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