Group Project -Summer 2019

BIOL 1050

Presented by:

Terri Lee-Johnson

Michele DeMeo (Shelly)

Paige Hesen

Marybeth Carolan

Hormones and their functions before, during, and after labor

Relaxin

• During ovulation, a follicle within an ovary ruptures to release an egg; what remains of that ruptured follicle forms a small, yellow body called the corpus luteum (Marshall and Raynor, 2014, p. 94).
• This small body is responsible for producing the hormone relaxin in the beginning of pregnancy (Marshall and Raynor, 2014, p. 94).
• Before labor
• keeps the uterus calm and softens pelvic ligaments
• creates more room in the pelvis
• may result in pelvic girdle pain
• During labor
• softens cervix and pelvic ligaments
• After labor
• Relaxin has no further function

Endorphins

• Endorphins are opiate-like pain blockers
• Endorphin levels peak at delivery (Coad, 2001, p. 306).
• Before labor
• No function
• During labor
• “Pregnancy induced analgesia” (Coad, 2001, p. 306).
• After labor
• Supports release of prolactin which is the main hormone in human milk production (Coad, 2001, p.352).

Oxytocin

• Oxytocin is a hormone produced by the hypothalamus
• Levels of oxytocin rise during pushing, postpartum, and breastfeeding (Frye, 2013, p.249).
• Before labor
• Facilitates stimulation of the uterus
• During labor
• Facilitates stimulation of the uterus
• After labor
• Stimulates human milk delivery/ let-down reflex
• Promotes bonding between the birthing parent and infant

Stages of labor and what the

birthing person might be doing, feeling or saying

Photos owned by Shelly DeMeo

The Four Phases of Labor - simple breakdown

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• Stage One
• Divides into 3 phases: Latent, Active, and Transition
• Stage two
• Passage of the baby through the birth canal
• Stage three
• Delivery of the placenta
• Stage four
• Recovery
• ​

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Let’s break this down further...

Photo credit: https://images.app.goo.gl/xwSZ4AhNMznDG2aLA

Stage One: Latent or Preparation Phase

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• Contractions that remain constant but do not increase with frequency, duration or intensity.
• You will begin to feel excited and nervous, you may start engaging in last minute birth preparation or making phone calls.
• Stay hydrated and nourished -eat, rest, sleep, continue with normal activity as early labor could begin at any time.
• Trust that your body is doing good work preparing for progressive uterine activity.

Stage one: early and active labor

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• Early labor: contractions with increasing intensity, do not go away with change in activity. Contractions may be 15-40 sec long, and occur 15-30 min apart. Uterus is changing with each contraction. May see bloody show, feel nesting instincts, feel excited.
• Active Labor: Cervical dilation to 4-5 cm. Contractions will progressively occur at shorter intervals, cervical effacement occurring, May begin to look for outward for support or go inward to become more focused. Deeper breathing and rocking as intensity and pressure increase across pelvis, back or symphysis pubis.

Stage One: hard labor and transition

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• Hard Labor: cervical dilation 7-9 cm. Contractions will usually be 60 sec or longer now. Effacement continues, Intensity of contractions will slow you down, may begin to feel overwhelmed and fearful. Important to be have quiet, peaceful, safe space allowing for natural release of endorphins.
• Transition: Cervix changes to 8-9 cm or to complete. Contractions may become irregular and come back to back as cervix opens all the way and baby descends to pelvic floor. Labor intensifies sharply, reaching a deep level of surrender and altered state of consciousness as brain waves move to theta frequency. It is common to experience shaking, nausea & vomiting, flip between hot & cold, and express doubt in the phase of labor

Stage One: the resting phenomenon

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• Cervix becomes fully dilated and effaced, baby is moving down +2 station may occur
• Contractions may ease up and may stop temporarily. Birthing person may become more clear headed and optimistic OR may start to worry that labor has stopped.
• This is normal!!! And it may range from minutes to an hour or more.
• It is okay to rest or doze off, allow the uterus to recover in preparation for pushing that comes next. Trust me, you’ll know when it is time.
• We call this the “rest and be thankful phase”.

Stage one: pushing

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• Spontaneous bearing down: Will feel deep urge to push at peak of contractions, may begin to hold breath involuntarily and make deep gutteral sounds as baby descends further.
• May feel good to push moving into active participation of labor. “Yes, let’s do this!”
• Baby may rotate and flex getting into good position. Will typically begin to see top of baby's head emerge but recede after contraction/push ends. This can be frustrating but patience is important and should be encouraged.
• Surge of hormones occur for both birthing person and baby.
• Crowning to birth: Babies head will no longer recede with end of push. The perineum will begin to burn as it stretches open, encourage importance to slow down pushing and breathe. Baby will complete rotation (neck and spine extend beneath the pubic bone).

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Stage two: the birth

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• Babies head will be born first, then after another contraction or two the shoulders and rest of body will follow.
• This is exhilarating and intense, remain patient while waiting for body to follow the head.
• The placenta remains attached and umbilical cord continues to pulse.
• Baby will transition from fetal circulation to room air and will need a few moments to breath on its own, rub babies back or feet, and talk to the baby.

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Post-Birth Rest

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• It is normal for the birthing person to need a few moment to recover and come back to one’s full self. Stay warm and close to baby, skin to skin if possible. Skin to skin contact will encourage oxytocin release allowing for detachment of placenta and uterine involution
• There will be a drop in adrenaline and this will often cause shivering in the birthing person. Keep them warm to encourage release of oxytocin which helps placenta to detach.
• As the placenta detaches the umbilical cord will lengthen and there may be a “separation gush” of blood
• Occasionally the birthing person feels discomfort with these contractions but relief once the placenta is birthed

Stage three: delivery of placenta

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• Contractions will resume as uterus clamps down in response to oxytocin.
• Placenta detaches and is birthed. Placenta will be moved closer as baby is likely to still be attached to the umbilical cord. It is normal to have a gush of separation blood. Bleeding will be monitored closely.
• Delayed cord cutting is encouraged until no longer feeling a pulse in the cord (usually takes several minutes)
• Expect gentle but firm, external massage of the uterus to encourage it to shrink down further (size of grapefruit).
• Placental involution encourages the uterus to return to pre-pregnancy size rather quickly

Stage Four: recovery

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• Stage four is considered to include the first two or three hours after birth.
• Consist of the golden hour, at least one full hour of uninterrupted baby and birthing person skin to skin contact.
• During this time there may be body tremors and chills, as well as discomfort from after-pains, episiotomy or tears. Use warm blankets.
• If there is swelling that may make it hard to pee, use cold packs, arnica, etc

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• May experience dizziness or faint feeling upon standing.
• Birthing person should not go to the bathroom on their own or carry baby until (both) one sleep and one meal has been had.
• Contractions will resume as uterus clamps down in, this is also common as baby begins breastfeeding, and will often occur for several days.

Cardinal Movements of the Baby during Labor & Birth

Cardinal Movements of Baby

Refers to changes in the fetal head position during its passage through the birth canal. There are 7 cardinal movements in labor & birth:

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• Engagement
• Descent
• Flexion
• Internal rotation
• Extension
• External rotation/restitution
• Expulsion

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Code Health, 2019

Anatomy Breakdown: Mini Lesson

• Ischial Spines:
• Bony protuberances on the birthing person’s pelvis - typically the narrowest part of the pelvis

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• Pelvic Inlet
• The widest part of the pelvis typically, where the baby enters into to prepare for birth

• Presenting Part
• The part of the baby that enters into the pelvis - typically the head

• What is optimal presentation for delivery?
• Cephalic - meaning “head”
• Head down entering into the pelvis is optimal
• Breech = variation of normal
• Buttocks present into pelvis first
• Occiput Anterior (OA)
• Baby is head down facing birthing parent’s spine
• Occiput Posterior (OA)
• Baby is head down facing birthing parent’s front
• “Sunny Side-Up”
• Delivery can be more difficult in this position

Code Health, 2019

Engagement & Descent

• Engagement
• Passage of the largest part of the fetal presenting part below the plane of the pelvic inlet
• Fetal head does not enter into pelvis in OA or OP position
• When the head is “engaged”, that means the the leading part is at the level of the ischial spines
• Can happen in last few weeks of pregnancy or when labor begins
• Descent
• Refers to the downward passage of the presenting part of the fetus through the bony pelvis
• Pressure from uterine contractions, hydrostatic pressure, abdominal muscles & gravity promote descent of fetus
• Not a steady process - can take time!
• Assessed by measurements called Stations

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Nurse Key, 2016

These 2 stages may happen simultaneously

Flexion & Internal Rotation

• Flexion
• Flexion of the fetal head occurs as the baby descends
• Due in part to the shape of the maternal bony pelvis + resistance of soft tissues - passive action
• Complete flexion places the fetal head in the optimal smallest diameter to fit through the pelvis
• Chin is brought to the chest
• Internal Rotation
• Baby begins to rotate while descending down the pelvis
• Typically rotates into a direct OA position
• Occiput Anterior
• Baby is facing towards the birthing parent’s spine

Cunningham, F., Leveno, K., Spong, C., Dashe, J., Hoffman, B., & Casey, B. (2018). Lever action produces flexion of the head. Conversion from occipitofrontal to suboccipitobregmatic diameter typically reduces the anteroposterior diameter from nearly 12 to 9.5cm [Digital image]. Retrieved from https://accessmedicine.mhmedical.com/content.aspx?legacysectionid=p9780071798938-ch022

Extension, External Rotation & Expulsion

• Extension
• Occurs when the baby reaches the opening of the vagina. This section of the birth canal curves upwards
• The fetal head, face and chin curve up under and past the pubic symphysis
• External Rotation (Restitution)
• There is typically a short pause in labor when the baby’s head is born
• The baby will then rotate to from a face down position to facing either of the birthing parent’s thighs
• This rotation is necessary for the shoulders to fit under the pubic arch
• Expulsion
• Almost immediately after the baby rotates externally, the anterior (top) shoulder moves out from the pubic symphysis & is delivered
• After the anterior shoulder is delivered, the posterior shoulder is born followed by the rest of the body

External Rotation

Extension

Cardinal movements

All photos: Code Health, 2019

Immediate Postpartum Actions of the Uterus, Placenta, Baby’s Transition, Hormones

Immediate Postpartum: Actions of the Uterus

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Contractions for the placenta

• Immediately after birth, the uterus begins to contract. This happens to aid the placenta in fully separating from the uterine wall and eventually birth the placenta

Contractions for prevention

• In addition to aiding the placenta birthing process, the uterus contracts to prevent blood loss/hemorrhaging by constricting blood flow of the vessels that run through the uterine muscle as the placenta separates.

Changes in size

• Within 24 hours after delivery, the uterus shrinks down significantly to a fundus height about level with the belly button. By week 6-8, uterus returns to its original size (Syed, 2019).

Placenta

• The placenta begins separating once the fetus is expelled from the uterine cavity decreasing its attachment area of the uterine wall by roughly half
• Simultaneously, the uterus begins contracting which squeezes the placenta forcing the blood in the intervillous spaces into the veins of the spongy layer of decidua
• Venous return from the uterus reduces significantly causing the decidua blood vessels to become congested and burst. These bursts, combined with the uterine contractions helps the placenta to fully separate
• Once separated the placenta moves into the lower part of the uterus and on the next contraction, the membranes are stripped from the decidua and the placenta and membranes are delivered (Wylie, 2005).
• “What remains of the inner surface of the uterine lining apart from the placental site, regenerates rapidly to produce a covering of epithelium. Partial coverage occurs within 7–10 days after the birth; total coverage is complete by the 21st day” (Myles, 2014 pg 505).

Position of the uterus before and after placental separation.

Newborn’s Transition

• The first 6 hours of life of the newborn is called Transition
• During this time the newborn stabilizes its respiratory and circulatory systems
• Newborn transition is “the most complex physiological adaptation that occurs in the human experience and involves virtually every organ system in the body” (Davidson, London, & Ludewig, 2020).
• The newborn experiences many system adaptations within the first few days to weeks after birth including hematopoietic, Thermoregulation, Hepatic, Gastrointestinal, Urinary, Immunologic and Neurologic

Cardiopulmonary Adaptation:

• Right before the onset of labor, fetal lung fluid secretions decrease
• Once labor begins, production of catecholamines is stimulated causing the fetal pulmonary epithelial cells to reabsorb any fluid in alveolar spaces
• Sensory changes in the newborns environment (from the warm womb to the cold birth room) helps to initiate its first breath. The cold initiates and sustains rhythmic respirations by stimulating its skins sensory receptors

(Drying and placing the newborn on the birthing person for skin-to-skin contact is a great way to provide comforting stimulation as well as prevent heat loss)

• The initial first breath creates high negative pressure, removing fluid from the lungs and filling the alveoli with air
• As the lungs are exposed to high levels of oxygen, causing blood flow increases to the lungs through pulmonary vasodilation
• The placenta is excluded from the newborns circulation upon clamping of the umbilical cord

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Newborn’s Transition: continued

Conversion from fetal to newborn circulation pg. 640-41 of Maternal-Newborn Nursing and Women’s Health

Initiation of respiration in the newborn

Postpartum Hormones

Oxytocin- Immediately after birth, oxytocin levels remain high and oxytocin is secreted from the posterior lobe of the pituitary gland to maintain uterine contractions. Again, these uterine contractions play a huge role in preventing hemorrhaging and releasing the placenta. Oxytocin is called the love hormone because it aids in bonding with you baby, but it also controls the let down or release of breastmilk when the newborn begins to feed. Chestfeeding also aids in the production of oxytocin, therefore chestfeeding after delivery is a big help in the oxytocin positive feedback loop.

Endorphins- During labor and birth endorphin levels are very high, but shortly after delivery these hormones (as well as oestrogen and progesterone) begin to decrease. Sometimes gradually, and for some it happens more drastically. This drop in endorphins postpartum contributes to the cause of the temporary “baby blues” as well as postpartum depression.

Prolactin- prolactin begins being released in the bloodstream at high levels (it’s there during pregnancy but its effects aren’t usually felt due to the counter effect of high progesterone) after the baby is born and progesterone levels decrease sharply. Prolactin aids in milk production, together with the help of oxytocin, chestfeeding is made possible. Prolactin is known to decrease the dopamine levels which also contributes to “baby blues.” Prolactin levels drop around 4-6 months which is why a lot of parents see a decrease in milk supply around this time.

References

Coad, J. & Dunstall, M. (2001). Anatomy and physiology for midwives. New York: Mosby.

Code Health. (2019). 7 Cardinal Movements of Labor & Birth. Retrieved from: https://codehealth.io/library/article-78/cardinal-movements-of-labor/

Cunningham, F., Leveno, K., Spong, C., Dashe, J., Hoffman, B., & Casey, B. (2018). Lever action produces flexion of the head. Conversion from occipitofrontal to suboccipitobregmatic diameter typically reduces the anteroposterior diameter from nearly 12 to 9.5cm [Digital image]. Retrieved from https://accessmedicine.mhmedical.com/content.aspx?legacysectionid=p9780071798938-ch022

Davidson, M., London, M. & Ladewig, P. (2020). Maternal Newborn Nursing, 11th Edition. Old Tappan, New Jersey: Pearson Education, Inc.

Frye, A. (2013). Holistic midwifery volume II: care during labor and birth. Portland, OR: Labrys Press.

Marshall, J. E., & Raynor, M. D. (2014). Myles' Textbook for Midwives E-Book. Philadelphia, PA: Churchill Livingstone.

Nurse Key. (2016). Cardinal Movements of Labor. Retrieved from: https://nursekey.com/cardinal-movements-of-labor/

Contributors

• Terri Lee-Johnson: Hormones and their functions before, during, and after labor
• Michele DeMeo: Stages of labor and what the birthing parent might be doing, feeling, or saying
• Paige Hesen: Cardinal movements of the baby during labor & birth
• Marybeth Carolan: Immediate postpartum actions of the uterus, placenta, baby’s transition, hormones

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