INTRAPARTUM CARE Irene L.

Gardiner, MD Maternal and Child Health Nursing FEU Institute of Nursing Intrapartum Period Extends from beginning of contractions that cause cervical dilation to the first 1-4 hours after delivery of the newborn and placenta Intrapartum Care Refers to the medical and nursing care given to a pregnant woman and her family during labor and delivery Goals of Intrapartum Care Promote physical and emotional well being in the mother and fetus Incorporate family centered care concepts into the labor and delivery experience Factors Affecting the Intrapartum Experience Previous experience with pregnancy Cultural and personal expectations Prepregnant health Motivation for childbearing Socioeconomic readiness Age of mother Partnered vs. unpartnered status Extent of prenatal care Extent of childbirth education Onset of Labor LABOR The process by which the fetus and products of conception are expelled as a result of regular, progressive, frequent and strong uterine contractions The coordinated sequence of involuntary uterine contractions Theories of Labor Uterine stretch theory

Oxytocin theory Progesterone Deprivation theory Prostaglandin theory Theory of aging placenta

Premonitory Signs LIGHTENING Descent of the fetus and uterus into the pelvic cavity 2 3 weeks before onset Easier respiration Frequent urination BRAXTON HICKS CONTRACTIONS Irregular, intermittent contractions that have occurred throughout the pregnancy Becomes uncomfortable and produces a drawing pain in the abdomen and groin CERVICAL CHANGES Bloody show Includes softening, ripening and effacement of the cervix that will cause expulsion of the mucus plug EFFACEMENT (%) Thinning and shortening of the cervix Primipara E before D DILATION (cm) Widening of the cervical os RUPTURE OF THE MEMBRANES May occur prior to onset of labor Sudden gush or scanty, low seeping of clear fluid from the vagina Note time of rupture and color of fluid Cord prolapse and intrauterine infection are risks AMNIOTOMY artificial rupture of membranes using an amniotome NESTING

Sudden burst of energy due to epinephrine Increased tension of fatigue WEIGHT LOSS 1

Loss of 1 3 lbs occurring at about 23 days before onset of labor

FALSE PELVIS Shallow portion above the pelvic brim Supports the abdominal viscera

FALSE LABOR vs. TRUE LABOR False Labor True Labor Irregular Contractions are regular contractions Increased intensity No increase in Pain begins lower back intensity radiates to abdomen Pain confined to Pain intensified by abdomen walking Pain relived by Cervical effacement & walking dilatation * major sx No cervical of true labor. changes Components of Labor Passage

PELVIMETRY Measurements done to determine adequacy of the pelvic size DIAGONAL CONJUGATE Anteroposterior diameter The narrowest diameter in the pelvic inlet TRANSVERSE DIAMETER The narrowest diameter in the pelvic outlet TYPES OF PELVIS GYNECOID Normal female pelvis Transversly rounded and blunt Most favorable for labor and delivery ANDROID Wedge-shaped or angulated ANTHROPOID Oval-shaped PLATYPELLOID Flat-shaped PELVIMETRY Clinical

The womans pelvis Passenger The fetus Powers The uterine contractions Psyche Placental factors

1. PASSAGE Refers to the adequacy of the pelvis and birth canal in allowing fetal descent Type of pelvis Structure of pelvis Pelvic inlet diameters Pelvic outlet diameters Ability of the uterine segment to distend, the cervix to dilate and the vaginal canal and introitus to distend

Xray / CT / MRI CPD Cephalopelvic disproportion

Exists when the capacity of the pelvis is inadequate to allow the fetus to negotiate the birth canal. 2. PASSENGER Refers to the fetus and its ability to move through the passageway, which is based on: Size and structure of the fetal skull (bones, fontanelles suture lines) molding Fetal LIE Fetal PRESENTATION 2

TRUE PELVIS Lies above the pelvic brim

Consists of the pelvic inlet, midpelvis and pelvic outlet

Fetal ATTITUDE Fetal POSITION

STRUCTURE OF THE FETAL SKULL 8 bones of the cranium

4 are important in childbirth because they are presenting parts Frontal Parietal (2) Occipital Mentum (if face presentation) The Suture Lines: Sagittal suture Joins the 2 parietal bones of the skull Coronal suture The line of juncture of the frontal bones and the 2 parietal bones Lambdoid suture The line of juncture of the occipital bone and 2 parietal bones. FONTANELLES Significant membrane-covered spaces that are found at the junction of the main suture lines VERTEX The space between two fontanelles Sinciput the area over the frontal bone Occiput the area over the occipital bone FONTANELLE Anterior Fontanelle Referred to as bregma Lies at the junction of the coronal and sagittal sutures Diamond-shape Anteroposterior diameter is 3-4cm Transverse diameter is 2-3cm

Lies at the junction of the lambdoidal and sagittal sutures. Triangular Smaller than the anterior fontanelle Only 2cm across its widest part MOLDING The change in shape of the fetal skull produced by the force of uterine contractions pressing the vertex of the head against the not-yet-dilated cervix Overlapping of sutures sagittal and coronal Lasts for 1 2 days and is not a cause of alarm DIAMETERS OF THE FETAL SKULL Suboccipitobregmatic Narrowest diameter - 9.5cm From the inferior aspect of the occiput to the center of the anterior fontanelle Occipitofrontal Measured from the bridge of the nose to the occipital prominence; 12cm Occipitomental The widest diameter - 13.5cm Measured from the chin to the posterior fontanelle CAPUT SUCCEDANEUM A diffuse, soft, puffy swelling of the scalp in a newborn caused by pressure from the uterus or vaginal wall during a head-first (vertex) delivery Swelling may or may not have some degree of bruising Swelling may extend over the midline of the scalp Most often seen on the portion of the head which presented first May be associated with increased molding of the head CEPHALHEMATOMA Swelling caused by bleeding into an area between the bone and its periosteum 3

Posterior Fontanelle Referred to as lambda

due to shearing forces of labor, forceps, prolonged labor Does not cross the suture line Resolves within 6 weeks without treatment Complications - anemia, shock, hyperbilirubinemia, infection, skull fracture, calcification FETAL LIE The relationship between the long axis of the fetal body and the long axis of a womans body Relationship of the spine of the fetus to the spine of the mother Longitudinal or vertical- 99% Transverse or horizontal Oblique FETAL PRESENTATION The fetal body part that will first contact the cervix or be born first Cephalic Most common Fetal head presents first Breech Buttocks or feet first Shoulder Arm, hand, shoulder, back, abdomen or side could present FETAL ATTITUDE Describes the degree of flexion a fetus assumes during labor The relation of the fetal parts to each other Vertex (full flexion)

Divided into 4 quadrants according to the mothers right and left Right anterior Left anterior Right posterior Left posterior FETAL POSITION 4 quadrants of the fetus are chosen as landmarks Vertex occiput

Face mentum / chin Breech sacrum Shoulder scapula or acrominion

FETAL POSITION Indicated by an abbreviation of 3 letters 1st letter Whether landmark is pointing at mothers R or L 2nd letter Denotes the fetal landmark used O (occiput); M (mentum); Sa (sacrum); A (acromnion) 3rd letter Denotes whether the landmarks point A (anteriorly); P (posteriorly); T (transverse) FETAL POSITION LOA Most common fetal position ROA Second most common ROP or LOP Extended labor More painful because the rotationof the fetal head puts pressure on the sacral nerves, causing sharp, back pain Most common malposition Abdominal Examination LEOPOLDS MANEUVER Systematic way to evaluate the maternal abdomen 4

Sinciput ( moderate flexion/Military attitude Brow (partial extension) Face (complete extension)

FETAL POSITION Relationship of the presenting part to a specific quadrant of a womans pelvis

Prior to examination Empty urinary bladder Dorsal recumbent position Drape properly to maintain privacy Explain the procedure to the patient Warm hands by rubbing together Use the palm for palpation and not the fingers LM 1 3 done facing the patients head LM 4 done facing the patients feet LM 1 FUNDAL GRIP Determines presentation

Examiner faces the patients feet Good attitude - FLEXION cephalic prominence (brow) same side as fetal parts Poor attitude EXTENSION / HYPEREXTENSION obstruction on the same side as fetal back STATION The relationship of the presenting part of the fetus to the level of the ischial spines Station -1 to 4 = above ischial spines - 4 = floating Station 0 = level of ischial spines engagement has occured Station +1 to + 4 = below the ischial spines + 4 = head is at the outlet / crowning 3. POWERS Refers to the uterine contractions that cause complete cervical effacement and dilation Begins at a pacemaker point located in the myometrium near the fundus then sweeps down over the uterus as a wave 2 types

What fetal pole or part occupies the fundus? BREECH irregular, nodular CEPHALIC - round

LM 2 UMBILICAL GRIP Determines position

Which side is the fetal back? BACK linear, convex, bony ridge SMALL PARTS numerous nodulations LM 3 PAWLIKS GRIP Determines engagement of the presenting part What fetal part lies above the pelvic inlet? HEAD NOT ENGAGED round, ballottable, easily displaced HEAD ENGAGED felt as relatively fixed, knoblike part LM 4 PELVIC GRIP Determines attitude or habitus

Involuntary uterine contractions Voluntary bearing down efforts

PHASES OF CONTRACTION INCREMENT

Intensity of contraction increases ACME Strongest point of contraction DECREMENT Intensity of contraction decreases

Which side is the cephalic prominence? Part of the fetal head that prevents the deep descent with one hand

TIMING OF CONTRACTION Duration Beginning of a contraction to the end of that same contraction 5

Frequency Time between the beginning of one contraction and the beginning of the next contraction Interval From the end of one contraction to the beginning of the next contraction TIMING OF CONTRACTION Intensity / Strength Strength of the contraction during acme Use the tips of the fingers spread lightly over the fundus Mild Moderate Strong 4. PSYCHE The psychological state or feelings that a woman brings into labor Ranges from apprehension, fright, excitement, awe Those with strong self esteem and meaning support system manage best in labor A positive attitude during labor yields a positive outcome. A woman who is: relax, aware and participating in the birth process: shorter, less intense labor A woman who is: fearful has high levels of adrenaline which slows uterine contractions 5. PLACENTAL FACTORS Refers to the site of placental insertion Normal : high-lying, anterior or posterior Abnormal : placenta previa Childbirth Preparation Overall goal: To prepare parents physically and psychologically while promoting wellness

behavior that can be used by parents and family, thus, helping them achieved a satisfying and enjoying childbirth experience. Admitting History Identifying information Labor history Contractions, bloody show, status of membranes, vaginal bleeding, last meal, headache, visual disturbances, dysuria Pregnancy history LMP, EDC, gestation, where received antepartal care, AP complications and treatment, drugs and medications during pregnancy, any special tests during pregnancy (eg, ultrasound, amniocentesis.) Past obstetric history gravida, parity, complications' during previous pregnancies, length of last labor, type of delivery (SVD, forcep, CS) size of largest and smallest babies, any fetal or neonatal deaths. Past medical and surgical history (include gyne history) Family history Social history Prenatal records (if available) may provide much of this information, which will only need to be confirmed. Admitting PE Review of systems and general physical exam, with special attention to: Maternal vital signs and fetal heart tones Abdominal Examination Fundal height Leopold's maneuvers Estimated fetal weight Uterine contractions, uterine tenderness, note any scars. Pelvic examination (unless there is rupture of membranes without labor or active vaginal bleeding): Dilatation, effacement and position of cervix Fetal presentation, station, and position Status of the membranes 6

Evaluation of bony pelvis (clinical pelvimetry)

Admitting Orders Admit Consents Lab tests Maternal vital signs and frequency Fetal monitoring continuous vs intermittent and external vs internal Ambulation vs bed rest Hydration - IV vs oral Analgesia Enema if patient desires and labor is not yet advanced STAGES OF LABOR First Stage (actual labor) Latent Phase Active Phase Transition Phase Second Stage (delivery stage)

Average duration Nullipara 6 hours Multipara 4.5 hours

Nursing Resposibilities Encourage CHEST BREATHING Encourage mother and partner to participate in care Assist with comfort measures, changes of position or ambulation Keep client and partner informed of the progress of labor Offer fluids and ice chips Encourage voiding every 1 2 hours First Stage of Labor ACTIVE PHASE IE : 4 7 cms Contractions every 3 5 mins, 40-60 secs in duration, moderate intensitY Mother may experience feelings of helplessness and becomes anxious and restless with each contraction Administration of analgesisc has little effect on the progress of labor Average duration: Nullipara : 3 hours Multipara : 2 hours

Third Stage (placental stage) Fourth Stage (recovery and bonding)

FIRST STAGE OF LABOR Begins with the onset of regular contractions progressive cervical effacement and dilation ends with full cervical dilation Latent

Active Transitional

First Stage of Labor LATENT PHASE Begins with onset of regular contractions Contractions every 15 30 mins, lasting for 20 40 secs, mild intensity Mother is talkative and excited to be in labor IE : 1 4 cms

Nursing Resposibilities Encourage ABDOMINAL BREATHING patterns Provide a quiet environment Prepare medications Provide oral care and dry linen Keep mother and partner informed about the progress of labor Promote comfort with backrubs, sacral pressure, pillow support, position changes Encourage voiding every 1 2 hours

First Stage of Labor TRANSITION PHASE Culmination of the 1st stage IE : 8 10 cms 7

Intensity, frequency and duration of contractions peak Contractions every 2 3 mins, 60 90 secs in duration, strong intensity Mother feels tired, is restless and irritable, and feels out of control Irresistible urge to push

Nursing Responsibilities Encourage rest between contractions Encourage CONTROLLED CHEST BREATHING Keep mother and partner informed of progress of labor Prepare for delivery when the perineal area is bulging / crowning for primipara and when the cervix is 7-8 cms dilated in multipara Encourage and praise Provide privacy Encourage voiding First Stage of Labor IMPLEMENTATION Monitor maternal VS and FHR Assess FHR before,during and after each contraction Monitor uterine contractions by palpation, determing frequency, duration, and intensity Encourage voiding : facilitates fetal descent and avoids injury to the bladder Assess cervical effacement & dilation Assess fetal station, presentation and position Assist with pelvic examination Assess color of AF is membranes are ruptured Fetal Assessment FETAL MONITORING Periodic change or fluctuation in FHR occur in response to contractions and the fetal movements are described in terms of accelerations or decelerations Done through intermittent auscultation or electronic monitoring

Results of monitoring: normal FHR 120-160; must obtain a baseline External Transabdominal, noninvasive, monitors uterine contraction and FHR; client needs to decrease extra-abdominal movements Internal Membranes must be ruptured, cervix sufficiently dilated and presenting part visible; invasive procedure; continuous monitoring Acceleration

15 bpm rise above baseline followed by return; usually in response to fetal movement or contractions; indicates fetal well-being FETAL MONITORING Deceleration fall below baseline lasting 15 seconds or more, followed by a return to the baseline Early Deceleration are periodic decreases in the FHR resulting from pressure on the fetal head during contraction (head compression) Late Deceleration indicative of fetal hypoxia because of deficient placental perfusion (uteroplacental insufficiency) Variable Deceleration occurs at unpredictable times during contractions and indicates cord compression SECOND STAGE OF LABOR Begins with complete cervical dilation Ends with delivery of the newborn Average duration Nullipara: 3 hours Multipara: 1 hour Contractions are severe at 2 -3 minutes interval, with a duration of 50 to 90 seconds Progress of labor is measured by DESCENT of the fetal head through the birth canal change in STATION

The newborn exits the birth canal by going through the CARDINAL MOVEMENTS OF LABOR Nursing Responsibilities Perform assessment every 5 minutes Monitor maternal VS and FHR Assess FHR before, during and after each contraction Monitor uterine contraction Encourage and praise, rest periods Assist in position that promotes comfort and assist pushing efforts Monitor for signs of approaching birth, such as perineal bulging and crowning Prepare for birth Cardinal Movements of Labor Mechanism of normal labor in vertex presentation Positional changes of fetal head to accommodate the diameters of maternal pelvis Engagement nestles into the pelvis Descent assessed by measurement of station Flexion fetal head towards fetal chest Internal rotation from occiput transverse to occiput anterior Extension enables the head to emerge Restitution realignment of the fetal head with the body after head emerges External rotation rotation of the shoulders Expulsion birth of entire body DESCENT Downward movement of the biparietal diameter of the fetal head to within the pelvic inlet Full descent occurs and the fetal head extrudes beyond the dilated cervix and touches the posterior vaginal floor

FLEXION The head bends forward onto the chest, making the smallest anteroposterior diameter INTERNAL ROTATION The occiput rotates until it is superior, or just below the symphysis pubis, bringing the head into the best relationship to the outlet of the pelvis EXTENSION As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. The head extends, and the foremost parts of the head, the face and chin are born. EXTERNAL ROTATION Almost immediately after the head of the infant is born, the head rotates (from the anteroposterior position it assumed to enter the outlet) back to the diagonal or transverse position of the early part of labor EXPULSION The rest of the baby is born easily and smoothly because of its smaller part size. Second Stage of Labor CROWNING Occurs when the newborns head or presenting part appears at the vaginal opening EPISIOTOMY Surgical incision of the perineum Shortens the 2nd stage of labor Relieves the pressure of the fetal head May be done to facilitate delivery and avoid laceration of the perineum Median or mediolateral Anesthesia During Delivery Local Pudendal Block Epidural 9

Caudal Spinal

Begins with delivery of the newborn

Ends with delivery of the placenta 5 to 10 minutes after delivery of baby 2 phases Placental separation Placental expulsion

Modified Ritgens Maneuver

Place towel at perineum/ perineal support To prevent laceration Will facilitate complete flexion & extension. Support head & remove secretions, check cord if coiled, pull shoulder down & up. Immediately after delivery: Infant Position: Head lower than the rest of the body to allow drainage of secretions NEWBORN is held below the level of the mothers vulva for a few seconds to allow placental blood to enter the infants body through gravity flow Provide warmth by wrapping the baby in a sterile diaper or cloth to keep him warm. Place the baby on the mothers abdomen The weight of the baby will help contract the uterus. Clamping and Cutting the Cord Do not cut until the pulsations have stopped because 50-100 ml. of blood is still flowing from the placenta to the baby at this time Clamp twice, an inch apart, and cut between. Second Stage of Labor Information to record Time of delivery of baby Delivery of the whole body Sex of baby

Slowly pull cord and wind to clamp BRANDT ANDREWS MANEUVER Hurrying of placental delivery will lead to inversion of uterus. Umbilical Cord is pulled gently with one hand Other hand pushes uterus up from pubis Use See-Saw motion between the two hands Signs of Placental Separation Uterus becomes globular CALKINS SIGN Fundus rises into the abdomen Lengthening of the cord Sudden gush of blood

Contraction of the uterus controls bleeding and aids with placental separation and expulsion Administration of OXYTOXIC drugs Placental Expulsion / Separation Schultze Separation of the placenta from the central to the periphery Shiny fetal surface

Minimal Blood Duncan Peripheral separation to the central Dull, red, rough maternal side Bloody and dirty 10

Presence of nuchal cord

THIRD STAGE OF LABOR

Nursing Responsibilities Assess maternal VS Assess uterine status Following birth of the placenta, uterine fundus remains firm and is located 2 fingerbreadths below the umbilicus Examine cotyledons and membranes to verify that it is intact Check fundus (if relaxed, massage uterus) Administer methergine IM Give oxytocin IV Check perineum for lacerations Assist MD for episiorrhapy Flat on bed Chills-due dehydration.provide blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy. Information to record Time the placenta is delivered. How delivered (spontaneously or manually removed by the physician). Type, amount, time and route of administration of oxytocin. If the placenta is delivered complete and intact or in fragments FOURTH STAGE OF LABOR Lasts from 1 4 hours after birth Mother and newborn recover from the physical process of birth Maternal organs undergo initial adjustement to the nonpregnant state Newborn body systems begin to adjust to extrauterine life and stabilize Uterus contracts in the midline with fundus midway between umbilicus and symphysis pubis Nursing Responsibilities Maternal assessment every 15 mins for 1 hour every 30 minutes for 1 hour hourly for 2 hours Placement of fundus

Lochia and blood loss Perineum (redness, hematoma, discharges, edema Provide warm blankets Apply ice pack to the perineum Massage the uterus if needed Provide breastfeeding support as needed Empty bladder to prevent uterine atony Intrapartum Pain Experience A subjective experience of physical sensations associated with uterine contraactions, cervical dilation and effacement and fetal descent during labor and delivery Physical responses: Increased BP, PR, RR, perspiration Muscle tension (face, hands) Muscle activity (pacing, twisting,turning) Nonverbal expression Withdrawal Hostility Fear depression Verbal expressions Statementsof pain Moaning and groaning Shouting Physiologic Causes of Pain Uterine anoxia Compression of nerve ganglia in the cervix and lower uterine segment Stretching of the cervix Traction on, stretching and displacement of the perineum Pressure on the urethra, bladder and rectum during fetal descent Distention of the lower uterine segment Stretching of the uterine ligaments 11

Pain Management Goal Provide maximal pain relief of pain with maximal safety for mother and fetus To facilitate labor and delivery as a positive family experience Factors to consider in the choice of pain relief: Gestational age of the fetus

impulse at the level of the spinal cord so the impulse is never perceived at the brain level Cutaneous stimulation Stimulation of large periphery nerves Rubbing, applying TENS, heat or cold Effleurage Distraction breathing techniques, imagery Reduction of anxiety TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) Relieves pain by counterirritation on nociceptors Stimulation blocks the afferent fibers, preventing pain from travelling from the uterus to the spinal cord synapses Bradley Method Partner-coached method Advocates active participation of husband at delivery process. Based on imitation of nature. Features: Quiet environment Closed eyes & appear like sleeping Relaxation techniques Darkened room Psychophysical Dick Read Method Fear leads to tension, which leads to pain Break the chain between fear and tension or tension and pain Focusing on abdominal breathing during contraction The Psychosexual Method Developed by Shiela Kitzinger Stresses that pregnancy, labor and birth, and the early newborn period are important points in a womans life Conscious relaxation, levels of progressive breathing Flow with rather than struggle against a contraction 12

Frequency, duration, intensity of contractions Labor progress Maternal response to labor and pain Allergies and sensitivities to drugs

NONPHARMACOLOGIC Prepared childbirth methods working with the contractions Hypnosis

clients

Interventions aimed at supporting the

Providing information on labor progress Reinforcing learned techniques Directing breathing methods Based on 3 premises: Discomfort can be minimized if a woman comes into labor informed Discomfort can be minimized if a womans abdomen is relaxed and the uterus is allowed to rise freely against the abdominal wall Pain perception can be altered by distraction techniques or by the gating control theory of pain perception GATE CONTROL MECHANISMS Mechanism in the substancia gelatinosa that are capable of halting an

Lamaze Method Psychoprophylactic method Requires discipline, conditioning & concentration Husband is the coach Breathing patterns & focusing can block pain sensations from reaching the cortex Features: Conscious relaxation Cleansing breath inhale nose, exhale mouth Effleurage gentle circular massage over abdominal to relieve pain Imaging sensate focus PHARMACOLOGIC Anesthesia Encompasses analgesia amnesia, relaxation and reflex activity. It abolishes pain perception by interrupting the nerve impulses to the brain. The loss of sensation may be partial incomplete, sometimes with loss of consciousness.

Rising or falling BP Abnormal pulse Inadequate or prolonged contractions

Abnormal lower abdominal contour due to full bladder injury to bladder, block descent of head Increasing apprehension

PATHOLOGIC RETRACTION RING Bandls Ring An indentation across a womans abdomen, where the upper and lower segments of the uterus join Sign of extreme uterine stress Sign of impending rupture Medications OXYTOCIN Stimulates the smooth muscles of the uterus and induces contraction of the myometrium Promotes milk letdown

Analgesia Refers to the alleviation of the sensation of pain or in the raising of the threshold for pain perception without loss of consciousness Danger Signs of Labor FETAL DANGER SIGNS High or low fetal heart rate

USES: Induces or augments labor Controls postpartum bleeding

Meconium staining A green color in the amniotic fluid Loss of sphincter control due to hypoxia Hyperactivity Frantic motion is a reaction to the need for O2 Fetal acidosis (pH below 7.2) Scalp capillary technique Danger Signs of Labor MATERNAL DANGER SIGNS

METHYLERGONOVINE (Methergin) Ergot alkaloid Directly stimulate uterine muscle and increase the force and intensity of contraction Produce a firm tetanic contraction of the uterus Not administered BEFORE the delivery of the placenta Monitor BP drug causes vasoconstriction and may further elevate BP

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