Intrapartum NRS 317

Intrapartum definition

the period of pregnancy surrounding labor and birth

intrapartum: whats going on

•Health of patient who is delivering the baby

•Health of newborn before, during, and after birth --> FHR!

•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 (pelvis)

• passenger (fetus)

• power (contractions)

• psyche

• placenta

• parity 

What should the nurse do to help with patients psyche (factors of labor and birth)?

• managing patients pain

• patients coping

• comforting patient

• assess where the patient is at

What should the nurse do to help with patients parity

(factors of labor at birth)?

• number of births (delivery)

• Has patient given birth before if so patient has muscle memory

What is PROM?

Rupture of the amniotic sac (membranes) at or near term (37 weeks of gestation or later). 

What is PPROM?

Rupture of the amniotic sac before 37 weeks of gestation. 

physiology of labor: cervical changes

•Bloody show

•Mucus plug expelled – a strong signal when combined with bloody show

•Sign that labor will begin in 24-48 hours (not always)

physiology of labor: rupture of membranes

•After their "water breaks," 90% of women will experience spontaneous labor within 24 hours

•Rupture typically occurs by the active stage of labor

physiology of labor: rupture of membranes —> questions (the other 10 percent when the patient doesn’t go to labor within 24-48 hrs after “water breaks”)

What do you think a nurse needs to worry about with PPROM or PROM? How would you assess for it?

Physiology of Labor: Cervical changes & Rupture of membranes —> Assessment

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

Physiology of Labor (2 parts)

• effacement

• dilation  

contractions are responsible for

dilation and effacement 

Physiology of labor: more notes

•Uterine myometrial activity

•The hormone oxytocin stimulates contractions

•Assessment of contractions is important!

• •Frequency

• •Duration

• •Intensity

what hormone stimulates contractions?

oxytocin 

What to assess for contractions?

• frequency

• duration

• intensity

What are the stages of labor?

• latent

• active

• 1- Transition

• 2

• 3

• 4

Latent: what defines this stage

Beginning of contractions that are regular

Latent: How long does it last?

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

Latent: Dialation 

0 to 6 cm

Latent: Contraction frequency

10-30 min

Latent: Contraction duration 

30-40 sec

Latent: Contraction Intensity

Mild to moderate

Active: What defines this stage

"Main" part of labor, contractions & dilation progressing 

Active: How long does it last?

Medium – approx. 1-4 hours

Active: Dialation

6 to 8 cm

Active- Contraction frequency

2-5 min

Active: Contraction duration

40-60 sec

Active: Contraction intensity

Moderate to strong

Transition 1: What defines this stage?

Getting up to 10cm dilation and full effacement

Transition 1: How long does it last?

Short – approx. 30 min to 3 hours

Transition 1 - Dilation

8 to 10 cm

Transition 1: Contraction frequency 

1.5-2 min

Transition 1 - Contraction duration

60-90 sec

Transition 1- Contraction Intensity

strong

2 - What defines this stage?

Pushing and baby is born

2 - How long does it last?

Short – a matter of minutes up to 3 hours

2 - dilation

10 cm

2: Contraction frequency 

1.5 -2 min

2 - Contraction duration

60-90 sec

2 - Contraction Intensity

Strong

3 - What defines this stage?

Placenta is delivered

3 - How long does it last?

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

4 - What defines this stage?

First few hours after baby and placenta is delivered

4 - How long does it last?

1-4 hours after birth

How Do The Patients Adapt To Labor?: Patient

•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 Do The Patients Adapt To Labor?: Fetus

•FHR on average = 110-160

•During a contraction:

oFHR (early) decelerations --> WHY?

oBlood 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

Assessment Details

• 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

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!

Assessment details: pain 

coping and plan 

Assessment Details: fetus

•FHR, position, presentation, status

Diagnostic details: contractions

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

oIntrauterine pressure catheter = internal monitoring (palpation still required)

Diagnostic details: Fetal Heart Rate (FHR)

oDoppler

oElectronic fetal monitoring (external ultrasound)

oInternal monitoring (spiral electrode placed on fetal scalp)

Diagnostic details: Membranes

oNitrazine tape

oFerning pattern on microscopy

Clinical Management

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

•Pain management – assess & advocate for the pt!- maybe add non pharm and take out local??

oOpioids (IV or IM) – temporary relief, crosses placenta

oEpidural 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

oNitrous oxide – safe & temporary

•Education – assess and fill gaps!

Stage specific Interventions

•1/Latent = baseline assessments, understanding plan, assess for progression​

•1/Active = comfort, assess for progression, document membrane rupture​

•1/Transition = DO NOT LEAVE THE PATIENT, comfort, assess for final progression, emotional support, breathing​

•2 = 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

Stage specific interventions: 1/Latent

•baseline assessments, understanding plan, assess for progression​

Stage specific interventions: 1/Active

•comfort, assess for progression, document membrane rupture​

Stage specific interventions: 1/Transition

•DO NOT LEAVE THE PATIENT, comfort, assess for final progression, emotional support, breathing​

Stage specific interventions: 2/Transition

•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

Alterations/Complications: Premature Rupture of Membranes (PROM)

•Membranes rupture but labor does not start

•Assess fetal health, appearance of fluid (TACO)

•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

Alterations/Complications: Failure to progess

•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

Alterations/Complications: Preclampsia

•HTN occurs in 1 in every 12-17 pregnancies (CDC, 2020)

•Preeclampsia occurs in 3-7% of all pregnancies (CDC, 2020)

•Exact cause is unknown

•Occurs in the second half of pregnancy (20w+)

•Previous hx of HTN not required

•BP greater than or equal to 140/90 x2 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 dealth, and intrauterine growth restriction

Oxytocin: Assessment

•Is the med appropriate? ​

•Uterine contractions​

•Fetal health – FHR, gestational age

Oxytocin: Caution with use/side effect/ contraindication

•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)

•Antidiuretic side effect​

Oxytocin: Implementation/ Patient Teaching

•Route: IV with pump​

•Monitor: patient BP, patient HR, uterine contractions, fetal HR/rhythm (looking for 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​ --> will discuss with postpartum exemplar!

Oxytocin: Evaluation 

•Did the drug do what we were hoping it would do?