Intrapartum Exam

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CU NSG 3010

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104 Terms

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Stage 1 of labor

from the onset of labor contractions to complete dilation

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Assessment of contractions (3 things)

  • frequency

  • duration

  • intensity

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

frequency

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

duration

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

intensity

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Vaginal exam (three things)

  • dilation

  • effacement

  • station

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

dilation

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

effacement

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

station

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phases of stage one of labor (2 phases)

  • latent phase

  • active phase

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latent phase measurements

0-5 cm

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active phase measurements

6-10 cm

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Stage 2 of labor and delivery

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

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stage three of labor and delivery

from birth of baby to delivery of placenta

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Stage four of labor and delivery

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

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

  • VS

  • fundus

  • perineum

  • locia

  • etc.

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cervical dilation of 10cm and 100% effacement

Goals for 1st stage of labor

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birth of baby

Goals for 2nd stage of labor

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delivery of placenta

Goals for 3rd stage of labor

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Uncomplicated recovery

Goals for 4th stage of labor

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Five Essential Factors of labor and delivery

  • passenger

  • passageway

  • powers

  • positions

  • psyche

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passenger

fetus and placenta

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passageway

maternal bony pelvis and soft tissues

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powers

uterine contractions and maternal pushing efforts

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position

of laboring woman

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psyche

laboring woman

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passenger: fetal size (especially head)

  • fetal skull bones

  • fetal sutures and fontanels

  • fetal skull diameter

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fetal skull bones

  • frontal

  • temporal

  • parietal

  • occipital

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fetal sutures and fontanels

  • frontal

  • coronal

  • sagittal

  • lambdoidal

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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)

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Fetal skull diameter

  • widest transverse measurement = biparietal diameter (9.5 cm)

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

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

fetal presentation

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Types of fetal presentations

  • cephalic (head down) - 96% = occiput

  • breech - 3% = sacrum

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

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

vertex

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Cephalic positions: neck straight, bregma presents

military

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

brow

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

face

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breech positions: both knees and hips flexed

complete

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

Frank

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

footling

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

scapula

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

Fetal lie

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Types of fetal lie (2 types)

  • longitudinal (may be either cephalic of breech)

  • transverse (impossible to deliver vaginally)

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the relationship of the fetal body parts to one another

Fetal attitude

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Types (in relationship to cephalic presentation) - 3 types

  • flexed (“vertex'“)

  • extended (“brow/face”)

  • neutral (“military”)

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

fetal positions

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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)

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Most common fetal position

OA (R or IOA)

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term image

Fetal positions

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term image

frank breech

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Obstetric abdominal examination

Leopold’s maneuvers

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First maneuver

curve fingers of both hands at top of fundus

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Second maneuver

place both hands on sides of uterus

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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

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fourth maneuver

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

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Bony Pelvis: bones

  • ilium

  • pubis

  • ischium

  • sacrum

  • coccyx

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true pelvis is where?

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

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three divisions of true pelvis: (3 things)

  • inlet

  • midpelvis

  • outlet

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upper pelvic opening (top of pubis and sacrum)

inlet

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pelvic cavity (ischial spines project into this space)

midpelvis

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lower pelvic opening

outlet

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

diagonal conjugate

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

  • gynecoid (50%)

  • anthropoid (25%)

  • android (20%)

  • platypelloid (5%)

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

gynecoid

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

anthropoid

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

android

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

platypelloid

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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)

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powers (2 types)

  • uterine contractions

  • maternal pushing efforts

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

uterine contractions

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voluntary power (secondary)

maternal pushing efforts

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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.

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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

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

estrogen, progesterone

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

progesterone

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

estrogen

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stimulates contractions (which hormone)

oxytocin

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cervical ripening agent

prostaglandin

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

prostaglandin

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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

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increase production by fetus nearing term

fetal cortisol

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two possible effects of fetal cortisol

  • slows production of progesterone

  • stimulates prostaglandin precursors

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

uterine distention (mechanical stimulation)

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divides into two portions above and below the physiologic retraction ring

uterus

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

upper uterus

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

lower uterus

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effaces def

thins

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dilates def

opens

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_____ effaces and dilates

cervix

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

oxytocin

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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

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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)

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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

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<p>*dilation-effacement-station is the three things documented </p>

*dilation-effacement-station is the three things documented

cervical changes “ripening” summarized in Bishop’s score

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

>8 (score up to 13)

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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

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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

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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

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bloody show in true labor

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

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bloody show of false labor

bloody show not usually present