intrapartum 1 Flashcards
the 5 P’s
passage, passenger, position, powers, psyche
passage
size and type of pelvis
cervix ability to dilate and efface and ability of vaginal canal and external opening to distend
Bony pelvis -> lower uterine segment (support) -> cervix (thin and stretch) -> pelvis floor muscles (rotate fetus) -> vagina -> introitus
passage - gynecoid
wider and broader, ischial spines less prominent
best for vaginal delivery
passage - android
longer sacrum, males, narrow arch (CPD), posterior position of baby more likely
passage - anthropoid
apes, OP position
passage - platypelloid
flat, longer, transverse
most likely c/s
cervical effacement
gradual thinning, shortening, drawing up of cervix (0-100%), shorten distance btw internal and external os
cervical dilation
gradual opening of cervix (0-10cm)
usually occurs faster than effacement
can be longer with damage (scar tissue)
passenger
fetus
passenger: head
frontal, 2 parietal, 2 temporal, occipital bone (6 bones)
connected by 4 membranous sutures -> intersect at fontanelles, cone head disappears after 24 hrs (modeling), allow flexibility, delivery, brain growth
anterior = diamond, closes 12-18 mo
posterior = triangle, closes 6-8 wk
passenger: attitude
refers to relation of fetal parts to one another
rounded back, chin to chest, thighs to abd, legs flexed at knees, arms crossed
BPD = head size
passenger: lie
relationship of long axis of fetus to long axis of mom
passenger: lie - longitudinal
vertical
cephalic (vertex) = head down
breech = butt down
passenger: lie - transverse
shoulder, horizontal
cephalic - suboccipitobregmatic
best!, smallest diameter
cephalic - occipitofrontal
military
chin not flexed
cephalic - occipitomental
brow
cephalic - submentobregmatic
face
previous births, bruise and edematous face
passenger: presentation
Cephalic: suboccipitobregmatic, occipitofrontal, occipitomental, submentobregmatic
breech
frank: hips flexed, knees extended, butt presents
complete: hips and knees flexed, thighs on abd, butt and feet first
footling: hips and legs extended, single or double foot
shoulder
position
R or L side of pelvis
landmark: occiput, mentum, sacrum, acromium process (scapula)
anterior, posterior, transverse
position - station
relationship of presenting park to ischial spines (0), above = -, below = +
engagement = presenting part at 0
ballotable = floating, not engaged
powers - primary
uterine muscular contractions until complete dilation, cause dilation and effacement
contraction: increment, acme, decrement
described with freq, duration, intensity
Involuntary
powers - secondary
abd pushing (bear down - ferguson) -> oxytocin, ferguson, stretch receptors
reduces blood flow (dont overdo), gravity (increase c strength), walk, squat, sit, kneel -> increase CO and blood flow to placenta, uterus, and kidneys; change position (help with fatigue, comfort, circulation)
Voluntary
psyche
fear and anx: pain of labor, loss of control, injury of self or infant
excitement: joy and anticipation
exhaustion (work, stress)
level of support: father, system
factors associated with
psyche - factors associated with positive birth experience
motivation for pregnancy, attendance at classes, sense of competence or mastery, self confidence/esteem, empowerment, maintaining control, relationship with partner, support, not being alone, trust in staff, personal control of breathing patterns, comfort measures, hcp with similar philosophy of care, clear info regarding procedures
abnormalities potentially affecting process of labor
passage: too small
passenger: malpresentation
position: posterior (occiput posterior)
powers: inadequate
psyche: fear, anx, poor support, exhaustion
premonitory s of impending labor
lightening: presenting part in true pelvis, gradual relive P on diaphragm, increased P on bladder
braxton hicks: practice - mild and irregular, dont lead to cervical change
cervical changes: effacement and dilation
bloody show/expulsion of mucus plug: brown/blood tinged, concern if <37wk
ROM (SROM)
sudden burst of E = nesting
weight loss = not hungry
GI upset
true s of labor
regular contraction intervals, intervals shorten, contractions increase in duration and intensity, discomfort beings in back and radiates to abd, progressive dilation and effacement, contractions dont decrease with rest or warm bath
false s of labor
irregular contractions, no change in intervals, intensity, or duration; discomfort in abd, no change in dilation or effacement, rest and warm tub lessens contractions
stage 1
onset -> fully dilated
stage 1: latent
“early labor”
nullipara = 8.6hr, multipara = 5.3 hr (these times can increase with scaring)
dilation: 0-3cm
contract q 10-30 min, 30 sec, mild-mod (25-40mmHg)
Usually dilate faster than efface
psych: cope with discomfort, relief to start, anx (recognize and express), increased excitement, eager to talk
stage 1: active
nulli = 4.6hr, multi = 2.4 hr
dilate: 4-7 cm
contractions q 2-5, 40-60s, mod-strong (50-70mmHg)
psych: increased anx, need E and focus, fear loss of control, decreased ability to cope, helplessness, support = greater satisfaction and less anx
stage 1: transition
nulli = 3hr, multi = <1hr
dilate: 8-10cm
contract q 1.5-2min, 60-90s, strong (70-90mmHg)
psych: withdraw into self, acutely aware of C intensity, doubt coping ability, apprehensive, restless, irritable, freq position change, scared of being alone, doesn’t want to talk or touch
stage 2
“pushing stage”
complete dilation and effacement -> birth
urge to push, crowning
nulli = up to 3hr, multi = <1 and avg 15 min
contractions q 1.5-2min, 60-90s, strong (70-100)
psych: relived pain is over, relived to push, control bc involved, frightened, fatigue
kangaroo care = skin to skin (temp, HR, bonding, increase oxytocin, breast stim)
stage 2: mechanism of labor
Every Darn Fool In Egypt Eats Raw Eggs
engagement (widest part of presenting part enters pelvis)->
descent (P of fluid, c, pushing effort, fetus extension, head moves down in pelvis) ->
flexion (head and chin to chest, so smaller diameter presents) ->
internal rotation (occiput transverse -> anterior, fetus turns to face spine) ->
extension (occiput -> face -> chin, head extends for delivery under pubic bone) ->
external rotation (head rotate to OT and shoulders align vertically with mom’s pelvis) ->
expulsion (birth, anterior shoulder delivers then posterior shoulder and rest of baby)
stage 3
birth -> placenta delivered
no longer than 30 min (hemorrhage and placenta retention)
oxytocin IV bolus after delivery of placenta to decreased blood loss
fundal massage to see of continues to be firm
S of placental separation: globular uterus rises in abd, gush or trickle of blood, increased protrusion of umbilical cord
placental delivery: dirty duncan (meaty) vs shiny schultze (chorion and amnion)
stage 4
placental -> up to 4 hrs after birth
vaginal delivery avg blood loss (250-500); c/s avg (<1000mL)
promote bonding
post anesthesia care: return of sensation, O2 sat
check fundus and vaginal bleeding and perineum q15 for first hour, tempt at beginning and ending of recovery, bladder fullness, fam involvement, breast feed, kangaroo care
physiologic readjust: thirst and hunger, bladder often hypotonic (I&O cath, bed pan, can displace uterus), uterus remains contracted (midline, btw symphysis pubis and umbilicus), shaking 1-2 hrs after birth (CNS response, fluid and heat loss - warm blanket)
laboring down
passive, letting baby drop before pushing
biparietal diameter
largest transverse diameter of fetal skull
Passage - determinants for possible vaginal birth
Pelvic inlet diameter, mid pelvis and outlet, curve of sacrum
