Intrapartum Exam

CU NSG 3010

Stage 1 of labor

from the onset of labor contractions to complete dilation

Assessment of contractions (3 things)

• frequency

• duration

• intensity

timing from the beginning of one contractions to the beginning of the next contraction

frequency

from the beginning of one contraction to the end of the same contraction

duration

palpate fundus with fingers to determine strength of contractions: mild, moderate, strong, or use IUPC to calculate Montevideo units

intensity

Vaginal exam (three things)

• dilation

• effacement

• station

the gradual opening of the cervix (closed to 10cm dilated)

dilation

the gradual thinning of the cervix (thick to 100% effaced)

effacement

the location of the baby’s presenting part (hopefully the head) in comparison to mom’s ischial spines

station

phases of stage one of labor (2 phases)

• latent phase

• active phase

latent phase measurements

0-5 cm

active phase measurements

6-10 cm

Stage 2 of labor and delivery

from complete dilation to pushing/delivery/birth of the baby

stage three of labor and delivery

from birth of baby to delivery of placenta

Stage four of labor and delivery

recovery-the first 2 hours (minimum) after delivery or until patient is stable, assess pt every 15 minutes

4th stage: every 15 minutes, what are you assessing?

• VS

• fundus

• perineum

• locia

• etc.

cervical dilation of 10cm and 100% effacement

Goals for 1st stage of labor

birth of baby

Goals for 2nd stage of labor

delivery of placenta

Goals for 3rd stage of labor

Uncomplicated recovery

Goals for 4th stage of labor

Five Essential Factors of labor and delivery

• passenger

• passageway

• powers

• positions

• psyche

passenger

fetus and placenta

passageway

maternal bony pelvis and soft tissues

powers

uterine contractions and maternal pushing efforts

position

of laboring woman

psyche

laboring woman

passenger: fetal size (especially head)

• fetal skull bones

• fetal sutures and fontanels

• fetal skull diameter

fetal skull bones

• frontal

• temporal

• parietal

• occipital

fetal sutures and fontanels

• frontal

• coronal

• sagittal

• lambdoidal

fetal fontanels

• anterior fontanel - is diamond shape (much easier to palpate)

• posterior fontanel - is triangle shape (more difficult to palpate, very small and closes early)

Fetal skull diameter

• widest transverse measurement = biparietal diameter (9.5 cm)

• anterior-posterior measurement (smallest = suboccipito = 9.5 cm)

First fetal part to enter the pelvic inlet. First part felt on vaginal exam.

fetal presentation

Types of fetal presentations

• cephalic (head down) - 96% = occiput

• breech - 3% = sacrum

• shoulder - 1% = scapula (baby’s CANNOT deliver vaginally this way!!!!)

Cephalic positions: head flexed, occiput presents (most ideal)

vertex

Cephalic positions: neck straight, bregma presents

military

Cephalic positions: head partially extended, sinciput presents (most of the time cannot deliver vaginally)

brow

Cephalic positions: head fully extended, mentum presents (difficult to deliver vaginally)

face

breech positions: both knees and hips flexed

complete

breech positions: hips flexed but knees extended (at risk for hip dysplasia)

Frank

breech positions: single or double with both knees and hips extended

footling

Shoulder position: baby’s cannot deliver vaginally this way!!!

scapula

relation of the long axis (spine) of fetus in relation to long axis (spine) of mother

Fetal lie

Types of fetal lie (2 types)

• longitudinal (may be either cephalic of breech)

• transverse (impossible to deliver vaginally)

the relationship of the fetal body parts to one another

Fetal attitude

Types (in relationship to cephalic presentation) - 3 types

• flexed (“vertex'“)

• extended (“brow/face”)

• neutral (“military”)

the relationship of the presenting part to the four quadrants of the maternal pelvis

fetal positions

Types of fetal positions: denoted by a 3-letter abbreviation

• 1st letter: R or L

• 2nd letter: O (occiput) - could be m/chin or s/sacrum)

• 3rd letter: A or P or T (transverse)

Most common fetal position

OA (R or IOA)

Fetal positions

frank breech

Obstetric abdominal examination

Leopold’s maneuvers

First maneuver

curve fingers of both hands at top of fundus

Second maneuver

place both hands on sides of uterus

Third maneuver

with thumb and middle finger of one hand, press gently but deeply into the mother’s abdomen immediately above the symphysis pubis and grasp the presenting part

fourth maneuver

place both hands on sides of lower uterus, press deeply and move fingertips towards pelvic inlet

Bony Pelvis: bones

• ilium

• pubis

• ischium

• sacrum

• coccyx

true pelvis is where?

below the linea terminalis, and the false pelvis is above it

three divisions of true pelvis: (3 things)

• inlet

• midpelvis

• outlet

upper pelvic opening (top of pubis and sacrum)

inlet

pelvic cavity (ischial spines project into this space)

midpelvis

lower pelvic opening

outlet

pelvic measurements: measured from bottom of pubic bone to top of sacrum

diagonal conjugate

four pelvic types (most people are combinations of the 4)

• gynecoid (50%)

• anthropoid (25%)

• android (20%)

• platypelloid (5%)

female type pelvis, most favorable and most common for vaginal delivery; round inlet adequate for vaginal delivery

gynecoid

fairly common, usually favorable for vaginal delivery; more oval inet

anthropoid

male pelvic type; babies get hung up at the inlet; a heart-shaped pelvis, unfavorable for vaginal delivery unless forceps/vacuum is used

android

flat pelvis where pubic arch is wide, very unfavorable for vaginal delivery

platypelloid

soft tissues: lower uterine segment

• cervix

• pelvic floor muscles

• vagina

• bladder (most common soft tissues dystocia, mom should be emptying her bladder every 2 hours)

powers (2 types)

• uterine contractions

• maternal pushing efforts

involuntary power (primary), frequency, duration, intensity, resting tone (if effective, cause cervical changes (dilation and effacement), and fetal descent)

uterine contractions

voluntary power (secondary)

maternal pushing efforts

general principle of position of mother (5 things)

• frequent position changes enhance the labor process

• the position most beneficial for the baby may be critically important

• position most comfortable for the mom

• certain positions help solve specific problems

• options: upright, gravity assistance (walking, sitting, squatting), lateral, on hands and knees, etc.

personality/psyche of mother; depends on various factors (6 listed)

• mom’s physical, intellectual, emotional, social, and spiritual preparation for labor

• previous childbirth experience

• personal attitude and readiness

• involvement and input from significant people/the support system in her life

• expectation

• culture

theories of labor onset (37-42 weeks gest) > labor initiation is caused by increased _______ and decreased __________

estrogen, progesterone

a placental hormone that relaxes uterine smooth muscle, levels decrease as placenta ages near term

progesterone

increases uterine sensitivity to oxytocin, increase at 34-35 weeks gestation

estrogen

stimulates contractions (which hormone)

oxytocin

cervical ripening agent

prostaglandin

Known to stimulate sooth muscle, levels increase just before labor begins

prostaglandin

stimulates uterine smooth muscle contractions, released from maternal posterior pituitary, fetal _______release (silences brain which is helpful for labor and helps to stimulate fetal contractions), receptors on the uterus increase as labor begins

oxytocin

increase production by fetus nearing term

fetal cortisol

two possible effects of fetal cortisol

• slows production of progesterone

• stimulates prostaglandin precursors

most smooth muscle contracts when it is stretched (the hormones keep this from happening), and also stimulates prostaglandin production

uterine distention (mechanical stimulation)

divides into two portions above and below the physiologic retraction ring

uterus

2/3 portion is actively contracting (pushes baby down)

upper uterus

1/3 portion is passing (cervix included) (pressure from baby effaces and dilates the cervix)

lower uterus

effaces def

thins

dilates def

opens

_____ effaces and dilates

cervix

stimulates contractions, increases fluid retention (acts like an antidiuretic hormone), and silences fetal brain

oxytocin

contractions stimulate the baby to be pushed down onto the cervix, the stimulates the brain (PP/posterior pituitary) to release oxytocin which stimulates stronger and more contractions > feedback loop

ferguson reflex

S/S of impending labor (may have some or all of these

• lightening (when baby “drops”)

• weight loss of 1/3 lbs in the last 1-2 wks of pregnancy

• GI upset, N/V & diarrhea

• Braxton Hicks contractions increased (irregular and not uncomfortable, may do some cervical ripening but not true labor)

• energy spurt (“nesting” 24-48 hrs before onset of labor)

• rupture of membranes (gush or leaking fluid from vagina: SROM = spontaneous rupture of membranes)

lightening s/s

• decreased fundal height

• frequent urination

• generalized pelvic pressure

• easier breathing

• backache increased (baby’s head puts on her sacrum)

• leg cramps increase

• edema in LEs in response to decreased venous return

*dilation-effacement-station is the three things documented

cervical changes “ripening” summarized in Bishop’s score

Bishop’s Score of ____ = cervix is favorable for induction

>8 (score up to 13)

Bloody show ___-___ hrs before labor common (the cervical mucous plug that is blood-tinged) - starts to be expelled as cervix is thinning, no integrity to hold the mucous plug in place

24-48

Contractions of True labor

• regular UCs

• increasing frequency

• increasing duration

• painful

• pain starts in back

• walking intensifies true labor

• UC’s CONTINUE WITH REST AND WARM BATH

contractions of false labor

• irregular or infrequent UCs

• no increase in frequency or duration of UCs

• abdominal comfort (may be painful but only in the front)

• walking does not affect intensity

• REST AND WARM BATH DECREASES UCs

bloody show in true labor

present (may also be caused by recent vaginal exam or intercourse)

bloody show of false labor

bloody show not usually present