Intrapartum Flashcards
Contractions are
coordinated and involuntary
- organized, increase frequency and intensity as term closes in
The power of the contractions comes from
top of the uterus (fundus)
Cervical changes in labor
Effacement
Dilation
Effacement
thinning and shortening of the cervix
- estimated as % of original cervical length
Dilation
opening expressed in cm
- pulled up and fetus is pushed down
At 10 cm, the cervix is _________ felt by examiners
not
Nullipara cervical changes
efface early in cervical dilation
Multipara cervical dilation
cervix is thicker at all points of labor
Cardiovascular during contractions
fondus muscles constrict on spiral arteries supplying placenta
- temp shunts 300-500 mL OF BLOOD back to mom
VS are best assessed during what in labor
interval between contractions
If the pregnant mother lays on her back it can cause
supine hypotension
Respiratory system changes of labor
depth and RR increase
-Hyperventilation
If the laboring mother is experiencing hyperventilation, what should the nurse instruct
May feel tingling of her hands and feet and numbness and dizziness
Nurse should help slow breathing through relaxation techniques
Breathe into paper bag or into cupped hands
GI system changes of labor
mobility decrease - N/V and constipation
need calories but NPO
Urinary system changes of labor
reduce sensation of a full bladder
- inhibit fetal descent
- bladder status evaluated throughput labor for distension
Hematopoietic system changes of labor
blood loss vaginal birth = 500, Csection 1000mL
CLOTTING FACTORS ELEVATED
- DVT risk in postpartum
Anything over
Vgainal 500 mL
Csection 1000 mL
of blood loss indicates
hemorrhage
Placental circulation
Placental exchange occurs during the interval between contractions
Exchange of oxygen, nutrients, and waste products occur in the intervillous spaces
Fetal Cardiac system in labor
Rate or rhythm change may result from normal labor or suggest intolerance to labor stress
Fetal Pulmonic system in labor
lungs fluid to allow normal airway development which decrease near term
Compression of the fetal thorax at birth clears lung fluid for normal breathing after delivery
- surfactant and amniotic fluid - keep lungs lubed
What are the 4 components of birth?
Power - contractions and pushing effort
Passage - pelvis and soft tissue
Passenger - fetus
Psyche - response to labor influenced by anxiety, culture, expectations, experiences, and support
The Four P’s = Powers
Uterine contractions
- The primary force that moves the fetus through the maternal pelvis
Maternal pushing efforts
- 2nd stage of labor: contractions continue to propel the fetus through the pelvis
- Ferguson Reflex
- Crowning
Ferguson reflex
Fetus distends vagina and puts pressure on rectum
Woman feels an urge to push and bear down
The Four P’s = Passage
True pelvis - inlet for fetus to pass through
- Bones and joints do not readily yield to forces of labor
- Relaxin softens cartilage linking pelvic bones near term
Cervix and vagina
Most favorable pelvis types
Gynecoid: Most common; found in 50% of women; round shape big diameter
Anthropoid: Resembles pelvis of anthropoid apes; found in 24% of women; oval shape
Least favorable pelvis types
Android: Resembles the male pelvis; found in 23% of women; heart-shaped
Platypelloid: Flat pelvis; found in 3% of women; Flat shape
The Four P’s = Passenger
Fetal Head: bones, sutures, and fontanels
- molding and assists in fetal position
Head Diameters
Fetal lie
Fetal Attitude
Presentation
Fetal lie is
orientation of the long axis of the fetus to long axis of the woman
- longitudinal, transverse, oblique, breech
Longitudinal lie
cephalic or breech
Transverse lie
perpendicular
Oblique lie
slanted
Fetal Attitude
relationship of the fetal part to one another
- positioning of the head
Tuck head to chest or extending head to the back
Flexion
good
- smallest diameter part to move though the pelvis
Tucks the head to chest
Extension
head sticks out with posterior to the back
bad - can cause neck snap if birthed
Fetal Presentation
fetal part first entering the pelvis is the presenting part
- Cephalic (vertex, military, brow, face)
swelling of the face and difficulty passing
Frank breech
fetus legs are folded flat up next to head
- bottom the closest to birth canal
Complete breech
fetus butt is downward
- both hips and knees are flexed
Footling breech
the foot is the 1st thing out and moving
- also prolapsed cord possible
Compound presentation
the hand is on top of the head with both entering the pelvis at the same time
Shoulder presentation
malpresentation when the fetus is in transverse lie
- leading part of seen is the arm/shoulder/chest
The Four P’s = Passenger
Fetal Positioning
relationship of point of reference (landmark on the fetus) on the presenting part (vertex, face,breech, shoulder) to the mom’s pelvis
Fetal Positioning
Right or Left
[resenting part pointing to mom’s right or left
Fetal Positioning
Occiput or Sacrum
what part coming out 1st
Fetal Positioning
Anterior, Posterior, or Transverse
presenting part (occipital bone or sacrum) pointing
- toward the front of mom’s body (anterior)
- mom’s sacrum (posterior)
- towards hip (transverse)
Cardinal Movements of Labor can cause the fetal position
chnage during labor as the fetus moves downward and adapts to the pelvis contours
Where would you put the fetal heart monitor if the fetus is facing the Right occiput posterior?
RLQ
Where would you put the fetal heart monitor if the fetus is facing the left occiput posterior?
LLQ
With antroior and posterior positioning, how do you know what to label them?
where the occipital bone is located
OP positioning causes
back pain
Pregnant Anxiety
- decrease ability to cope with labor pain
release catecholamines - inhibit uterine contractions and placenta blood flow - enhance perception of pain
The Four P’s = Psyche
- Anxiety
- Culture and Expectations (language, support, symbols, practices, and norms and restrictions
- Experience
- Support
Support in labor
positive effects (physical comfort, advocate, praise, reassure, and presence)
maintain calm and comfortable environment
Nurse’s Role in Intrapartum
Advocate for the laboring woman and her support person
Increase their sense of control and mastery of labor
Reduces anxiety and fear
Achieve their desired birth
Factors to causing labor
Changes in ratio of maternal estrogen to progesterone
Fetal membranes release prostaglandin
Prostaglandins prepare uterus for oxytocin stimulation
Increased secretion of natural oxytocin
Oxytocin receptors in the uterus increase markedly
Large quantities of cortisol released by fetal adrenal glands
Stretching, pressure and irritation of the uterus and cervix
Premonitory/Prodromal Signs of Labor
Braxton Hicks contractions
Lightening (easier breathing and baby on bladder)
Increased vaginal mucous secretions
Cervical softening and slight effacement
Bloody show or loss of “mucous plug”
Energy Spurt or “Nesting instinct”
Weight Loss (slight)
Diarrhea, nausea
True Labor contractions
Consistent increase in frequency, duration, and intensity
Increase in frequency/intensity with walking
Starts in the lower back and moves around to the lower abdomen
True Labor discomfort
May persist as back pain in some women
Increasing intensity and pain
True Labor cervix
Progressive effacement and dilation (most important factor)
False Labor contractions
Inconsistent in frequency, duration and intensity
Decrease in frequency/intensity with walking
False Labor discomfort
Localized in abdomen
More annoying than truly painful
False Labor cervix
No significant change effacement or dilation
When should a patient go to the hospital or birth center?
Contractions (Nullipara = 5 minutes apart; Multipara = 10 minutes apart)
Ruptured membranes
Bright red vaginal bleeding immediately
Low or no fetal mvmt
Concerns
A patient SHOULD go to the hospital or birth center if they have these concerns?
severe pain, vision changes, headache, epigastric pain, feeling “something not right”
Labor Mechanisms
Descent of the fetal presenting part through the true pelvis
Fetal station
Engagement
Fetal station
descent of the fetal presenting part to ischial spines
Engagement is what station
0, widest part of the fetal presenting part reaches the level of the aternal ischial spines
Cardinal MVMT of Labor Steps
Descent
Engagement
Flexion
Internal rotation
Extension
External rotation
Expulsion
1st Stage of Labor is what phase
latent
1st Stage of Labor is the only stage with
phases
1st Stage of Labor begins with __________ and ends with
onset of truelabor
complete dilation of the cervix
1st Stage of Labor is when what occurs in cardinal mvmt
cervical dilation and effacement
- expanding of the cervix (10 cm)
- station 0
What are the 3 phases of 1st stage of labor?
Latent
Active
Transition
Latent Phase dilates to
1-3 cm
Latent Phase Mother’s attitude
pass unnoticed
sociable and excited
Latent Phase contractions
5 minutes apart with gradual intensity
Latent Phase average dilation
Primi
Multi
primigravida 1.2 cm/hr., Multipara 1.5 cm/hr.
Prolonged Latent phase
primigravida > 20 hrs., multipara > 14 hrs.
Active Phase starts at
4 cm and accelerates to 7 cm
Active Phase is when cardinal mvmt starts
internal rotation
Active Phase contractions
2-5 minutes apart
last 40-60 seconds
- moderate intensity
Active Phase Mothers attitude
discomfort increases
increasing anxiety
sense of helplessness
inwardly focused
Transition Phase starts at
8 and continues to 10 cm
Transition Phase cardinal mvmts
descends further into pelvis
- bloody show increases
Transition Phase contractions
very strong
1.5-2 minutes apart last 60-90 seconds
Transition Phase may feel what reflex?
Ferguson - urge to push and bear down
Transition Phase may have the mothers experience what else
leg tremors
N/V
Transition Phase ATTITUDE
irritable and lose control
easily discouraged, overwhelmed, and panicky
“can’t continue”
actions are not helping anymore
2nd Stage of Labor is the
stage of expulsion
2nd Stage of Labor starts with ________ and ends with
Begins with complete dilation (10cm) and 100% effacement and ends with birth of baby
2nd Stage of Labor can last how long?
Primigravida is 1 hour and the Multipara is 15 minutes
Allow a labor down if
epidural
8-10 cm
-1 station
2nd Stage of Labor
Ferguson’s Reflex signs
May feel need to have a bowel movement or say “the baby is coming” or “I have to push”
Voluntary pushing efforts augment involuntary contractions
Vulva distends as fetus descends into pelvis
Crowning of fetal head, may cause a stretching or splitting sensation
Allow to “labor down”
Woman often regains a feeling of control
Episiotomy
incision in perineum made to provide more space for presenting part
Mediolateral episiotomy is used for
large infants
Episiotomy Indications
Shoulder dystocia
Face presentation
Breech delivery
Macrosomic fetus
Vacuum or forceps-assisted births
Episiotomy Risk
Infection
Perineal pain
- they can still tear
Laceration
tears in the perineum occurring at delivery
1st degree laceration
perineal skin and vaginal mucous membrane
2nd degree laceration
skin, mucous membrane, and fascia of the perineal body
3rd degree laceration
skin, mucous membrane, muscle of the perineal body, and extends to rectal sphincter
4th degree laceration
extends into rectal mucosa exposing the lumen of rectum
3rd stage of Labor start with ______ and end with
Begins with birth of baby and ends with expulsion of placenta
How long does the 3rd stage of labor last?
of 5-15 minutes
Signs of placental separation
Uterus rises in abdomen as placenta descends into vagina and pushes fundus upward
Cord descends (lengthens) from the vagina
Gush of blood appears from vagina as blood trapped behind placenta is released
How does the uterus prevent a hemorrhage
contract firmly to compress open vessels
Nursing Interventions for preventing a hemorrhage after expulsion of the fundus
Massage the fundus!
Administer uterotonic medications
If the placenta has not dropped after minutes the physician will
grab it out
If the uterus does not clamp down, what could occur?
postpartum hemorrhage
What are the 2 ways placentas are described when delivered?
Shiny Shultze (fetal side iwth membranes and cord)
Dirty Duncan (maternal with spiral arteries)
Uterotonic Medications
Oxytocin
Methylergonovine
Carboprost Tromethamine
Misoprostol
What is the 1st choice of uterotonic medications?
Oxytocin
Methylergonovine is used for
IV emergency only
CONTRAINDICATED for Hypertensive pts
Carboprost Tromethamine will cause
massive diarrhea
Carboprost Tromethamine CONTRAINDICATED in
asthma pts