Reproduction: Intrapartum

What is the definition of intrapartum?

the period of pregnancy surrounding labor and birth

What is the nurse doing while the patient is intrapartum?

• health of patient who is delivering the baby

• health of newborn before, during, and after birth → FHR (fetal heart rate)

• consideration 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

Factors important to labor and birth

• Passage

• Passenger (fetus)

• Power (contractions)

• Psyche

• Placenta

• Parity

What is the “bloody show?”

• Mucus plug expelled

• Sign that labor will begin in 24-48 hours

What occurs during an amniotic membrane rupture?

• The fluid from the amniotic sac leaks. The membrane holding the amniotic fluid in “ruptures”

What is another word for rupture of membranes (ROM)?

Water breaking

What happens after their water breaks?

90% of women will experience spontaneous labor within 24 hours

When do ruptures happen?

occurs by the active stage of labor

What do you assess with a rupture of membranes?

color, odor, amount of fluid, and time the rupture occurred (patient education to be prepared if it happens at home!)

What is PROM?

Premature rupture of membranes

• Membranes break before the woman goes into labor

What is PPROM?

Preterm premature rupture of membranes

• membranes rupture before the 37th week of pregnancy

What is effacement?

thin cervix

What is dilation?

Cervical opening

What hormone stimulates contractions?

Oxytocin

What three things should you assess with contractions?

• Frequency

• Duration

• Intensity

How to time contractions:

1. Mark the time when a contraction starts

2. Mark when it ends

3. Note how long it lasted

4. Mark the start time of the next contraction

5. Head to the hospital when the contractions last for 45 to 60 seconds every 3-5 minutes

How many stages of labor are there?

4

How many phases does the 1st stage of labor have?

3

What are all of the stages of labor?

1 - Latent

1 - Active

1 - Transition

2

3

4

What is the first phase of the first stage of labor?

Stage 1: Latent

What defines the latent stage of labor?

Beginning of contractions that are regular

How long does the latent stage of labor last?

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

What is the dilation of the latent stage of labor?

0-6 cm

What is the contraction frequency of the latent stage of labor?

10-30 min

What is the contraction duration of the latent stage of labor?

30-40 sec

What is the contraction intensity of the latent stage of labor

Mild to moderate

What defines the active stage of labor?

"Main" part of labor, contractions & dilation progressing 

How long does the active stage of labor last?

Medium – approx. 1-4 hours

What is the dilation of the active stage of labor?

6-8 cm

What is the contraction frequency of the active stage of labor?

2-5 min

What is the contraction duration of the active stage of labor?

40-60 sec

What is the contraction intensity of the active stage of labor?

Moderate to strong

What does the patient look like in the active stage of labor?

• Loss of control

• Frustrated

• Irritable

What defines the transition stage of labor?

Getting up to 10cm dilation and full effacement

How long does the transition stage of labor last?

Short – approx. 30 min to 3 hours

What is the dilation of the transition stage of labor?

8-10 cm

What is the contraction frequency of the transition stage of labor?

1.5-2 min

What is the contraction duration of the transition stage of labor?

60-90 sec

What is the contraction intensity of the transition stage of labor?

strong

What does the patient look like in the transition stage of labor?

needs support person

What defines the 2nd stage of labor?

Pushing and baby is born

How long does the 2nd stage of labor last?

Short – a matter of minutes up to 3 hours

What is the dilation of the 2nd stage of labor?

10 cm

What is the contraction frequency of the 2nd stage of labor?

1.5-2 min

What is the contraction duration of the 2nd stage of labor?

60-90 sec

What is the contraction intensity of the 2nd stage of labor?

strong

What defines the 3rd stage of labor?

Placenta is delivered

How long does the 3rd stage of labor last?

Short – usually within 30-60 minutes of baby being born

What defines the 4th stage of labor?

First few hours after 

How long does the 4th stage of labor last?

1-4 hours after birth

How does the mother adapt to labor?

• Increased CO r/t pain, anxiety, contractions

  • Positioning also impacts CO

• Increased BP during contractions

• Increased oxygen demand and consumption

  • Hyperventilation can affect acid/base balance

• Decreased GI motility and absorption

• Increased WBC count = physiologic response to stress

• Decreased blood sugar

How does the baby adapt to labor?

• FHR on average = 110-160

• During a contraction:

  • FHR (early) decelerations --> baby getting squished

  • Blood flow decreases to the fetus  --> affects acid/base balance especially if patient is holding their breath to push

• At 37-38 weeks, the fetus experiences light, sound, and touch, so it is aware of pressure and experiences labor even if it cannot process the input

What are some baseline assessments gathered during labor/while in L&D?

• Baseline assessment upon arrival at L&D (lots of information gathering: head to toe, birth plan, psych/social/cultural, high risk, etc.)

• Vitals during labor

  • Patient – usually q 1 hour

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

• Progression of labor

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

  • Cervical status = dilation!

• Pain – coping and plan

• Fetus – FHR, position, presentation, status

How are contractions monitored (hospital-wise)?

• Tocodynamometer

• Intrauterine pressure catheter

What does a tocodynamometer do?

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

What does a Intrauterine pressure catheter do?

internal monitoring (palpation still required)

• rare, dangerous

How is the fetal heart rate (FHR) monitored?

• Doppler

• Electronic fetal monitoring (external ultrasound)

• Internal monitoring (spiral electrode placed on fetal scalp)

What does clinical management look like for intrapartum?

• Comfort care – positioning and water/ice chips → food?

• Pain management – assess & advocate for the pt!

  • Opioids (IV or IM) – temporary relief, crosses placenta

  • Local anesthetic injections – injected into perineal area, rarely affects baby

  • Epidural anesthesia – regional from approximately belly button down to legs, no walking, doesn't eliminate all sensations always, low risk for baby, risk for pt hypotension

  • Nitrous oxide – safe & temporary

• Education – assess and fill gaps!

Latent stage specific interventions

• baseline assessments

• understanding plan

• assess for progression​

Active stage specific interventions

• comfort

• assess for progression

• document membrane rupture​

Transition stage specific interventions

• DO NOT LEAVE THE PATIENT

• comfort

• assess for final progression

• emotional support

• breathing​

2nd stage specific interventions

• DO NOT LEAVE THE PATIENT

• comfort

• emotional support

• breathing

• pushing

• assisting HCP

• possible second nurse to help with baby

• assist with skin-to-skin ASAP when appropriate

General info about Premature Rupture of Membranes (definition, assessments, what to do)

• Membranes rupture but labor does not start

• Assess fetal health, appearance of fluid

• Monitor for infection

• 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 continually monitor for infection

General info about a failure to progress through labor (definition, assessments, what to do)

• Cervix does not dilate all the way

• Contractions do not progress in strength, frequency, & duration

• Need to monitor fetal status throughout this process

• Can artificially rupture membranes, 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, & what the provider determines is best

What is the indication to give oxytocin?

initiation or improvement of uterine contractions (intrapartum) & to control bleeding/hemorrhage (postpartum)

What assessments to do before giving oxytocin

• Is the med appropriate? ​

• Uterine contractions​

• Fetal health – FHR, gestational age

Contraindication for oxytocin

Contraindicated in patients who should not have a vaginal delivery

• (ex: fetal malpresentation, history of major surgery to uterus or cervix, urgent fetal distress, active genital herpes)

Side effect of oxytocin

can be an antidiuretic

Route of oxytocin

IV with pump

What to monitor with oxytocin

• patient BP

• patient HR

• uterine contractions

• fetal HR/rhythm (looking for fetal distress)​

Warning signs to interrupt infusion of oxytocin

• 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​

Other use for oxytocin

can control bleeding in postpartum time period​