Intrapartum (class 7,8,9,10)

Labor

onset of regular contractions to full dilation of cervix

full dilation to delivery of baby

delivery of baby to delivery of placenta

delivery of placenta to first 4 hours after birth

Lightening (fetal engagement) \n Braxton Hicks contractions \n Bloody Show \n Backache \n Spontaneous Rupture of membranes (SROM)

Diarrhea \n Spurt of energy (nesting) \n Weight loss

true

false

True labor: Contractions continue no matter if comfort measures.

False labor: Contractions may stop or slow down with comfort measures

true labor: Progressive dilatation & effacement.

false labor: Cervix may be soft but no sign in change in effacement or dilation and no show

false

true

becomes stronger with time; vaginal pressure is felt

freq weak; not getting stronger with time

Power

Passageway

passenger

position

Psychological response

Primary – Involuntary uterine contractions that result in Effacement and Dilatation of the cervix

Secondary – Involuntary urge to push

1

1.5

Refers to Maternal Pelvis

-Structures,

-Types (shape),

-Diameter, -

and Soft tissues

-“Give” of joints –effect of hormones

the cervix stretches and gets thinner

Dilatation means that the cervix opens

Fetal head – dimensions

Cranial Vault (Bones)

 Sutures (sagittal/lambdoidal/coronal)

 Fontanelles \n Biparietal diameter

*Fontanelles/ \n sutures and fetal head positioning are important mechanisms to aid in passing through the maternal pelvis

Fetal lie refers to the relationship between the longitudinal axis of the baby with respect to the longitudinal axis of the mother (longitudinal lie, transverse lie, oblique lie)

Fetal presentation refers to the part of the baby that is overlying the maternal pelvis.

the presenting part is the part of the baby that leads the way through the birth canal. Most often, it is the baby's head, but it can be a shoulder, the buttocks, or the feet.

Station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines and is a measure of the degree of descent of the presenting part of the fetus through the birth canal.

Engagement is the term used to indicate that the largest transverse diameter of the presenting part (usually the biparietal diameter) has passed through the maternal pelvic brim or 405inlet into the true pelvis and usually corresponds to station 0. Engagement often occurs in the weeks just before labour begins in nulliparas and may occur before or during labour in multiparas. Engagement can be determined by abdominal or vaginal examination.

Relationship between cervical E&D and fetal descent in relation to time and progression of labour

circulation

fetus rotate

opens the pelvis

first

latent, active, transition

7-8 hours

0-3cm

30-45 seconds

3-5 hours

4-7cm

40-80%

40-60 seconds in length

8-10cm

30 min - 2 hrs

80-100%

60-90 seconds

-Vaginal examination- to determine the progress of labour (cervical effacement and dilation)

- Uterine activity- Contractions pattern and strength

- Bloody show

- Amniotic fluid

-  Comfort level

-Vital signs

-  Fetal assessment – fetal heart rate patterns

- Leopolds manoeuvres

-Hydration status

-  Bowel, bladder status

sodium chloride

-meconium stained amniotic fluid.

-Meconium in the amniotic fluid increases the risk for meconium aspiration syndrome.

• Endotracheal intubation and suctioning in infants who

are not vigorous at birth should occur prior to drying and stimulation to remove any meconium from the trachea.

• Contractions – Q 30 -45 sec duration, mild to mod, 5 – 20 min apart

• Encourage mobility, change positions frequently

• Encourage voiding q2h

• Maintain adequate hydration/ diet

• Support/ comfort measures

• Monitoring of labour progress and fetal adaptation to labour stress

• Maternal positioning that facilitates descent of the fetus and comfort for the labouring person

active phase

-Continue with latent phase interventions (mobility, positioning, voiding, hydration, etc... )

-Monitor comfort/pain management – pain becomes more intense during this phase

-Fetal monitoring and assessment – important to note how fetus is responding to labour progress

back pain

(non pharm pain management)

a form of massage involving a circular stroking movement made with the palm of the hand.

70-90 secs in duration.

strong.

30-60 seconds apart

-Emotional support +++/positive reinforcement. May need frequent focus and direction

- Help control breathing through contractions \n -Begin to get for delivery

- Prepare bed and positioning for pushing

childbirth \n - Pharmacologic Pain control may be too late at

this point (respiratory effects on neonate)

first

artificial initiation of labor

Bishop Score System -Measures cervical readiness for induction by scoring 5 characteristics of the cervix 5 characteristics include:

1. Dilation (5 cm or more) 2. Effacement (80% or more) 3. Station (+1 or more ) 4. Cervical consistency (firm, medium, soft) 5. Cervical Position (Posterior, midposition, anterior**)

• Post term infant

• Diagnosed issue of intrauterine environment

  ie.) perfusion of fetus

• Fetal distress (if not severe) or risk for fetal

  distress identified.

labor has started but it needs help

-Supplementation of a naturally occurring labour with synthetic oxytocin. \n • Purpose would be to increase the strength/

pattern or duration of contractions to improve the labour process.

41

-tears/lacerations

-Labour dystocia

-Increased risk of infection and hemorrhage

• Meconium aspiration

• Infant injury from birthing process

  • Mortality rate increases after 40 weeks

Natural endogenous oxytocin release:

• Sexual intercourse

Mechanical methods: \n • Amniotomy \n • Stripping or sweeping of membranes

Pharmacologic methods:

• Prostaglandins \n • Oxytocin

• Frequently used to ripen the cervix.

• Cervix has to be ripened for labour to be initiated. If bishop score is less than 6, a cervical ripening agent such as prostaglandins must be used before labour induction.

  • If cervix is not ripened, augmentation or induction with oxytocin will not be successful

• Synthetic form of the naturally occurring hormone

• Used to facilitate uterine contractions \n • Can be used to induce labour or augment labour

• Piggybacked into main IV infusion line

and titrated until regular contraction pattern is established

• V/S q30mins (BP &P) and on increase of drip

• Record FHR & contractions q15mins \n • Monitor contractions closely

• If fetal distress- \n -d/c oxytocin, increase main line \n -turn on left side \n -administer oxygen \n -reevaluate contractions and fetal response -notify doctor \n -document

-initial latent phase

-descent (cardinal ,ovements)

-active expulsion phase (pushing and crowning)

lasts up to 1 hour

second stage of labor

Sudden appearance of sweat on upper lip

Vomiting episode \n Increase in bloody show

Increased restlessness/agitation ;

verbalization – “I cant go on”

Involuntary bearing down efforts

Bulging perineum, labia

-Descent \n -Flexion \n - Internal Rotation

- Extension

- Restitution \n - External Rotation

- Expulsion

1 min after birth and 5 mins

first

second

third

fourth

5-30

-Firmly contracting uterus

-  Change in shape of uterus from discoid

to globular

-  Lengthening of cord \n - Sudden gush of blood \n -Vaginal fullness or membranes at the

introitus

shiny schultz

dirty duncan

30 mins after delivery… not good if its still there

1- 4 hr after birth of the newborn; period of maternal physiological adjustment.

-Restoration of physiology \n -Myometrial contractions and retractions & vessel thrombosis \n -BLEEDING MAIN CONCERN \n -Formation of mother-newborn relationship

-Consolidation of family unit

undisturbed first hour after birth spent skin to skin on mother’s (or father’s) chest, unclothed

• Many benefit for infant as well as mother’s transition to postpartum period

• Facilitates bonding and attachment

• Promotes regulation of newborns physiological

  transitions to extra uterine life (Eases transition period)

  • Allows mother to adjust to puerperium stage physically and emotionally

37

• rupture or membranes prior to onset of labour regardless of gestational age

• Preterm PROM (pPROM) – rupture of membranes before 37 weeks gestation

• Predisposing factors- maternal nutritional deficiencies, substance use, placental abruption, polyhydramnios, multiple pregnancy, prior preterm birth or PPROM, infections **primarily chorioamnionitis or trauma

• Once membranes rupture - risk of infection- chorioamnionitis. Usually caused by normal flora e.g. E coli

• Restrict activity with ongoing assessment.

• Ie) Temp at least Q2hr together with WBC and CBC

monitoring daily. Admin of broad spectrum antibiotics

• Try to prevent infection- no pv exams, frequent changing of pads, observe amniotic fluid for signs of infection, tachycardia in baby, adequate hydration

induction

induce right away

-Generally painless cervical dilation \n -Often associated with pPROM and preterm birth

-Risk Factors: Excessive cervical dilation for curettage or biopsy, history of previous cervical lacerations during childbirth, cervical and uterine anomalies, a hx of short labours and/or losses at early gestations

-TX: Cerclage, Restricted Activity (potentially bedrest)

-Placed at 13 – 14 weeks and removed at 37 weeks gestation

• Bedrest – left lateral

• incraesed hydration so increased plasma volume

• Avoid unnecessary pv exams

• Tocolytics

• Corticosteroids- betamethasone/dexamethasone•

• Continuous monitoring of FHR and contractions

• Needs lots of psychological support

long, difficult, or abnormal labor

4 hours of < 0.5 cm/hr dilation (active first

phase)

\n OR

1 hr with no descent while pushing (second stage)

cervix does not dilate despite normal uterine contraction and no CPD

-Unable to dilate cervix normally \n -Uterus is easily indented at peak of contraction \n -Usually occurs in active phase of First Stage \n -Possible causes: Uterine overdistention, fetal malposition, analgesics, regional anaesthesia

If membranes intact and presenting part is engaged – amninotomy and/or oxytocin augmentation

Possible cause may be synthetic oxytocin ,hyperstimulation, or placental abruption

Usually occurs in latent phase in the first stage of labor

Management:

• Rest

• Fluids

• Sedation/ analgesia

• No oxytocin (Stop infusion -Short half life)

hypertonic labor

frequency, duration, intensity

(of contractions)