Intrapartum (class 7,8,9,10)

Process of moving the fetus, placenta and membranes out of the birth canal

Labor

First stage of labor

onset of regular contractions to full dilation of cervix

second stage of labor

full dilation to delivery of baby

third stage of labor

delivery of baby to delivery of placenta

fourth stage of labpr

delivery of placenta to first 4 hours after birth

**Impending signs of approaching labour involve a variety of physiological and psychological signs. Like:**

**Lightening (fetal engagement)** \n **Braxton Hicks contractions** \n **Bloody Show** \n **Backache** \n **Spontaneous Rupture of membranes (SROM)**

**Diarrhea** \n **Spurt of energy (nesting)** \n **Weight loss**

True or False labor: Contractions are regular and close together

true

true or false labor: contractions are irregular and not occurring closer together

false

How would change in activity affect true labor vs false labor

True labor: Contractions continue no matter if comfort measures.

False labor: Contractions may stop or slow down with comfort measures

cervical changes in true vs false labor:

true labor: Progressive dilatation & effacement.

false labor: Cervix may be soft but no sign in change in effacement or dilation and no show

True or false labor:Contraction discomfort is Usually felt in the front of the abdomen. May be felt in the back

false

true or false labor: contraction discomfort Starts in the back and radiates towards the front of the abdomen

true

contraction strength of true labor

becomes stronger with time; vaginal pressure is felt

contraction strength of false labor

freq weak; not getting stronger with time

what are the P’s of labor

Power

Passageway

passenger

position

Psychological response

Powers

**Primary** – Involuntary uterine contractions that result in Effacement and Dilatation of the cervix

**Secondary** – Involuntary urge to push

average primiparous woman dilates __ cm / hr

1

average multiparous woman dilates __ cm / hr

1\.5

Passageway

**Refers to Maternal Pelvis**

\-**Structures,**

**-Types (shape),**

**-Diameter,** -

**and Soft tissues**

\
**-“Give” of joints –effect of hormones**

Effacement

the cervix stretches and gets thinner

dilation

Dilatation means that the cervix opens

passenger

**Fetal head – dimensions**

**Cranial Vault (Bones)**

 **Sutures (sagittal/lambdoidal/coronal)**

 **Fontanelles** \n **Biparietal diameter**

\
\*Fontanelles/ \n sutures and fetal head positioning are important mechanisms to aid in passing through the maternal pelvis

fetal lie

Fetal lie refers to the relationship between the longitudinal axis of the baby with respect to the longitudinal axis of the mother (longitudinal lie, transverse lie, oblique lie)

fetal presentation

Fetal presentation refers to the part of the baby that is overlying the maternal pelvis.

fetal presenting part

the presenting part is the part of the baby that leads the way through the birth canal. Most often, it is the baby's head, but it can be a shoulder, the buttocks, or the feet.

fetal station

Station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines and is a measure of the degree of descent of the presenting part of the fetus through the birth canal.

Engagement

Engagement is the term used to indicate that the largest transverse diameter of the presenting part (usually the biparietal diameter) has passed through the maternal pelvic brim or 405inlet into the true pelvis and usually corresponds to station 0. Engagement often occurs in the weeks just before labour begins in nulliparas and may occur before or during labour in multiparas. Engagement can be determined by abdominal or vaginal examination.

friedman’s curve

Relationship between cervical E&D and fetal descent in relation to time and progression of labour

lateral position improves

circulation

hands and knees position makes

fetus rotate

squatting position does what

opens the pelvis

what stage is labor: is the process of effacement (%) and dilation (cm) of the cervix

first

what are the 3 phases of the first stage of labor

latent, active, transition

latent phase of first stage takes how long?

7-8 hours

how much dilated are they in latent stage

0-3cm

how long are contractions in the latent phase of phase 1

30-45 seconds

how long is the active phase in the first stage of labor

3-5 hours

how far dilated are they in the active stage

4-7cm

\

what % effaced in the active stage

40-80%

how long are contractions in the active stage of the first stage

40-60 seconds in length

how many cm dilated in the transition stage

8-10cm

how long is the transition stage

30 min - 2 hrs

what % effaced in the transition phase

80-100%

how long are contractions in the transition phase

60-90 seconds

first stage physical assessment

\-Vaginal examination- to determine the progress of labour (cervical effacement and dilation)

- Uterine activity- Contractions pattern and strength

\- Bloody show

\- Amniotic fluid

\-  Comfort level

\-Vital signs

\-  Fetal assessment – fetal heart rate patterns

\- Leopolds manoeuvres

\-Hydration status

\-  Bowel, bladder status

rupture of membranes there will be a presence of ______ in amniotic fluid

sodium chloride

what if rupture of membranes is green amniotic fluid

\-meconium stained amniotic fluid.

\-Meconium in the amniotic fluid increases the risk for meconium aspiration syndrome.

\
* Endotracheal intubation and suctioning in infants who

are not vigorous at birth should occur prior to drying and stimulation to remove any meconium from the trachea.

stage 1 latent phase nursing interventions :

• Contractions – Q 30 -45 sec duration, mild to mod, 5 – 20 min apart

• Encourage mobility, change positions frequently

• Encourage voiding q2h

• Maintain adequate hydration/ diet

• Support/ comfort measures

• Monitoring of labour progress and fetal adaptation to labour stress

• Maternal positioning that facilitates descent of the fetus and comfort for the labouring person

what part of the first stage of labor is this:

\
Contractions- Q 2- 4 min apart, moderate to strong, 60 seconds duration.

Progression of emotional display as labour progresses

active phase

active phase of labor nursing interventions

\-Continue with latent phase interventions (mobility, positioning, voiding, hydration, etc... )

\-Monitor comfort/pain management – pain becomes more intense during this phase

\-Fetal monitoring and assessment – important to note how fetus is responding to labour progress

Op position during labor is a lot of

back pain

OP vs OA position

effleurage

(non pharm pain management)

a form of massage involving a circular __stroking__ movement made with the palm of the hand.

transition stage contractions

70-90 secs in duration.

strong.

30-60 seconds apart

transition phase nursing care

\-Emotional support +++/positive reinforcement. May need frequent focus and direction

\- Help control breathing through contractions \n -Begin to get for delivery

\- Prepare bed and positioning for pushing

childbirth \n - Pharmacologic Pain control may be too late at

this point (respiratory effects on neonate)

induction of labor is a common intervention during the ____ stage of labor

first

what is induction of labor

artificial initiation of labor

important considerations prior to induction of labour

Bishop Score System -Measures cervical readiness for induction by scoring 5 characteristics of the cervix 5 characteristics include:

1. Dilation (5 cm or more) 2. Effacement (80% or more) 3. Station (+1 or more ) 4. Cervical consistency (firm, medium, soft) 5. Cervical Position (Posterior, midposition, anterior**)

why would induction of labour be required

• Post term infant

• Diagnosed issue of intrauterine environment

  ie.) perfusion of fetus

• Fetal distress (if not severe) or risk for fetal

  distress identified.

augmentation

labor has started but it needs help

why would augmentation of labour be reuired

\-Supplementation of a naturally occurring labour with synthetic oxytocin. \n • Purpose would be to increase the strength/

pattern or duration of contractions to improve the labour process.

post term pregnancy continues past the end of the ____ completed weeks of gestation

41

risks of post term labor on mother

\-tears/lacerations

\-Labour dystocia

\-Increased risk of infection and hemorrhage

risk of post term labor on infant

• Meconium aspiration

• Infant injury from birthing process

  • Mortality rate increases after 40 weeks

methods of cervical ripening

__Natural endogenous oxytocin release:__

• Sexual intercourse

\
__Mechanical methods:__ \n • Amniotomy \n • Stripping or sweeping of membranes

\
__Pharmacologic methods:__

• Prostaglandins \n • Oxytocin

synthetic prostaglandins (PGE2)

• Frequently used to ripen the cervix.

• Cervix has to be ripened for labour to be initiated. If bishop score is less than 6, a cervical ripening agent such as prostaglandins must be used before labour induction.

  • If cervix is not ripened, augmentation or induction with oxytocin will not be successful

synthetic oxytocin

• Synthetic form of the naturally occurring hormone

• Used to facilitate uterine contractions \n • Can be used to induce labour or augment labour

• Piggybacked into main IV infusion line

and titrated until regular contraction pattern is established

nursing care for oxytocin induction

• V/S q30mins (BP &P) and on increase of drip

• Record FHR & contractions q15mins \n • Monitor contractions closely

\
• If fetal distress- \n -d/c oxytocin, increase main line \n -turn on left side \n -administer oxygen \n -reevaluate contractions and fetal response -notify doctor \n -document

second stage of labor Phases:

\-initial latent phase

\-descent (cardinal ,ovements)

\-active expulsion phase (pushing and crowning)

how long is the second stage of labor

lasts up to 1 hour

from complete dilation (10 cm) to birth of the newborn

second stage of labor

physiological s/s of full dilation (2nd stage of labor)

Sudden appearance of sweat on upper lip

Vomiting episode \n Increase in bloody show

Increased restlessness/agitation ;

verbalization – “I cant go on”

Involuntary bearing down efforts

Bulging perineum, labia

7 cardinal movements

\-Descent \n -Flexion \n - Internal Rotation

\- Extension

\- Restitution \n - External Rotation

\- Expulsion

when is apgar scoring done

1 min after birth and 5 mins

what degree tear? involves fourchette, perineal skin, vaginal mucous membrane without involving any muscles.

first

what degree tear? muscles of perineum

second

what degree tear? also extends to rectal sphincter

third

what degree tear?also extends into rectum

fourth

third stage of labor is the separation and delivery of the placenta. usually takes ? mins after birth of baby

5-30

signs of separation of placenta in the 3rd stage of labor

\-Firmly contracting uterus

\-  Change in shape of uterus from discoid

to globular

\-  Lengthening of cord \n - Sudden gush of blood \n -Vaginal fullness or membranes at the

introitus

what is the baby side of the placenta

shiny schultz

maternal side of placenta

dirty duncan

when is the placenta considered retained?

30 mins after delivery… not good if its still there

fourth stage of labor

1- 4 hr after birth of the newborn; period of maternal physiological adjustment.

\-Restoration of physiology \n -Myometrial contractions and retractions & vessel thrombosis \n -BLEEDING MAIN CONCERN \n -Formation of mother-newborn relationship

\-Consolidation of family unit

the golden hour

undisturbed first hour after birth spent skin to skin on mother’s (or father’s) chest, unclothed

• Many benefit for infant as well as mother’s transition to postpartum period

• Facilitates bonding and attachment

• Promotes regulation of newborns physiological

  transitions to extra uterine life (Eases transition period)

  • Allows mother to adjust to puerperium stage physically and emotionally

Preterm labour is true labour that begins before __ completed weeks of gestation

37

premature rupture of membranes (PROM)

• rupture or membranes prior to onset of labour regardless of gestational age

• Preterm PROM (pPROM) – rupture of membranes before 37 weeks gestation

• Predisposing factors- maternal nutritional deficiencies, substance use, placental abruption, polyhydramnios, multiple pregnancy, prior preterm birth or PPROM, infections **primarily chorioamnionitis or trauma

• Once membranes rupture - risk of infection- chorioamnionitis. Usually caused by normal flora e.g. E coli

care for PROM

• Restrict activity with ongoing assessment.

• Ie) Temp at least Q2hr together with WBC and CBC

monitoring daily. Admin of broad spectrum antibiotics

• Try to prevent infection- no pv exams, frequent changing of pads, observe amniotic fluid for signs of infection, tachycardia in baby, adequate hydration

most women will go into labor within 24hr of PROM. but if not, ______ is necessary if they are over 37 weeks (not preterm)

induction

Prom.

if fetal distress or infection..

induce right away

cervical insufficiency

\-Generally painless cervical dilation \n -Often associated with pPROM and preterm birth

\-Risk Factors: Excessive cervical dilation for curettage or biopsy, history of previous cervical lacerations during childbirth, cervical and uterine anomalies, a hx of short labours and/or losses at early gestations

\-TX: Cerclage, Restricted Activity (potentially bedrest)

\-Placed at 13 – 14 weeks and removed at 37 weeks gestation

suppressing premature labor

• Bedrest – left lateral

• incraesed hydration so increased plasma volume

• Avoid unnecessary pv exams

• Tocolytics

• Corticosteroids- betamethasone/dexamethasone•

• Continuous monitoring of FHR and contractions

• Needs lots of psychological support

dystocia

long, difficult, or abnormal labor

criteria for dystocia

> 4 hours of < 0.5 cm/hr dilation (active first

phase)

\n OR

1 hr with no descent while pushing (second stage)

failure to progress

(dystocia)

cervix does not dilate despite normal uterine contraction and no CPD

hypotonic labor

\-Unable to dilate cervix normally \n -Uterus is easily indented at peak of contraction \n -Usually occurs in active phase of First Stage \n -Possible causes: Uterine overdistention, fetal malposition, analgesics, regional anaesthesia

\

management of hypotonic labor

If membranes intact and presenting part is engaged – amninotomy and/or oxytocin augmentation

hypertonic labor

Possible cause may be synthetic oxytocin ,hyperstimulation, or placental abruption

Usually occurs in latent phase in the first stage of labor

Management:

• Rest

• Fluids

• Sedation/ analgesia

• No oxytocin (Stop infusion -Short half life)

Occurs when the uterus never fully relaxes between contractions.

\
Contractions are erratic and poorly co-ordinated

\
Cervix doesn’t dilate as normal (labour prolonged)

\
Placental Perfusion is compromised; Fetal oxygenation is reduced

hypertonic labor

FDI

frequency, duration, intensity

(of contractions)