Intrapartum Exemplar

what is intrapartum?

the period of pregnancy surrounding labor and birth

what is going on with intrapartum?

• health of patient who is delivering the baby

• health of newborn before, during, and after birth →FHR!

• considerations of high risk scenarios (ex. abnormal fetal positioning)

• assessment of progression of labor

• psychosocial assessment

• comfort and coping of patient (including modesty considerations)

• cultural considerations 

• pain management

what are factors important to labor and birth

• passage (pelvis)

• passanger (fetus)

• power (contractions)

• Position

• Psyche

• Placenta

• Parity (knowing prior experience)

what to include in phsyiology of labor?

cervical changes and rupture of membranes

what are cervical changes

• bloody show

• mucus plug expelled - a strong signal when combined with bloody show

• sign that labor will begin in 24-48 hrs (not always)

what is rupture of membranes?

• after their “water breaks,” 90% of women experience spontaneous labor  within 24 hrs

• rupture typically occurs by the active stage of labor

what to assess in labor?

• Always TACO = note the color, odor, amount of fluid, and time the rupture occurred

what is effacement?

thinning of cervix

what is dilation?

cervix becomes wider

what is responsible for dilation and effacement?

contractions

Uterine myometrial activity causes

contractions that can start in lower back, low abdomen, or pelvis

what is the hormone that stimulates contractions?

oxytocin from posterior pituitary gland

what assessment of contractions are important?

• frequency (start 1→start 2)

• duration (how long it last)

• intensity (strength)

what is false labor?

Braxton hicks which is abdomen pains contraction

what is part of stage 1?

• Latent

• active

• transition

what happens in latent part of stage 1?

beginning of contractions that are regular

how long does latent part of stage 1?

long- average is 5-8 hours but no more than 14-20 hours

what happens in active part of stage 1?

“main” part of labor, contractions and dilation progressing

how long is active part of stage 1?

medium- approx. 1-4 hours

what is transition part of stage 1?`

getting up to 10cm dilation and full effacement

how long is transition part of stage 1?

short - approx. 30 min to 3 hrs

what is stage 2?

Pushing and baby is born

how long is stage 2?

short- matter of minutes up to 3 hours

what is stage 3?

placenta is delivered (contracting)

how long is stage 3?

short - usually within 30-60 min of baby being born

what is stage 4?

first few hours after

how long is stage 4?

1-4 hours after birth

how does the patient adapt to labor?

• increased CO r/t pain, anxiety, contractions

  • positioning also impacts CO

• increased BP during contractions

• increases oxygen demand and consumption

  • hyperventilation can affect acid/base balance

• decreased GI motility and absorption

• increased WBC count = physiologic response to stress

• decreased blood pressure

what is a normal fetal heart rate?

110-160

what happens to a fetus during a contraction?

• FHR (early) decelerations

• blood flow decreases to the fetus →affecting acid/base balance especially if patient is holding their breath to push

what happens to a fetus at 37-38 weeks?

they experience light, sound, and touch, so it is aware of pressure and experiences labor even if it cannot process the input

what are assessment details to pay attention to?

• baseline assessment upon arrival at L&D (head to toe, birth plan, psych/social/cultural, and high risk

• Vitals during labor

• Progression of labor

• Pain: coping and plan

• Fetus: FHR, position, presentation, status 

what to assess for vitals during labor?

• patient - usually q 1 hr

• fetus (FHR)- q 15-60 min depending on stage of labor

what to assess for progression of labor?

• contractions - intensity via palpation, duration, frequency - usually q 15-30 min

• cervical status = dilation

what is part of diagnostics details?

• contractions

• fetal heart rate

• membranes

what is diagnostic details are part of contractions?

• tocadynameter = external monitoring (frequency and duration, but intensity measurement is not accurate

• intrauterine pressure catheter = internal monitoring (palpation still required)

what is diagnostic details are part of fetal heart rate?

• doppler

• electronic fetal monitoring (external ultrasound)

• internal monitoring (spiral electrode placed on fetal scalp

what diagnostic details are part of membranes?

• nitrazine tape

• ferning pattern on microscopy

what are clinical management for intrapartum?

• comfort care - positioning and water/ice chips

• patient management - assess and advocate for pt

  • opioids - temporary relief, crosses placenta

  • local Anesthetics - in perineal area, rarely affects baby

  • epidural anesthesia - region of approx. belly button down to legs, no walking, doesn’t eliminate all sensations always, low risk for baby, risk for pt hypotension

    • nitrous oxide - safe and temporary

• Education - assess and fill gaps

what are specific interventions for stage 1: Latent?

• baseline assessments

• understanding plan

• assess for progression

what are specific interventions for stage 1: active?

• comfort 

• assess for progression

• document membrane rupture

what are specific interventions for stage 1: transition?

• DO NOT LEAVE THE PT

• comfort

• assess for final progression

• emotional support

• breathing

what are specific interventions for stage 2?

• DO NOT LEAVE THE PT

• comfort

• emotional support

• breathing, pushing, assisting HCP

• possible second nurse to help with baby

• assist with skin to skin ASAP when appropriate

what are the main alterations/complications?

• premature rupture of membranes

• failure to progress

what happens in premature rupture of membranes?

• membrane ruptures but labor does not start

• assess fetal health, appearance of fluid (TACO)

• monitor infection (fever, abnormal discharge)

• wait for spontaneous labor vs. induce labor

  • depends on many factors like concern for infection, patient/fetal ongoing health

  • if waiting for spontaneous labor, need to continuously monitor for infection

what is failure to progress?

• cervic does not dilate all the way

• contractions do not progress in strength, frequency, and duration

• need to monitor fetal status throughout this process

• can artificially rupture membrane, utilize medications to soften cervix or strengthen contractions, utilize vacuum/forceps, or switch to C-section

  • all depends on what stage of labor, how baby is doing, and what the provider determines is best

what are signs and symptoms of preeclampsia?

• headaches

• Pain in belly, right side of under ribs

• swelling in legs, hands, or face

• changes in vision

• trouble breathing

• severe nausea and vomiting

• gaining weight

what to watch out for preeclampsia?

• HTN occurs in 1 in every 12-17 pregnancies

  • preeclampsia occurs in 3-7% of all pregnancies

• exact cause is unknown

• occurs in the second half of pregnancy

• BP greater than or equal to 140/90 ×2 at least 6 hours apart

• can result in organ damage (kidneys, liver, lung, heart, eyes) → considered eclampsia if a seizure occurs

• can escalate to early delivery depending on severity of sx in pt and baby

• can result in maternal mortality, preterm birth, perinatal death, and intrauterine growth restriction

what is the medication for intrapartum?

oxytocin

what to assess for oxytocin?

• is the med appropriate?

• uterine contractions

• fetal health - FHR, gestational age

what to be caution with oxytocin?

• contraindicated in patients who should not have a vaginal delivery (ex. fetal malpresentation, history of major surgery to uterus or cervix, urgent fetal, and active genital herpes)

• antidiuretic side effect

what implementations are needed for oxytocin?

• Monitor: patient BP, HR, uterine contractions, and fetal HR/rhythm (fetal distress)

• warning signs to interrupt infusion

  • elevated resting uterine pressure above 15-20 mm Hg, contractions lasting longer than 1 min, contractions occurring more than every 2-3 min, pronounced alteration in fetal HR/Rhythm

• can also be used to control bleeding in postpartum time period

what to evaluate for oxytocin?

did the drug do what we were hoping it would do?