Care Lecture 17: Intrapartum Period

-cervix

-fundus

what is the uterus composed of?

cervix

lower cylindric portion of the uterus; thins and dilates to expel the newborn

1. endometrium (what placenta is attached to)

2. myometrium (lets vascularity go to placenta)

3. peritoneum

what 3 layers compose the uterine wall?

upon implantation

when does the placenta begin to form?

day 17

maternal-placental-embryonic circulation is in place by what day of pregnancy?

produces hormones (hCG, hCs) necessary to maintain pregnancy and support embryo and fetus

what is true of the placenta and its endocrine functions?

-oxygen

-nutrients

-waste products

-carbon dioxide

what is involved in placental perfusion and exchange? (4)

by day 14

when day of the intrapartum period does the umbilical cord form by?

two arteries and one vein (AVA)

what does the umbilical cord consist of?

↑ in length throughout pregnancy

what is true of the length of the umbilical cord throughout the intrapartum period?

2 cm in diameter and an ~55 cm long

at term, about how long and wide is the umbilical cord?

chorion

outermost membrane of the amniotic sac that surrounds the amnion and developing embryo

amnion

innermost membrane of the amniotic sac surrounding the developing fetus; contains the amniotic fluid

diffusion from the maternal blood

what is amniotic fluid derived from?

-↑ weekly

-volume constantly changes

what is true of the volume of amniotic fluid throughout the intrapartum period?

oligohydramnios

too little amniotic fluid (less than 300 mL)

not enough fluid = baby has no place to grow --> fetal respiratory problems

what is the main concern associated with oligohydramnios?

hydramnios (polyhydramnios)

excessive amounts of amniotic fluid (> 2L)

-preterm labor (overstretches the uterus)

-congenital abnormalities

what is the main concern(s) associated with hydramnios (polyhydramnios)?

-maintains constant body temp

-source of oral fluid

-repository for waste

-maintenance of fluid and electrolytes

-barrier to infection

-allows fetal lung development

-cushions fetus

-allows freedom of movement

what are some functions of the amniotic fluid?

differentiate amniotic fluid from urine

what is the purpose of nitrazine paper (pH paper)?

yellow = acidic = urine

blue = basic = suggested that its amniotic fluid

what color is the nitrazine paper when there is amniotic fluid or urine?

lubricant, semen, and blood

what other fluids can cause nitrazine paper to appear blue (basic)?

what time did the leaking of fluid start? --> #1 risk of concern = infection

if the nitrazine paper appears blue, what should the nurse ask, and why?

SROM

spontaneous rupture of membranes; happens on its own

AROM

artificial rupture of membranes; provider or nurse will rupture the amniotic sac; done for inductions

triggers release of oxytocin = stimulates labor

what does AROM trigger?

PROM

premature rupture of membranes; at term, and the amniotic sac ruptures, but they don't go into labor/have no contractions; big infection risk

deliver within 24 hrs of amniotic sac rupturing

when the amniotic sac ruptures, how soon do we want the mom to deliver?

PPROM

preterm premature rupture of membranes; not at term, amniotic sac ruptures; monitor for infection

24 weeks

when does viability of life begin?

COAT (color, odor, amount, temperature)

what assessment should be used for amniotic fluid?

any green = meconium stained

↓

baby had bowel movement (means baby was in distress at some point)

↓

baby could be breathing in meconium

↓

deliver the baby

if amniotic fluid is green, what does this mean and what should be done?

possible placental complication

port-wine stained colored amniotic fluid could indicate what?

-↑ oxytocin (contracts uterus)

-↑ estrogen

-↑ prostaglandins/inflammatory process

-↓ in progesterone (relaxes uterus)

what are the hormonal influences on labor?

cannot be attributed to a single cause --> infection is a big one

what is the cause of labor?

factors affecting labor:

1. passenger(s) - baby and placenta

2. passageway - birth canal

3. powers - contractions and pushing

4. position

5. psychology

what are the "5 P's" and what is the significance of them?

not fused until ~1 year old = help it fit through pelvic canal during delivery

what is true of the bones in the skull of a newborn?

head down - go through cervix with biggest part first

how do we want the head of the baby to deliver?

presentation

part of the fetus that enters the pelvic inlet first

-cephalic

-breech

-shoulder

what are the types of fetal presentation?

vertex

what type of cephalic fetal presentation is preferred?

military, brow, face (left to right in pic)

what are some variances associated with cephalic fetal presentation?

-head down is

-head is tucked in

-chin pointed in

describe vertex cephalic presentation

commonly requires external means or c-section

what is true of the delivery of breech babies?

frank breech presentation

type of breech presentation in which the fetal legs are flexed at the hips and extend toward the shoulders; most common type of breech presentation

footling breech presentation

type of breech presentation in which the extension of one or both thighs and legs so that one or both feet are presenting

complete breech presentation

type of breech presentation in which buttocks and feet present, fetal hips and knees are flexed, lower legs crossed

fetal lie

the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother (position in accordance with maternal spine)

-longitudinal/vertical

-transverse/horizontal/oblique

what are the types of fetal lie?

longitudinal/vertical

type of fetal lie in which the long axis of the fetus is parallel with the long axis of the mother; desired type of lie

transverse/horizontal/oblique

type of fetal lie in which the long axis of the fetus is at a right-angle diagonal to the long axis of the mother; usually leads to c-section

fetal attitude

the relation of the fetal body parts to each other

fetal 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

term used to indicate that the largest transverse diameter of the presenting part has passed through the maternal pelvis

station

how the baby is coming down/presenting/progressing as its making its way through the pelvis

ischial spine of pelvis

what is the fetus even with when the station is 0?

(-) = not good for term infant, baby is up high in pelvis

(+) = baby moves down the pelvis; labor progression

what type of station do we want to see?

-mother's bony, rigid pelvis

-soft tissues of cervix

-the pelvic floor

-vagina and the introitus

what are the components of the passageway?

at the first prenatal visit and when in labor

when does assessment of the fetal passageway usually occur?

10 cm

what value constitutes complete cervical dilation?

primary power

involuntary uterine contractions

thins the cervix and causes dilation

every time the uterus dilates, how does this affect the cervix?

1. frequency

2. duration

3. intensity

what 3 characteristics are used to assess contractions?

frequency

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

we like to see every 3 minutes apart

what do we usually like to see regarding frequency of contractions?

duration

the beginning of one contraction through the end

60-90 seconds

what do we usually like to see regarding duration of contractions?

intensity

**tip of nose (mild), tip of chin (moderate), forehead (strong)

strength of the contraction; found by palpating the top of the fundus

soft = no contraction

rock hard = contraction

when palpating the fundus for contractions, what might the nurse feel?

at least one minute

the resting period between contractions should be how long?

no more than 5 contractions in 10-minute period

what is the maximum amount of contractions we want in a 10-minute period?

effacement

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

-labor = very thin

-nonpregnant = 2-3 cm thick

how does the cervix compare to a woman in labor vs a nonpregnant woman?

dilation

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

13 cm --> why we want presentation to have chin tucked

what is the average head size of an infant?

ferguson's reflex

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

when she is 10 cm dilated and 100% effaced

when should we tell the mother to start begin pushing?

feel for the top of the baby's head during a cervical exam

how do we assess the primary powers?

both need to dilate

for cervical dilation to occur, what must happen to the internal and external os?

secondary powers

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

Valsalva maneuver

forcible exhalation against a closed glottis, resulting in increased intrathoracic pressure; used during labor when bearing down

open glottis pushing

method of expelling the fetus that is characterized by air being released during the pushing effort; mothers make a lot of noise in labor

3 hours

how long can we allow a patient to push before making her stop?

-can help baby into right position for delivery

-can help relieve pain

-can open up pelvis and rotate baby

what is the benefit of changing positions during labor?

-helps open up the pelvis

-relaxes the muscles

what is true of progesterone and the pelvis/muscles?

-lightening

-↑ urinary frequency

-back pain

-braxton hicks

-weight loss of 0.5 to 1.5 kg

-surge of energy - "nesting"

-cervical ripening

what are some possible signs preceding labor?

lightening

when the fetus's presenting part descends into the true pelvis; characterized by a drop of fundal height as baby drops into the pelvis

braxton hicks

false labor; more frequent and stronger contractions without the dilation

due to hormones --> progesterone ↓ and estrogen ↑

why might a woman experience weight loss of 0.5 to 1.5 kg (3.5 pounds) right before labor begins?

↑ vaginal discharge (mucous plug/blood) = starting to dilate

cervical ripening can lead to what occurring right before labor?

true labor has cervical change

what is the key thing that differentiates true labor from false labor?

-more regular

-↑ frequency, intensity, & duration

what is true of contractions when a woman is in true labor?

-lower back --> radiates to abdomen

-feel when resting and ambulating

for a woman in true labor, where and when are contractions felt?

-do not ↑ in frequency, intensity, duration

-may be regular or irregular

what is true of contractions when a woman is in false labor?

-true labor = not relieved by ambulation, comfort measures, fluids

-false labor = relief w/ ambulation or comfort measures

what is the difference between contraction relief measures in true vs false labor?

2 doses b4 delivery to protect fetus

how many doses of group beta strep antibiotics would we like to give, if needed, before delivery?

pneumonia

what is the biggest complication associated with group beta strep?

-age, GTPAL, OB history

-fetal movement

-membrane status, COAT

-leaking of fluids?

-pain, allergies

-gestational age

-EDC

-prenatal lab work

-weight gain

-immunizations

-current meds, surgical history

what should be included in the admission assessment for an intrapartum woman?

-vitals, DTRs/clonus

-heart, lung sounds

-edema assessment

-Leopold's maneuvers

-electronic fetal monitoring

-uterine activity (dilation status)

-sterile vaginal examination

-nitrazine paper

-ultrasound

-CBC, H&H

what maternal assessments, diagnostics, and screenings should be completed for the intrapartum woman?