INTRAPARTAL CARE ASSESSMENT Flashcards by Althea Caryll Lebeco

e series of events by which uterine contractions and abdominal pressures expel the fetus and placenta from the woman’s body

LABOR

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 Uterine muscle stretching which results in prostaglandin release
 Pressure on the cervix, which stimulates the release of oxytocin
 Oxytocin stimulation which works together with prostaglandin
 Change in the ratio of estrogen to progesterone
 Placental age
 Rising fetal cortisol level
 Fetal membrane production of prostaglandin
 Seasonal and time influences

Factors that influence labor onset

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-Lightening
-Increase level of activity
-Braxton Hicks contraction
-Ripening of the cervix

Preliminary Signs of Labor

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Uterine contraction
Show – blood and mucus
Rupture of the Membranes

Signs of True Labor:

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initiation of effective, productive, involuntary uterine contractions

Uterine contraction

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Increment/ Crescendo – intensity of contraction increases
Acme/ Apex – contraction reaches its height or peak
Decrement/Decrescendo – intensity of contraction decreases

Uterine contraction Phases

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 Duration
 Intervals
 Frequency
 Intensity

Observation of Contraction

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from the beginning of one contraction to the end of same contraction.

Duration

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Duration during EARLY STAGE OF LABOR

20 to 30 seconds

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Duration during LATE STAGE OF LABOR

60 to 70 seconds

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from the end of one contraction to the beginning of the next

Intervals

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Interval during EARLY STAGE OF LABOR

40-45 minutes

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Interval during LATE STAGE OF LABOR

2-3 minutes

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from the beginning of one contraction to the beginning of the next contraction

Frequency

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– the strength of the contraction
– mild, moderate, strong

Intensity

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Intrauterine infection
Prolapse of the umbilical cord

Two risks associate with Rupture of Membranes (ROM)

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Passage – uterus, cervix, vagina, external perineum
Passenger - fetus
Power – uterine factors
Psyche
Placenta

Components of Labor (5 Ps)

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Are systemic method of observation and palpation to determine fetal presentation and position

Leopold’s Maneuver

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Determine what fetal part is at uterine fundus

First Maneuver (Fundal Grip)

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buttocks should feel irregular shape and firm

fetus is in the vertex position (head first)

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head should feel hard, round and movable

fetus is in breech position

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Identifies and describes the fetal parts contained on each side of the uterus.
Locates for the position of the fetal back and auscultate for the fetal heart beat

Second Maneuver (Umbilical Grip)

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smooth, hard surface on one side

fetal back

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Identifies the presenting part to determine the presentation and it’s mobility to determine engagement.

Third Maneuver (Pawlick’s Grip)

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If the fetus is in the vertex and has descended

you’ll feel a less distinct mass

If the fetus is in the breech position

you’ll also feel a less distinct mass, which could be the feet or knees

- Determines the fetal attitude. - Can determine flexion or extension of the fetal head and neck

Fourth Maneuver (Pelvic Grip)

- the position of the fetal presenting part and its descent into the pelvis --- - how far has the fetus descended - the ischial spines of the maternal pelvis are used to describe station 0.

Fetal station

described by the relationship of the long axis of the fetus to the long axis of the mother

Fetal Lie

the most common fetal lie

vertical lie

a problem with a term baby and labor approaching

Transverse lie

a problem in a term pregnancy

Oblique Lie

Denotes the body part that will first contact the cervix or deliver first

Fetal Presentation

1. Cephalic 2. Breech Presentation 3. Shoulder (Transverse)

Types of Fetal Presentation

a) Vertex b) Brow c) Face d) Mentum

Types of CEPHALIC PRESENTATION

parietal bone (full flexion)

VERTEX PRESENTATION (CEPHALIC)

head is moderately flexed (military)

BROW PRESENTATION (CEPHALIC)

extension of head, face

FACE PRESENTATION (CEPHALIC)

hyperextension of the head (chin)

MENTUM PRESENTATION (CEPHALIC)

head is the presenting part

CEPHALIC PRESENTATION

buttocks of the baby are presenting first at the bottom of the uterus

BREECH PRESENTATION

1. Frank Breech 2. Complete Breech 3. Incomplete Breech

Types of BREECH PRESENTATION

legs are flexed at the hips and extended at the knees so the feet are up by the head.

Frank Breech

one or both of the legs are flexed.

Complete breech

one or both hips are not flexed and the feet and knees are often below the buttocks

Incomplete Breech

– fetus is lying horizontally in the pelvis. - Presenting part can be the shoulder, iliac crest, hand, or elbow

SHOULDER (TRANSVERSE) PRESENTATION

 Relaxed abdominal walls from grand multiparity  Pelvic contraction in which horizontal space is greater than the vertical space  Placenta previa (placenta located low in the uterus)

CAUSES OF SHOULDER (TRANSVERSE) PRESENTATION

the relationship of the presenting part to a specific quadrant of the woman’s pelvis

Fetal Position

1. Right Anterior 2. Left Anterior 3. Right Posterior 4. Left Posterior

FOUR QUADRANTS

1. Occiput 2. Breech – Sacrum 3. Face – Chin (Mentum) 4. Shoulder – Scapula or acromion process

FOUR LANDMARKS

whether the landmark is pointing to the mother’s right or left

FIRST LETTER

denotes the fetal landmark: O- occiput Sa – sacrum, M – mentum A- acronium

MIDDLE LETTER

whether the landmark points anteriorly (A), posteriorly (P), transverse (T) (w/ regards to mother's ante and poste)

LAST LETTER

 Combined abdominal inspection and palpation  Vaginal Examination  Auscultation of FHT  Sonography

FOUR METHODS USED TO DETERMINE FETAL POSITION, PRESENTATION, AND LIE

1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External Rotation (Restitution) 7. Expulsion EDFIrEErE

Cardinal Movements (Mechanisms) of Labor

at 0 station (Ischial Spine)

Engagement

head within the pelvic inlet

Descent

fetal head flexed against the chest

Flexion

fetal head rotates from transverse to anterior

Internal Rotation

head extends with crowning

Extension

head returns to its’ transverse orientation

External rotation (restitution)

shoulders and torso of the baby are delivered

Expulsion

1. Dilatation 2. Effacement

Cervical Changes:

How far the cervix has opened

Dilatation

Thinning of the cervix

Effacement

STAGE 1: CERVICAL DILATITION (LAT) STAGE 2: DELIVERY STAGE STAGE 3: PLACENTAL STAGE STAGE 4: RECOVERY AND BONDING

STAGES OF LABOR

Begins with true labor contraction and ends w/ full dilatation

STAGE 1: CERVICAL DILATITION

1. Ambulation if with intact membranes 2. If in bed, LIE ON ONE SIDE or the other…NOT flat on her back 3. Check vital signs Q4 HRS 4. NPO EXCEPT ice chips or small sips of water for hydration

Management of Early Labor

1. Latent Phase 2. Active Phase 3. Transition Phase

THREE PHASES OF STAGE 1: CERVICAL DILATITION

0 to 3 cm dilatation

Latent Phase

NULLIPARA: 6 hours MULTIPARA: 4 to 5 hours

Latent Phase

1. Backache 2. Cramping 3. Bloody show 4. Mother is talkative, cheerful, anxious

SIGNS DURING LATENT Phase

1. Diversional activities 2. Time the contractions 3. Assess maternal-fetal status 4. Promote hydration 5. Utilize breathing patterns – SLOW, CHEST BREATHING 6. Evaluate labor progress

NURSING CARE DURING LATENT Phase

4-7 cm dilatation

Active Phase

3-5 minutes apart

ACTIVE Phase CONTRACTON INTERVAL

40-60 seconds long

ACTIVE Phase CONTRACTON DURATION

Stronger and more intense

ACTIVE Phase CONTRACTON INTENSITY

NULLIPARA: 3 hours MULTIPARA: 2 hours

Active Phase

1. Assess maternal and fetal status 2. Instruct the client PANT-BLOW 3. Backrubs, comfort measures 4. Provide encouragement 5. Provide analgesia if requested and if appropriate 6. Promote hydration and elimination 7. Keep perineum clean 8. Promote rest between contractions 9. Evaluate labor progress

NURSING CARE DURING ACTIVE Phase

During EARLY labor, for LOW RISK patients, note the fetal heart rate every

1-2 HOURS

During ACTIVE labor, evaluate the fetal heart every

30 MINS

Normal FHR

120-160 BPM

 Continuously records the instantaneous fetal heart rate and uterine contractions  Patterns are of clinical significance.  Use in high-risk patients.  Use in low-risk patients is OPTIONAL

Electronic Fetal Monitors

2-3 minutes apart

TRANSITION Phase CONTRACTON INTERVAL

8-10 cm dilatation

Transition Phase

40-90 seconds long

TRANSITION Phase CONTRACTON DURATION

1. Leg cramps 2. Perspiration on forehead and upper lip 3. Dark profuse bloody show 4. Mother is Irritable, anxious and self-oriented.

SIGNS DURING TRANSITION Phase

1. Assess maternal-fetal status 2. Provide comfort measures 3. Pant-blow w/ PUSHING URGES 4. Be supportive and help mother maintain control with breathing 5. Evaluate labor progress

NURSING CARE DURING TRANSITION Phase

- From time of full dilatation until the infant is born - Mother has urge to push

STAGE 2: DELIVERY STAGE

1. Assess maternal-fetal status 2. COACH pushing 3. Provide comfort 4. RECORD time of delivery, episiotomy/ lacerations, medications/ anesthesia 5. Evaluate labor progress 6. Promote bonding

STAGE 2: DELIVERY STAGE NURING CARE

1. Narcotics 2. Paracervical 3. Pudendal 4. Epidural 5. Saddle (spinal) anesthesia

Anesthesia/ Analgesia for Labor and Delivery

- Meperidine HCl (Demerol), after mixed with Promethazine (Phenergan) to potentiate. - Do NOT give if within TWO hours of delivery, infant may be depressed

Narcotics

- numbs cervix, good for STAGE 1 of labor; should NOT be given AFTER 8 CM - can cause fetal bradycardia

Paracervical

numbs vagina and perineum; good for STAGE 2 of labor

Pudendal

numbs from the waist down

Epidural

1. BP every 15 minutes until stable 2. Assess bladder 3. Assist in turning and pushing 4. Hydrate client 5. Assess FHR

Nursing Interventions for EPIDURAL

1. Hypotension 2. Fetal distress

EPIDURAL COMPLICATIONS

numbs waist down

Saddle (spinal)

Headache

Saddle (spinal) Complications

1. Flat on bed 4-6 hours

Nursing Intervention for Saddle (spinal)

 Avoids lacerations  Provides MORE ROOM for obstetrical maneuvers  SHORTENS the 2nd Stage Labor  MIDLINE associated with GREATER risk of rectal lacerations, but heals FASTER  Many women don’t need them. * If there are lacerations, vaginal episiorrhaphy (repair) is done.

Episiotomy

Gauze is compacted into the vagina to absorb the blood and apply pressure on the arteries of the uterus and can slow bleeding

Vaginal packing

- must be done to MAINTAIN PRESSURE on the suture line - Must be REMOVED after 6-8 hrs.

Vaginal Packing

Clamp and Cut the Cord when

pulsations stop

Clamp and Cut the Cord for about

an inch from baby's abdomen

Check the Cord for these 3 vessels

AVA

From time the infant is born until after the delivery of the placenta

STAGE 3: PLACENTAL STAGE

1. Separation 2. Expulsion

TWO PHASES OF STAGE 3: PLACENTAL STAGE

1. Lengthening of the umbilical cord 2. Sudden gush of vaginal blood 3. Change in the shape of the uterus

SIGNS OF PLACENTA SEPARATION

1. Assess maternal status - Palpate the uterus to see if its contracted, may develop uterine atony 2. Assess blood loss (250 ml), note time (30 mins) of delivery of placenta 3. Administer medications if ordered 4. OXYTOCIN (Methergin)– once placenta is delivered, oxytocin is ordered by IM/IV, to increase uterine contraction & minimize uterine bleeding. BP should be monitored as oxytocin causes HPN by vasoconstriction. 5. Inspect the Placenta

NURSING CARE DURING STAGE 3: PLACENTAL STAGE

1. Make sure it is complete 2. Look for missing pieces 3. Look for malformations 4. Look for areas of adherent blood clot

how to Inspect the Placenta

Begins after delivery of the placenta and continues for 1-4 hours after delivery

STAGE 4: RECOVERY AND BONDING

1. Assess VS, fundus and flow every 15 minutes 2. Encourage hydration and elimination 3. Promote comfort 4. Promote bonding

NURSING CARE DURING STAGE 4: RECOVERY AND BONDING

- A tool for managing labor, a graphic representation of the events of labor plotted against time in hours - Started only when a woman is in labor

PARTOGRAPH

1. Fetal Condition 2. Progress of Labor 3. Maternal Condition

3 COMPONENTS OF PARTOGRAPH

Use to monitor the ff parameters: 1. FHR 2. Membranes and Color of Liquor 3. Descent/Molding of fetal skull

Fetal condition

Use to plot the parameters: 1. Cervical Dilatation 2. Descent of fetal head 3. Uterine contractions (IFD)

Progress of labor

Use to monitor the parameters: 1. VS 2. Urine 3. IV fluids 4. Drugs and Oxytocin

Maternal condition

1. Early detection of deviation from normal progress of labor. 2. Prevention of prolonged labor. 3. Reduce the risk of postpartum hemorrhage and sepsis. 4. Eliminate obstructed labor, uterine rupture.

PURPOSES OF PARTOGRAPH

5. Improvement in maternal morbidity, perinatal morbidity and mortality. 6. Serve as an early warning system and assist in early decision on: - Transfer - Augmentation - Termination of labor 7. Prevention of asphyxia ,brain damage, infection and death in infant.

PURPOSES OF PARTOGRAPH

1. To reduce prolonged labor and sequela of morbidity and mortality for both women and infants. 2. To improve quality of care for women in labor and to increase the observation and interpretation skills of the on the progress of labor by health personnel. 3. To encourage timely referral from the periphery

OBJECTIVES OF PARTOGRAPH

1. Patient identification 2. Time 3. Zero 4. Fetal heart rate 5. Membranes and color of liquor 6. Cervical dilatation 7. Descent of Head 8. Uterine contractions 9. Drugs and Fluids 10. Blood pressure 11. Pulse rate 12. Oxytocin 13. Urine Analysis 14. Temperature Record

Description of indicators used in Partograph

It is recorded at an interval of one hour.

Time

time for spontaneous labor, is time of admission in the labor ward and, is time of induction

Zero Time

Is recorded at an interval of 30 minutes

FHR

"I" designates intact membranes "C" designates clear liquor "M" designates meconium stained liquor "B" designates bloody liquor "A" designates absence of liquor

Membranes and color of liquor

measured by the diameter in cm 0-10. (X is designated )

Cervical dilatation

O is designated

Descent of Head

Squares in vertical columns are shaded according to duration and intensity

Uterine contractions

It is recorded in vertical lines at an interval of 2 hours

It is also recorded in vertical lines at an interval of 30 minutes.

Concentration is noted down in upper box; while dose is noted in lower box

OXYTOCIN

Perform internal examination every

4 HOURS or more often if necessary

if plotting stays on or to the left of the alert line (green part)

Progress of labor is normal

Plotting that passes the alert line (yellow part) more so if it reaches or passes the action line (red part) indicates

ABNORMAL progress of labor

1. Reassess woman and consider criteria for referral. 2. Alert transport services 3. Encourage woman to empty bladder 4. Encourage upright position and walking if woman wishes. 5. Monitor intensively. 6. If referral takes a long time, refer immediately. DO NOT WAIT TO CROSS ACTION LINE

IF PLOTTING PASSES ALERT LINE:

Refer urgently to hospital unless birth is imminent

IF PLOTTING REACHES ACTION LINE: