesion formation are also pros for this incision. (2) Low vertical incision is
advantageous since the opening could be extended if a larger opening is needed. Risks posed by this option are its
increased probability to rupture during a subsequent birth, and the possibility for the incision to extend towards the
cervix. (3) The classic incision is the primary choice for Previas, dense adhesions, and a transverse lie of a large fetus
with shoulder dystocia. Risks posed are being the most likely to rupture during subsequent births therefore making
VBAC unattainable.
 Upon incision of the abdomen the bladder is retracted down, and the uterus is incised. Upon incising the uterus,
the membranes are ruptured and suctioned out of the area. Color, odor and amount are noted. The presenting part is
lifted out and if needed, vacuum extractors or forceps are utilized. After delivery, Oxytocin is given to contract the uterus
and then the incision is closed.

INDUCTION AND AUGMENTATION OF LABOR

These include the use of artificial methods to stimulate uterine contractions. Indications of inducing labor is
mainly when if the pregnancy should continue, it would pose risks and might jeopardize the health of either the mother
or the fetus. Labor induction should only be performed if labor and vaginal birth is deemed safe for both the mother
and the fetus. Labor induction usually takes up an ample amount of time so if the birth is to be delivered more quickly
than the situation permits labor induction is not advised and a cesarean birth is indicated. There are however increased
risks in this type of labor. In inducing labor, the fetus’ respiratory maturity should be considered since preterm infants
are most likely to undergo this procedure.
Indications: Contraindications:
 Hostile intrauterine environment  Placenta previa
 PROM  Vasa previa – fetal hemorrhage
 Post term Pregnancy  Umbilical cord prolapse – cord compression
 Chorioamnionitis  Nonreassuring FHR patterns
 HTN w/ reduced placental blood flow  Uterine overdistension – Higher risk for
 Abruptio placentae (minor cases) rupture
 Maternal medical conditions that may worsen
with pregnancy
 Fetal death
DETERMINING WHETHER INDUCTION IS INDICATED
The attendant should first outweigh the benefits of ending the pregnancy as to continuing it for the mother and
fetus. The main factors for determining whether labor could be induced is fetal lung maturity and term gestation.
Induced labor during term gestation is more favorable since prelabor cervical changes facilitate dilation of the cervix.
Cervical assessment estimated whether the cervix if favorable for induction. Birth attendants would use the Bishop
Scoring System to evaluate the cervix’s readiness. A score of 8 or more assures that vaginal birth is more likely.
Although studies have shown that multigravidas could undergo successful induction with a score of 5.
MEDICAL METHODS
Prostaglandin E2 Intravaginally and Prostaglandin E1 (Misoprostol 25mcg) Intravaginal/Oral can be given
but both of these, especially PGE1, produce a higher risk of uterine hyperstimulation. Therefore, emergency care and
fetal monitoring must be present. Intravaginal application of these medications might leak so the mother is placed in a
supine position for 15-20 minutes. The nurse should monitor for excessive contractions and abnormal FHR patterns.
Oxytocin administration is the most common drug used in induction and augmentation of labor. It is given
diluted in a isotonic infusion as a piggyback to the main IV line to be able to stop administration as soon as possible if
complications occur. The drug should be started slowly and increased gradually and monitored with an infusion pump
ideally. Uterine activity and FHR patterns are monitored continuously throughout labor. The woman’s uterus becomes
more sensitive to oxytocin as labor progresses. Therefore, the rate of oxytocin infusion may be gradually reduced when
she is in the active phase of labor (about 5 to 6 cm of cervical dilation).
Serial induction may be performed when the woman’s cervix is not favorable, and she has an indication for
induction, but same-day birth is not imperative. In this variation, an oxytocin solution is given over a 2-3-day period for
8-10 hours each day. If the labor has not progressed that day, the infusion is stopped, the mother is given a light meal
and the infusion is given again the morning after. These medications can stimulate uterine contractions which could
possibly lead to tachysystole (Contraction longer than 90-120 minutes with rest periods less than 2 minutes apart or
relaxations of less than 30 seconds), wherein the contractions become too strong which in turn reduces blood exchange
between the mother and placenta. FHR is determined before administration of these medications and is monitored
every 15 minutes during the first stage of labor and every 5 minutes during the second stage. If tachysystole does
occur, stop or reduce oxytocin, increase iv fluid rate, position in lateral position, give O2 per face mask 8-10 LPM.
Mechanical
Mechanical methods of cervical ripening work by manually pushing the cervix open using hydrophilic inserts.
These inserts inserted in the cervix attract water and inflate, gradually dilating the cervix. Examples would be Dilapan
(synthetic material), Lamicel (synthetic sponge w/ MgSO4), Laminaria tents (sterile, dried seaweed cones).