Intrapartum Care
SIGNS OF PRECEDING LABOUR
lightening
Braxton hicks contractions
backaches
bloody show
SROM
diarrhea
spurt of energy
weight loss of 0.5-1.5kg
return of urinary frequency
Onset of Labour
hormonal factors
progesterone withdrawal is required for the activation of myometrial contractions (why we give progesterone to antepartum pts with risk of preterm birth)
oxytocin works with prostaglandins to contribute to cervical ripening and dilation
estrogen stimulates uterine contractions
mechanical factors
uterine distention theory
stretch of lower uterine segment
Fetal physiological adaptation of labour
fetal heart rate.
fetal heart rate changes due to circulation, position changes, blood flow, maternal BP, during labour contractions reduce circulation
fetal respiration chemoreceptors prepare fetus for initiation respiration at birth
The five P’s
powers ( contractions )
primary powers are involuntary uterine contractions ( signal the start of labour )
needed to accomplish the work of labour
effacement
dilation
secondary powers
involuntary urge to push (occurs when presenting part reaches pelvic floor)
in addition to contractions, the other poor is the intra abdominal force provided by the labouring woman, maternal pushing or bearing down
uterine contractions CHARACTERISTICS
rhythmic (increasing tone; increment), pan (acme) relaxation (decrement)
effects of contractions cause decrease blood flow to uterus and placenta. the contractions dilates the cervix during the first stage of labour
**following the birth of the baby, uterus will begin involution, which is how uterus was pre pregnancy
Passageway (birth canal)
composed of bony pelvis, lower uterine segment, cervix, pelvic floor muscles, vagina, and intuits (external opening to vagina)
fetal lie: sutures and fontanels make skull flexible to accommodate growing brain
fetal altitude : relation of fetal body to another
fetal presentation: portion of fetus that overlies the pelvic inlet
fetal position: the reference point on the presenting part (occiput, sacrum, mentum or sinciput)
placental location )anterior or posterior or previa
Passanger
fetal attitude (vertex presentation)
head entering pelvis
fetal presentation
cephalic (vertex or head) usually occiput position of the fetal head
breech (complete, footling, frank)
shoulder with transverse lie
face
brow
compound presentation with more than one part
single fooling breech
lie ( longitdial or vertical)
presentation (breech, incomplete)
attitude (flexion, exception for one leg extended at hip and knee)
complete breech
lie (longitudinal or vertical)
presentation (breech, sacrum and feet presenting)
presenting part (sacrum, with feet)
attitude (general flexion)
Shoulder presentation
lie (transverse or horizontal)
presentation (shoulder)
Presenting part (scapula)
Attitude (flexion)
Fetal Positions
O (occiput) - vertex presentation
S (sacrum - buttocks) - breech presentation
M (mentum - chin) - face presentation
SC (scapula) - shoulder presentation
Position of Labouring Patient
Frequent changes in position relieve fatigue, increase comfort, improve circulation
alternate positions may assist in more desirable fetal positions
Mechanisms of Labour!
engagement
descent
flexion
internal rotation - to occipitoanterioir position
extension
restitution and external rotation
expulsion (birth)
Trauma Informed Care
require support and non judgement
safety, trust, choice and control, compassion, and collaboration are key
explain procedures
Assesments
determination of true to pre labour
contractions
cervix
fetus
physical examination
system assessment
vital signs and FHR
symphis - fundal height
urinalysis for protein and sugar
uterine activity
state of membranes
shwo
fetal activity
vaginal exam
les manouver
assessment of FHR and pattern
Continuation (assessment and nursing care)
assessment of uterine activity
frequency
intensity
duration
resting tone
palpation of uterus (milk, moderate, strong)
cervical effacement, dilation, station
status of membranes
vaginal examination
fetal position and presentation
Steps on auscultation fetal heart tones
locate back with Leos maneuver
auscultate
tunic souffle is a hissing souffle synchronous with fetal heart sounds likely from umbilical cord
uterine souffle is a suons made by the blood within arteries of gravid uterus
STAGES OF LABOUR
labour begins with first uterine contraction, then continues with work during carvical dilation and birth. End as woman and family begin attackment process with infant
four stages
first stage:
Latent phase 3 cm of dilation
0-3cm, 30-45 sec, 5-10 mins apart, mild to moderate contractions, lower back pain. Cervix thins less than 1cm, station nullipara 0, multipara 2 to +1
active phase 4-10cm in nulliparous and 4-5cm in transition
NURSING CARE (1st stage)
encourage breathing before contractions become intense
stay with the pt
limit assesments to when pt is not having contraction
continue to support with contractions, remind and reassure breathing and concentrate each contraction
assist with analgesia
prepare for birth
assess BP, P, rest q 30-60 depending on risk
FHR/CTX/ vaginal show q15-30
SROM rupture
assess fetal heart rate for at least 1 min, umbilical cord can be compressed
Second stage of labour
infant is born, begins with 10cm dilation
complete effacement
ends with birth of baby
two phases:
passive: time from full dilation to active pushing
help pt rest, encourage relaxation, cloth on forehead, ice chips, FHR Q15, BP, P, and reps Q30
descent: pushing and urges to bear down
active pushing, help pt change positions, encourage bearing down, coach pt and provide emotional support, FHR Q5 after every push
Third stage of labour
lasts from birth of baby to placental separation, descent and expulsion
signs of placental separation
firmly contracting funds
uterus changes shape (becomes globular in shape)
uterus rises in abdomen
apparent lightening go umbilical cord
cord descends 3 inches or more further out of vagina
sudden gush of dark blood from introitus
vaginal fullness
after placental delivery
monitor 15 x 4
funds
flow
BP
pulse
psychological relief
concern, may not recognize placental delivery
Assessments post placental delivery
when funds is well contracted and placenta visible at introitus, encourage mother to push to expel placenta
cord blood collection
maternal physical status
signs of potential problems
excessive blood loss
alteration in VS and consciousness
care of placenta after delivery
immediate assessment and care of newborn
BP, P, and resp q15 x 4 then q30 x 2
Risk of maternal hemorrhage if placenta is not completely expelled
active management
uterotonics
clamping and cutting of cord
controlled cord traction
fundal massage after birth of placenta
Fourth stage of labour (immediate postpartum period)
2 hours postpartum
watch for increased pulse
watch for decreased BP (late sign of PPH)
uterus:
contracts
should be located between umbilicus and symphysis pubis
shakiness
bladder
monitor Psychological
Perineal trauma related to childbirth
lacerations
perineal lacerations
vaginal clitoral and urethral lacerations
episiotomy
female genital mutilation
emergency childbirth
Classification of Perineal Tears
FIRST DEGREE
injury to perineal skin and vaginal epithelium only
SECOND DEGREE
involves injury that extends into fascia and muscles of perineum and includes deep and superficial transverse perineum muscles and fibres of pubococcygeous and bulbocavernosus muscles. Second degree lacerations do not extend into the anal sphincter muscles
THIRD DEGREE
involves injury through muscles and fascia of perineum and involves anal sphincter complex.
3A: less than 50% of external anal sphincter thickness torn
3B: more than 50% of EAS torn
3C: both EAS and internal anal sphincter torn
FOURTH DEGREE
fourth degree lacerations involve perineal fascia and muscles. Both external and internal anal sphincters and the anal epithelium
SIGNS OF PRECEDING LABOUR
lightening
Braxton hicks contractions
backaches
bloody show
SROM
diarrhea
spurt of energy
weight loss of 0.5-1.5kg
return of urinary frequency
Onset of Labour
hormonal factors
progesterone withdrawal is required for the activation of myometrial contractions (why we give progesterone to antepartum pts with risk of preterm birth)
oxytocin works with prostaglandins to contribute to cervical ripening and dilation
estrogen stimulates uterine contractions
mechanical factors
uterine distention theory
stretch of lower uterine segment
Fetal physiological adaptation of labour
fetal heart rate.
fetal heart rate changes due to circulation, position changes, blood flow, maternal BP, during labour contractions reduce circulation
fetal respiration chemoreceptors prepare fetus for initiation respiration at birth
The five P’s
powers ( contractions )
primary powers are involuntary uterine contractions ( signal the start of labour )
needed to accomplish the work of labour
effacement
dilation
secondary powers
involuntary urge to push (occurs when presenting part reaches pelvic floor)
in addition to contractions, the other poor is the intra abdominal force provided by the labouring woman, maternal pushing or bearing down
uterine contractions CHARACTERISTICS
rhythmic (increasing tone; increment), pan (acme) relaxation (decrement)
effects of contractions cause decrease blood flow to uterus and placenta. the contractions dilates the cervix during the first stage of labour
**following the birth of the baby, uterus will begin involution, which is how uterus was pre pregnancy
Passageway (birth canal)
composed of bony pelvis, lower uterine segment, cervix, pelvic floor muscles, vagina, and intuits (external opening to vagina)
fetal lie: sutures and fontanels make skull flexible to accommodate growing brain
fetal altitude : relation of fetal body to another
fetal presentation: portion of fetus that overlies the pelvic inlet
fetal position: the reference point on the presenting part (occiput, sacrum, mentum or sinciput)
placental location )anterior or posterior or previa
Passanger
fetal attitude (vertex presentation)
head entering pelvis
fetal presentation
cephalic (vertex or head) usually occiput position of the fetal head
breech (complete, footling, frank)
shoulder with transverse lie
face
brow
compound presentation with more than one part
single fooling breech
lie ( longitdial or vertical)
presentation (breech, incomplete)
attitude (flexion, exception for one leg extended at hip and knee)
complete breech
lie (longitudinal or vertical)
presentation (breech, sacrum and feet presenting)
presenting part (sacrum, with feet)
attitude (general flexion)
Shoulder presentation
lie (transverse or horizontal)
presentation (shoulder)
Presenting part (scapula)
Attitude (flexion)
Fetal Positions
O (occiput) - vertex presentation
S (sacrum - buttocks) - breech presentation
M (mentum - chin) - face presentation
SC (scapula) - shoulder presentation
Position of Labouring Patient
Frequent changes in position relieve fatigue, increase comfort, improve circulation
alternate positions may assist in more desirable fetal positions
Mechanisms of Labour!
engagement
descent
flexion
internal rotation - to occipitoanterioir position
extension
restitution and external rotation
expulsion (birth)
Trauma Informed Care
require support and non judgement
safety, trust, choice and control, compassion, and collaboration are key
explain procedures
Assesments
determination of true to pre labour
contractions
cervix
fetus
physical examination
system assessment
vital signs and FHR
symphis - fundal height
urinalysis for protein and sugar
uterine activity
state of membranes
shwo
fetal activity
vaginal exam
les manouver
assessment of FHR and pattern
Continuation (assessment and nursing care)
assessment of uterine activity
frequency
intensity
duration
resting tone
palpation of uterus (milk, moderate, strong)
cervical effacement, dilation, station
status of membranes
vaginal examination
fetal position and presentation
Steps on auscultation fetal heart tones
locate back with Leos maneuver
auscultate
tunic souffle is a hissing souffle synchronous with fetal heart sounds likely from umbilical cord
uterine souffle is a suons made by the blood within arteries of gravid uterus
STAGES OF LABOUR
labour begins with first uterine contraction, then continues with work during carvical dilation and birth. End as woman and family begin attackment process with infant
four stages
first stage:
Latent phase 3 cm of dilation
0-3cm, 30-45 sec, 5-10 mins apart, mild to moderate contractions, lower back pain. Cervix thins less than 1cm, station nullipara 0, multipara 2 to +1
active phase 4-10cm in nulliparous and 4-5cm in transition
NURSING CARE (1st stage)
encourage breathing before contractions become intense
stay with the pt
limit assesments to when pt is not having contraction
continue to support with contractions, remind and reassure breathing and concentrate each contraction
assist with analgesia
prepare for birth
assess BP, P, rest q 30-60 depending on risk
FHR/CTX/ vaginal show q15-30
SROM rupture
assess fetal heart rate for at least 1 min, umbilical cord can be compressed
Second stage of labour
infant is born, begins with 10cm dilation
complete effacement
ends with birth of baby
two phases:
passive: time from full dilation to active pushing
help pt rest, encourage relaxation, cloth on forehead, ice chips, FHR Q15, BP, P, and reps Q30
descent: pushing and urges to bear down
active pushing, help pt change positions, encourage bearing down, coach pt and provide emotional support, FHR Q5 after every push
Third stage of labour
lasts from birth of baby to placental separation, descent and expulsion
signs of placental separation
firmly contracting funds
uterus changes shape (becomes globular in shape)
uterus rises in abdomen
apparent lightening go umbilical cord
cord descends 3 inches or more further out of vagina
sudden gush of dark blood from introitus
vaginal fullness
after placental delivery
monitor 15 x 4
funds
flow
BP
pulse
psychological relief
concern, may not recognize placental delivery
Assessments post placental delivery
when funds is well contracted and placenta visible at introitus, encourage mother to push to expel placenta
cord blood collection
maternal physical status
signs of potential problems
excessive blood loss
alteration in VS and consciousness
care of placenta after delivery
immediate assessment and care of newborn
BP, P, and resp q15 x 4 then q30 x 2
Risk of maternal hemorrhage if placenta is not completely expelled
active management
uterotonics
clamping and cutting of cord
controlled cord traction
fundal massage after birth of placenta
Fourth stage of labour (immediate postpartum period)
2 hours postpartum
watch for increased pulse
watch for decreased BP (late sign of PPH)
uterus:
contracts
should be located between umbilicus and symphysis pubis
shakiness
bladder
monitor Psychological
Perineal trauma related to childbirth
lacerations
perineal lacerations
vaginal clitoral and urethral lacerations
episiotomy
female genital mutilation
emergency childbirth
Classification of Perineal Tears
FIRST DEGREE
injury to perineal skin and vaginal epithelium only
SECOND DEGREE
involves injury that extends into fascia and muscles of perineum and includes deep and superficial transverse perineum muscles and fibres of pubococcygeous and bulbocavernosus muscles. Second degree lacerations do not extend into the anal sphincter muscles
THIRD DEGREE
involves injury through muscles and fascia of perineum and involves anal sphincter complex.
3A: less than 50% of external anal sphincter thickness torn
3B: more than 50% of EAS torn
3C: both EAS and internal anal sphincter torn
FOURTH DEGREE
fourth degree lacerations involve perineal fascia and muscles. Both external and internal anal sphincters and the anal epithelium