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Intrapartum Flashcards

1
Q

Definition of Intrapartal Period

A

From contractions that cause cervix to dilate, through delivery of neonate & placenta, +
first 1-4 hours after delivery

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2
Q

Theories of Labor Onset: Progesterone Deprivation Theory

A

Pregnancy: both estrogen and progesterone increased (from placenta), but ratio of
estrogen low: progesterone high
Estrogen stimulates, progesterone relaxes

Just before labor: ratio shifts

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3
Q

Theories of Labor Onset: Oxytocin Theory

A

Oxytocin stimulates uterine contractions, but uterus not sensitive until closer to term

Therefore, unlikely oxytocin works alone to cause labor onset

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4
Q

Theories of Labor Onset: Fetal Endocrine Control Theory

A

Anencephalic fetus: low levels fetal steroids; pregnancy prolonged
? if steroids cause release of precursors to prostaglandins, which stimulate uterus to
contract

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5
Q

Theories of Labor Onset: Prostaglandin Theory

A

Prostaglandins: lipid substances
Induce contractions at any point in pregnancy
Used for:
1. IUFD (intrauterine fetal demise); suppository form
2. Induced abortion; injectable form
3. Cervical ripening; gel, tampon ( Cervidil), tablet forms

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6
Q

Labor = Myometrial Activity

A

Feedback loop: stretching of cervix causes increase of oxytocin, which increases
myometrial activity
Fetus distends uterus: ? relationship

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7
Q

In true labor, uterus divides

A

Upper segment: active & contractile, thickens as labor progresses
Lower segment & cervix: passive, thins and expands as labor progresses

In between 2 areas: physiologic contraction band

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8
Q

lower segment transverse (LST) AKA lower cervical transverse (LCT)

A

If patient desires trial of labor after Cesarean (TOLAC) to attempt a vaginal birth after
Cesarean (VBAC), must have this uterine incision

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9
Q

Vertical Uterine Incisions

A

Higher risk of uterine rupture with labor
In upper segment (contractile)
Will have future repeat C/S

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10
Q

Effacement of Cervix

A

Taking-up of internal os and cervical canal into uterine sidewalls
Usually precedes dilatation in primigravidas
Express in percentage: 0% - 100%
Some subjectivity

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11
Q
A
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12
Q

Dilation of Cervix

A

Longitudinal muscle fibers of uterus pull upward over baby’s head
Combined with pressure from bag of waters (BOW)
Cervix dilation from 0 cm to 10 (“complete”, “fully”)

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13
Q

“Pushing”

A

Once completely dilated, woman pushes to expel fetus & placenta
Using intra-abdominal pressure
Must be “complete” or can bruise/tear cervix; exhaustion ensues

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14
Q

Pushing Causes Fetal Head to Descend to Pelvic Floor

A

Head meets perineal structure; pressure causes it to thin from 5 cm thick to 1 cm
Thin = less blood = natural physiologic anesthesia
Anus everts, exposing internal rectal wall

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15
Q

Premonitory Signs of Labor: Lightening

A
  1. Fetus settles into inlet (becomes “engaged”)
  2. Uterus seems to move downward (“dropped)
    Breathe easier
    More pelvic pressure
    More leg cramps/pain
    More venous stasis
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16
Q

Premonitory Signs of Labor: Braxton-Hicks Contractions

A

Irregular, intermittent contractions
Experienced throughout pregnancy
Pain in abdomen or groin
Can become uncomfortable
Purpose: cervical ripening

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17
Q

Premonitory Signs of Labor: Cervical Ripening

A

Ripe cervix: soft, anterior, slightly effaced and dilated
Non-pregnant: cervix feels like tip of nose
Pregnant: like lower lip
Ripe: like pudding
Ripening important re: induction decisions (unlikely to be successful if unripe)
Bishop Score: Cervical Ripening

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18
Q

Cervical Ripening Balloon

A

No drugs needed ( mechanical pressure)
Eliminates side effects
Silicone balloons adapt to cervical contour
Easily placed & removed ( foleys can be used)

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19
Q

Premonitory Signs of Labor: Bloody Show

A

Mucus plug expelled; exposed capillaries bleed
Consistency: bloody mucus
Watery bleeding NEVER normal
Labor usually begins 24-48 hours
Confusion if recent vaginal exam

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20
Q

Premonitory Signs of Labor: ROM (Rupture of Membranes)

A
  1. SROM: Spontaneous Rupture of Membranes
  2. AROM: Artificial Rupture of Membranes, via amniotomy
    Most common L & D procedure
    No pain endings in BOW (bag of water)
    Additional terms:
  3. PROM: Premature Rupture of Membranes;
    >1 hour from ROM to labor onset
  4. PPROM: Preterm, Premature Rupture of Membranes
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21
Q

Prolonged ROM

A

anytime ROM >24 hours; increased risk of ascending infection
Chorioamnionitis: infected BOW; fever, tenderness, foul-smelling & cloudy amniotic
fluid

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22
Q

Sterile Speculum exam:

A

to check if BOW broke

rests ½ hour
Pooling, nitrazine, ferning

Normal fluid: clear, bloody streaks; not meconium-stained or port wine color

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23
Q

Umbilical Cord Prolapse

A

Major OB emergency
R/O: after ROM, check FHTs; if low, suspect prolapse
Glove hand, insert into vagina, push upward; place patient in Trendelenburg or hands &
knees (relieve pressure on cord)

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24
Q

Premonitory Signs of Labor: “Nesting Instinct”

A

Sudden burst of energy
24 – 48 hours prior to labor
Cause unknown
Woman “feathers her nest”
Warn not to over-exert

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25
Premonitory Signs of Labor: “Other”
1. Weight loss of 1-3 # Fluid & electrolyte shifts “progesterone deprivation theory” 2. More backache & sacroiliac pressure Relaxin influencing pelvis 3. N/V, diarrhea More room in pelvis Clear liquid absorption unchanged; may vomit solids (aspiration risk)
26
True Labor
1. Cervix progressively effaces/dilates 2. Contractions regular, become closer, longer, stronger over time 3. Pain begins in back, radiates to abdomen 4. Ambulation intensifies
27
False Labor
1. No progressive effacement/dilation 2. Contractions irregular, do not become closer, longer, stronger 3. Pain chiefly lower abdomen or groin 4. Ambulation relieves
28
Stages of Labor & Birth
1. First Stage - True labor until 10 centimeters dilation 2. Second Stage - Complete dilation thru birth of neonate 3. Third Stage - Birth of neonate thru birth of placenta 4. Fourth Stage - First 1-4 hours after delivery
29
Critical Factors in Labor: The 5 P’s (traditional)
1. Passageway (pelvis) 2. Passenger (fetus) 3. Powers (contractions) 4. Psyche (mental status of the woman) 5. Position (…of the woman)
30
Additional Critical Factors
Philosophy (low tech, high touch) Partners (support persons) Patience (respect for the natural timing of birth) Patient Preparation (knowledge base) Pain Management (comfort care)
31
Passageway: Pelvis
True pelvis: bony birth canal; must be adequate size, shape False pelvis: nothing to do with OB; holds up abdominal contents 3 planes Inlet (linea terminalis) Midpelvis (ischial spines) Outlet (ischial tuberosities)
32
1933, Caldwell-Malloy Pelvic Types: Inlet Shape
1. Gynecoid: “female” pelvis, 50% women; all diameters adequate for birth  2. Android: “male” pelvis, 20% women; OP (occiput posterior), long labors, C/S  3. Anthropoid: OP, but usually adequate; long AP diameter compensates  4. Platypelloid: flat pelvis, rare, inadequate for birth
33
Getting an OP to Rotate to OA
``` Occiput Posterior (OP) sunny side up Occiput Anterior (OA) ``` ## Footnote 1. Hands+knees 2. Lunging
34
Gynecoid pelvis measurments
1. Inlet Clinical Pelvimetry: measure diagonal conjugate (11.5 cm) 2. Midpelvis Clinical Pelvimetry: ischial spines blunt, pelvic sidewalls straight, sacrum hollow (curved), coccyx freely-movable 3. Outlet Bi-ischial diameter: 8 cm or \> Pubic arch: at least 90 degrees
35
Passenger (Fetus)
1. Must fit through bony pelvis Most are head-first Largest part Least compressible If head delivers, delivery of body rarely delayed ## Footnote Fetal head molds to accommodate pelvis Diameters of Fetal Skull: 1. Biparietal Diameter (BPD) 2. Suboccipitobregmatic Diameter Vertex: Most Common Suboccipitobregmatic diameter presents to pelvis Head well-flexed; chin onto chest
36
Fetal Lie
Relationship of fetus to long axis of mother Normal lie: longitudinal Fetus’ long axis in line with mother’s long axis Abnormal lies: transverse & oblique Oblique is unstable
37
Fetal Attitude
Refers to posturing of joints & relation of fetal parts to one another Normal attitude: flexion Deflexed = larger diameters of fetus meet pelvis
38
Fetal Presentation: “Presenting Part”
Part of fetus closest to internal os At term: Cephalic (head), 96-97% Breech (buttocks), about 3% Arm or shoulder, \<1% Transverse lie
39
Risks: Vaginal Breech Delivery
Few trained in methods After-coming head **Increased risk hypoxic events/cerebral palsy** Increased risk umbilical cord prolapse Preemie breech should never be delivered vaginally
40
Compound Presentation:
More than 1 part presenting, i.e. baby’s hand on top of head Larger diameter to fit through pelvis
41
Malpresentation:
Anything other than cephalic presentation Can lead to difficult labor & birth \*ECV External Cephalic Version
42
Relationship of Fetus to Pelvis
1. Engagement: widest diameter of presenting part reaches or passes through inlet Confirms adequacy of inlet 2 weeks before term in primigravida Can happen before or during labor in multipara 2. Station: relationship of head to ischial spines Confirms adequacy of midpelvic plane
43
Forceps/Vacuum Extraction
Can only be done if fetus descends to “0” station Otherwise, C/S Mother must be completely dilated
44
Forceps/Vacuum Extraction Reasons
Fetal distress #1 reason Maternal exhaustion Maternal cardiac disease Poor pushing (epidural)/prolonged 2nd stage
45
Forceps
MD only Open or closed blades Different types Preemies Breeches Term vertex Usually with vaginal delivery, but also C/S Pulling sensation; good anesthesia needed More room; episiotomy needed Like big “spoons”: 2 curves 1 fits around head Other conforms to shape of pelvis/birth canal Must know landmarks to avoid injury to baby Mother still pushes Gentle traction Deliver head to perineum or fully deliver
46
Vacuum Extraction Delivery
CNMs can also perform Same reasons & usage as forceps, but less precise landmarks Must use safe amount of suction
47
LOA - left occiput anterior - most common
48
LOT - left occiput transverse
49
LOP - left occiput posterior
50
ROA - right occiput anterior
51
ROT - right occiput transverse
52
ROP - right occiput posterior
53
The Powers (Contractions)
Intermittent shortening of muscle Propel fetus through birth canal Involuntary; action independent of mother’s will & extrauterine nervous control Phases of Contraction - increment, acme, decrement
54
Dystocia
“dys-” = difficult or painful “-tocia” = birth Abnormal labor patterns can lead to dystocia Hypertonic: uterus doesn’t relax sufficiently between contractions Hypotonic: uterus doesn’t contract strongly enough to be effective Friedman Labor Curves: Ideal Labor Friedman Labor Curve: Effect of Station
55
Catecholamines
Stress hormones; released in response to anxiety & fear Constrict blood vessels, including those to uterus Uterine muscle anoxic, causing pain (#2 cause of pain in labor) High catecholamine levels block release of oxytocin and may prolong labor
56
Endorphins
Morphine-like substances; come from pituitary gland & brain Laboring women have higher levels than non-pregnant Relaxation, touch, massage, activity can raise levels **Goal: minimize catecholamines, maximize endorphins** Decrease anxiety, use comfort measures, walk
57
Position (…of the woman)
Primary consideration: don’t lie on back in labor Vena cava compression worse in labor If cardiac output falls, can’t perfuse uteroplacental unit Alternate positions frequently; use upright & lateral positions Contractions more intense, but not more painful Fetal head descends quicker (gravity) Labor may be shorter Fetal diameters correspond better to pelvic diameters
58
First stage - Latent Phase (early labor)
Onset of regular contractions until 3 cm Nullipara: 8.6 hours, no **\>20 hours** Multipara: 5.3 hours, no **\>14 hours** Contractions: every 10-20 minutes x 15-20 seconds, mild---become every **5-7 minutes x 30-40 seconds, moderate** Average 40 mm Hg; resting tone 10 mm Hg Good time to review CB preparation
59
Latent Phase - Pain control
Gate control theory of pain relief: Stimulate peripheral nerves, message of pain can’t reach brain Examples: TENS units, effleurage, distraction, relaxation techniques, massage Alternative Pain Relief Aromatherapy Hydrotherapy Massage
60
Latent Phase - Breathing patterns:
_rhythmic chest breathing_ Slow rate 8/min Modified rate 16-20/min
61
Latent Phase - Nursing care
Time contractions Support efforts Monitor breathing/relaxation Conserve energy (many are excited, talkative) Clear fluids/empty bladder every 2 hours
62
Latent Phase - vitals
Maternal VS hourly, except T every 4 hours If ROM, T hourly with pulse FHT auscultation Hourly if low-risk  ½-hourly if high-risk Note fetal activity Note uterine contraction pattern every ½ hour Labor pain: #1 cause is cervical changes
63
Medications in Latent Phase
Labor not well-established Narcotics/epidurals can slow labor down Can’t give po meds Options: 1. **Vistaril 50 mg IM (sedative) 2. Inhalation analgesia (nitrous oxide)**
64
Active Phase (accelerated phase)
Labor well-established Dilates from 4-7 cm Nullipara dilates 1.2 cm/hr Multipara dilates 1.5 cm/hr Descent is progressive Contractions: every 2-3 minutes x 60 seconds, strong If ROM, increase in strength
65
Active Phase Breathing
Breathing patterns: combined, rhythmic chest or shallow (“he-he-hoo”) “count down” contractions Remind her that labor is intermittent
66
Active Phase - nursing care
1. Mouth care 2. Stroke arms and legs 3. Encourage efforts 4. Intake/output; full bladder impedes descent
67
Active Phase Medications:
Labor well-established, so unlikely to diminish Narcotics “take the edge off” pain: Nubain (nalbuphene) 10 mg IM or IV every 3-6 hours Inhalation anesthesia Nitrous oxide Regional anesthesia Epidural most common  60-80% in major city hospitals
68
Epidural Anesthesia: The Good
Relief of labor pain Allows for rest Decreases catecholamines Can be awake if C/S Partner may prefer this method
69
Epidural Anesthesia: The Bad, part 1
#1: ↓ BP due to peripheral vasodilation Inadvertent spinal + possible headache Immobility, unless “walking epidural” May ↓ contractions → more pitocin May ↑ length of 2nd stage → forceps/vacuum ? ↑ OP babies, ? ↑ C/S
70
Epidural Anesthesia: The Bad, part 2
Unable to void; may need catheter “Spotty” blocks Mild itching May ↓ neonate’s ability to breastfeed Maternal fever → blood cultures/antibiotics in neonate
71
Epidural Anesthesia: The Ugly (Contraindications)
Bleeding disorders/anticoagulants Mother low volume (PIH) Thrombocytopenia Infections near site (i.e., herpes)
72
Other Regional Anesthetics
Spinal Injected inside dura Uses less medicine & works faster than epidural More likely than epidural to decrease BP Used for C/S, not labor Pudendal Local anesthetic injected into pudendal nerve, near ischial spine Usually given 2nd stage Relieves pain around vagina/rectum Good for forceps, prolonged repairs Paracervical Local anesthetic injected into the cervix, during labor Can cause FHT to drop Could accidentally inject fetus
73
Active Phase - vitals
Check maternal VS hourly; T every 4 hours, unless ROM (hourly, with pulse) Check FHT every 30 minutes in low-risk; every 15 minutes high-risk Note uterine contraction pattern every 30 minutes
74
Transition Phase
Patient dilates from 8-10 cm Contractions strong and close together: every 1 ½ - 2 minutes, lasting 60 seconds or more Short phase Nullipara: no \>2 hours Multipara: no \>1 hour Descent progressive Nullipara: 1 cm/hour Multipara: 2 cm/hour
75
Transition Phase - breathing and nursing care
Breathing patterns: pant-blow during contractions & rhythmic chest breathing in-between Head descends; urge to push Patient irritable, discouraged, over-whelmed Give specific instructions Remind her that baby is almost here Encourage her Remain with her
76
Transition Phase - special considerations
Physical sensations: N/V, belching, chills, trembling, sweating, difficulty relaxing Special considerations: Hyperventilation: tingling, dizzy, light-headed Rebreathe exhaled air between contractions Back labor: small of back, difficult to relax, increase in tension Warm or cold compresses Counterpressure to small of back Increase in bloody show
77
Transition Phase - Vitals
Check maternal VS every 30 minutes Check FHT every 30 minutes low-risk; every 15 minutes high-risk
78
Second Stage of Labor
Nullipara: 48-174 minutes, 66 average Multipara: 6-66 minutes, 24 average “precip. packs” Prolonged second stage = \>2 hours Pushing sensation: pressure of fetal head on sacral & obturator nerves Woman feels relieved; birth near & actively involved Some fight pushing; fear, loss of control
79
Second Stage of Labor Coach efforts:
**open glottis pushing** Physical sensations: vaginal fullness, rectal pressure, burning, stretching Instruct to stop pushing at birth of head; use pant-blow
80
Second Stage of Labor- Vitals
Check maternal VS every 15 minutes Check FHT every 5-15 minutes (most RNs check after each contraction) Check delivery equipment; O2, suction, Code Pink Team/Code Pink Box, turn on warmer
81
Second Stage: Crowning
Ring of fire ; episiotomy performed
82
Cardinal Movements (Mechanisms) of Labor
1. Engagement 2. Descent 3. Flexion 4. Internal rotation 5. Extension 6. External rotation/restitution 7. External rotation/shoulder rotation 8. Expulsion
83
Extension (4., 5.):
: head meets resistance of pelvic floor + mechanical movement of vulva anterior & forward; head passes under pubic bone & occiput, then brow, then face emerge
84
External rotation/restitution (6.):
head rotates 45 degrees
85
External rotation/shoulder rotation (7.):
head rotates additional 45 degrees; head & shoulders lined up
86
Expulsion (7., 8.): anterior shoulder
meets underside of pubic symphysis & slips under it; delivery attendant lifts baby up & posterior shoulder born; body flexes laterally
87
Third Stage of Labor
Baby born, uterus contracts: less surface for placental attachment, hematoma forms between placenta & decidua Signs of separation usually 5 minutes after birth; 30 minutes or \> = retained placenta Globular shape to uterus Fundus rises Gush of blood Amount of cord lengthens
88
Third Stage of Labor - placenta delivery
Patient bears down; attendant aids with gentle traction  Always check to see if placenta complete \> 30 min - manual removal of placenta
89
Fourth Stage of Labor
1-4 hours after delivery BP returns to prelabor level Pulse slightly lower than labor FF @ U or below, midline No evidence of PPH Variation in emotional state Hungry, thirsty, shaking chills, hypotonic bladder
90
Interview/Risk Assessment
Why in L & D: labor? EDC? Contracting: when began? Pain? Fluid leakage or bleeding? Problems during pregnancy? Medical problems? Any surgeries? Recent exposure to illness ? Problems during pregnancy? Medical problems? Any surgeries? Recent exposure to illness? Take any medications? Allergies to meds.? Baby moving normally? Last ate and drank?
91
Admission Care - VS
Get VS Elevated BP suggests pre-eclampsia Elevated T suggests infection Pulse \>100 suggests hypovolemia Urine Dipstick 1+ proteinuria or \> suggests pre-eclampsia 1-2+ glycosuria or \> suggests diabetes CBC, Type & Screen Leopold’s Maneuvers Check FHT/place external monitors
92
Admission Care
Time frequency/duration of contractions Check fundus for strength of contractions If likely ROM, Nitrazine & prepare ferning slide Some settings: check cervical dilation & effacement Start IV or place heplock
93
EFM in Low-Risk Women
* *\>85% low-risk have EFM** 1. Does not decrease # perinatal deaths 2. Does not decrease # with CP 3. Does not decrease # admitted to NICU * *Continuous monitoring** 1. Increases risk of Vacuum or forceps delivery 2. Increases risk of C/S 3. Increases risk of infection
94
External monitoring (indirect)
2 belts Tocodynanometer (“toco”); placed over fundus, picks up contractions Ultrasound transducer; placed over baby’s chest or back, opening/closing of valves of heart read as FHTs More subject to artifact Can use on anyone
95
Internal Monitoring (direct)
2 types, placed inside uterus; must have ROM & be dilated at least 2 cm **IUPC:** intrauterine pressure catheter; goes between fetus’ head & wall of uterus, squeezed during contractions, transducer picks up strength in mm Hg **FSE**: fetal scalp electrode; internal spiral electrode, attaches to fetus’ head & picks up electrical activity of heart, reads it as FHT Less subject to artifact
96
Basics of EFM: “Dr. C. Bravado”
1. Determine Risk 2. Contractions 3. Baseline 4. Rate 5. And 6. Variability 7. Accelerations (periodic change of FHR) 8. Decelerations (periodic change of FHR) Early Late Variable 9. Overall impression
97
Determine Risk
Interpret tracing within context of clinical circumstances Patterns change over time; regular re-evaluation needed
98
Contractions
# in 10 minute period averaged over 30 minute period **_Normal \< or = 5/10 minutes_** **Tachysystole** \> 5/10 minutes Duration, intensity, rest between also important
99
Baseline Rate
Mean FHR rounded to increments of 5 bpm over 10 minutes, excluding accelerations, decelerations, marked variability **Bradycardia: baseline \< 110 bpm Tachycardia: baseline \> 160 bpm**
100
Baseline Bradycardia
Baseline \<110 **#1 cause: fetal hypoxia** Other causes uncommon: congenital heart block, maternal use of beta blockers
101
Baseline Tachycardia
Baseline \>160 **#1 cause: maternal/fetal fever** Other causes: infection, fetal hypoxia, tocolytic drugs (Terbutaline)
102
Variability
Baseline fluctuations, irregular in amplitude & frequency Peak-to-trough in bpm, seen over 10 minutes Parasympathetic/sympathetic nervous system
103
Categories of Variability
Absent: amplitude range undetected Minimal: range \< 5 bpm use **_Moderate: range 6-25 bpm_** Marked: range \> 25 bpm
104

Nursing - OB (9 decks)

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