CARE EXAM 3: Reproduction, Perfusion, & Pain in the Intrapartum Period

Population-Based Outcomes

• Progression of labor without complications

• Stabilization of mother and fetus/newborn

• Pain perception will be manageable

• Safe delivery of a healthy neonate/newborn

• Postpartum recovery will be free from complications

breast estrogen effects

Growth of Ducts; promotes prolactin effect

breast progesterone effects

Growth of lobules and alveoli; inhibits prolactin effects

vaginal mucosa estrogen effects

Squamous epithelium proliferation, ↑ glycogen content of cells; cellular cornification

vaginal mucosa progesterone effects

Squamous epithelium thinning; cellular decornification

cervical mucosa estrogen effects

Produces secretions favoring survival; enhances sperm motility

cervial mucosa progesterone effects

Produces secretions tending to plug the cervical os

Fallopian Tube estrogen effects

↑ motility & ciliary action

Fallopian Tube progesterone effects

↓ motility & ciliary action

Uterine muscle estrogen effects

↑ blood flow, ↑ contractile proteins, uterine muscle & myometrial excitability & action potential, ↑ oxytocin sensitivity

uterine muscle progesterone effects

Relaxes myometrium, ↓ oxytocin sensitivity

endometrium estrogen effects

stimulates growth, ↑ number of progesterone receptors

endometrium progesterone effects

Activates glands & blood vessels, ↓ number of estrogen receptors

Uterus

– Muscular Organ

– Supported by ligaments

– Composed of two major parts

– Uterine Wall

what are the two major drugs of uterus

• Cervix – lower cylindric portion

• Fundus – dome-shaped top of the uterus

what are the three layers of the uterine wall

• Endometrium

• Myometrium

• Peritoneum

placenta exchange what

of oxygen and nutrients with carbon dioxide and waste products through the maternal blood supply

what does placenta function as

an endocrine gland – producing hormones necessary to maintain the pregnancy and support the embryo and fetus

• hCG, hCs

when is the umbilical cord formed by

day 14

umbilical cord components

– Consists of two arteries and one vein (AVA)

– Increases in length throughout the pregnancy

• At term the cord is 2 cm in diameter and an average of 55 cm long

chorion

outermost membrane that surrounds the amnion and developing embryo

Amnion

Contains the amniotic fluid

what forms the amniotic sac

Amnion and Chorion

amniotic fluid is derived by

diffusion from the maternal blood

amniotic fluid characterisitcs

– Increases weekly

– Volume constantly changes

– Multi-functional

– Oligohydramnios – less than 300 mL

– Hydramnios (polyhydramnios) – more than 2L

what does amniotic fluid maintain

constant body temp

what does amniotic fluid serve as

a source of oral fluid and a repository for waste

what does amniotic fluid assist in

maintenance of fluid and electrolyte hemostasis

what does amniotic fluid allow for

freedom of movement for musculoskeletal development

what does amniotic fluid cushion

the fetus from trauma by blunting and dispersing outside forces

what does amniotic fluid act as

a barrier to infection

what development does amniotic fluid help with

fetal lung development

how to tell difference between amniotic fluid and urine

Nitrazine Paper (pH paper)

Amniotic Fluid - Assessment

urine or amniotic fluid

time of rupture

response of fetus

type of rupture

Type of Rupture

– SROM – Spontaneous Rupture of Membranes

– AROM – Artificial Rupture of Membranes

– PROM – Premature Rupture of Membranes

– PPROM – Preterm Premature Rupture of Membranes

Amniotic Fluid – “ COAT” Assessment

color

odor

amount

temp

• increase frequency of assessment at least every 2 hours

amniotic fluid colors

– Clear: Routine Monitoring

– Meconium Stained: Indicates Fetal Stress/Maturity and Requires Closer Observation

– Port Wine Stained: Possible placental complication and Requires Closer Observation

causes of labor cannot be

attributed to a single cause

labor causes

• Hormonal influence

• Increase in Oxytocin

• Increase in Estrogen

• Increase in Prostaglandins

• Decrease in Progesterone

• Uterine Distention and Increased Intrauterine Pressure

Factors Affecting Labor: The “Five P’s”

• Passenger

• Passageway

• Powers

• Position

• Psychology

Passanger: Fetal Head

• Size of fetal head: Bones, Sutures and Fontanels

• Molding

molding

slight overlapping of the fetal skull bones which occurs during labor

Passenger: Fetal Presentation

Presentation – part of the fetus that enters the pelvic inlet first

cephalic presentation

head: Vertex Preferred

cephalic presentation variances

Military, brow, face

cephalic presentation: breech

buttocks, feet or both

what does breech presentation requires

external version or cesarean section

cephalic presentation types

cephalic- head

breech- buttocks, feet or both

shoulder

Passenger – Fetal Lie

Lie – the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother

Longitudinal/vertical fetal lie

long axis of the fetus is parallel with the long axis of the mother

Transverse/horizontal/oblique fetal lie

long axis of the fetus is at a right angle diagonal to the long axis of the mother

Passenger – Fetal Attitude

Attitude – the relation of the fetal body parts to each other

Passenger – Fetal Position

Position – the relationship of a reference point on the presenting part (occiput, sacrum, mentum [chin]) to the four quadrants of the mother’s pelvis

• Engagement

• Station

two components of pathway in labor

– Mother’s bony rigid pelvis

– Soft Tissues of the cervix, the pelvic floor, the vagina and the introitus

passage way of labor assessment

Often occurs at the first prenatal visit and at the admission when in labor

primary powers

Involuntary contractions originate at certain pacemaker points in the thickened muscle layers of the upper uterine segment

contraction frequency

time from the beginning of one contraction to the beginning of another

contraction duration

beginning to end of one contraction

contraction intensity

Strength of the contraction

primary powers: effeacement

shortening and thinning of the cervix during the first stage of labor

• Expressed in percentages

primary powers: dilation

enlargement or widening of the cervical opening and the cervical canal that occurs once labor has begun

• Expressed in cm’s

• Ferguson’s Reflex

Ferguson’s Reflex

occurs upon complete dilation and is the maternal urge to bear down

secondary powers

• Utilizing of bearing-down efforts to aid in the expulsion of the infant from the uterus and vagina after the cervix is fully dilated

• Valsalva Maneuver – closed glottis and prolonged bearing down

• Open-glottis pushing

• Delayed pushing

• Position

Signs Preceding Labor

• lightening

• Urinary Frequency returns

• Back pain

• Braxton Hicks – more frequent and stronger

• Weight Loss of 0.5 to 1.5 kg (3.5 lbs)

• Surge of energy – “Nesting”

• Cervical ripening

lightening

fetus’s presenting part descends into the true pelvis

what do you see during cervical ripening

– Increased vaginal discharge (mucous plug/bloody show)

– Possible Rupture of Membranes

true labor

•Contractions

• Become Regular with Increase frequency, intensity & duration

• Not relieved by ambulation or comfort measures

•Cervix Changes in

• Dilation & Effacement

• Decent of baby

false labor

•Contractions

• Do not increase in frequency, intensity, duration; may be regular or irregular

• Relief with ambulation or comfort measures

•Cervix

• No significant change

Admission Assessment

• Name

• Age

• EDC

• GTPAL

• Fetal Movement

• Membrane Status

• Color of Amniotic fluid

• Pain

• Allergies

• Obstetrical History

• Prenatal Lab Work

• GBS

• Weight Gain

• Current Medications

• Medical Surgical History

• Physical Abuse

• Substance Abuse

• Immunization Status

Admission Considerations

• Interpreter

• Support Person(s)

• Childbirth Education

• Special Requests/Birth plans

• Newborn Feeding Preference

• Pictures

• Newborn Immunizations

Fetal Assessments, Diagnostics and Screenings

• Electronic Fetal Monitoring

• Leopold’s Maneuvers

• Uterine Activity

Maternal Assessments, Diagnostics and Screenings

• Assessment

• Vital Signs

• Head to Toe

• Deep Tendon Reflexes, Clonus

• Edema Assessment

• OB Assessments

• Sterile Vaginal Examination

• Nitrazine/Ferning/ SpeculumExamination

• Ultrasound

• CBC

• WBC

• Hgb/Hct

Stages of Labor

• Stage 1- contractions to full effacement & dilatation

• Stage 2 –Complete dilatation to Birth of fetus

• Stage 3- Birth of fetus to Delivery of placenta

• Stage 4- Delivery of placenta to 2 hours after

Stage 1 of labor: phase 1

Latent

• Dilation: 0-3 cm

• Ctx: freq 5 - 30 min

• Duration: 30-45 sec

Stage 1 of labor: phase 2

Active

• dilation: 4-7 cm

• Ctx freq: 3-5 min

• duration: 40-70 seconds

Stage 1 of labor: phase 3

Transition

• dilation: 8-10 cm

• Ctx freq: 2-3 min

• duration: 45-90 sec

Nursing Support: first stages of labor

induction of labor: bishop score

Calculation based upon dilation, effacement, station cervical consistency and cervical position

Augmentation/Induction of Labor

Initiation of uterine contractions before spontaneous onset birth

Augmentation/Induction of Labor: ripening methods

– Chemical Agents – Prostaglandins

– Mechanical Agents- Foley Bulb/Cook Catheter

what stimulates contractions

Synthetic Oxytocin

Foley v cooks catheter

foley: single ballon, sits in the cervix, helps begin cervical dilation

cooks: double ballon, one ballon in uterus one in vagina, applies gental tension to promote dilation

• both methods help sofen and open the cervix in preparation for labor

Amniotomy

artificial rupture of membranes

Amniotomy risks

Cord Prolapse – Patient needs to stay in bed and be monitored

• cord coming before baby

ways to Augmentation/Induction of Labor

• Amniotomy

• Nipple Stimulation

• Use of herbs (black cohosh, castor oil)

• Stripping of the Membranes

Oxytocin (Pitocin)

Natural hormone produced by the posterior pituitary

what does Oxytocin (Pitocin) do

Stimulates uterine contractions and aids in milk let-down

Oxytocin (Pitocin) patho

Causes excitability of the muscle cells present in the myometrium increasing the strength of the muscle and contraction

what is the goal of oxytocin (pitocin)

to produce contractions of normal intensity, duration and frequency using the lowest dose possible

When is oxytocin/Pitocin used during the labor and delivery process?

• Induction of Labor

• Augmentation of Labor

• Postpartum Hemorrhage

Labor – Vital Signs: bp

↑ during contractions and returns to baseline between (systolic increased more than diastolic values)

Labor – Vital Signs: hr

Pulse ↑ in first and second stage of labor

Labor – Vital Signs: cardiac output

↑10 – 15% in first stage; ↑30 – 50% in second stage

Labor – Vital Signs: body temp

increase slightly

Labor – Vital Signs: respiratory rate and pattern

increase rate

Labor – Vital Signs: blood glucose

decrease

Labor – Vital Signs: proteinuria

may be present

Labor – Vital Signs: gastric motility and absorption

↓ - nausea and vomiting may occur during transition to second stage

Electronic Fetal Monitoring (EFM) types

– External

– Internal (Scalp Electrode)

fetal heart rate

– Normal: 110 – 160 bpm

– Tachycardia: >160 bpm

• Causes: infection, caffeine, drugs

– Bradycardia: <110 bpm

• Causes: umbillical cord depression, contraction