Intrapartum Flashcards
series of processes by which the fetus and other products of conception are expelled from the mother’s body
Labor
regular rhythmic tightening of uterine muscle. Has increment, acme, and decrement
Contraction
–thinning and shortening of the cervix, measured by percentage
Effacement
enlargement of the diameter of cervix, measured in centimeters
Dilation
descent of present part, measured in +/- numbers
- = baby is higher
+ = baby is below ischial spine
station
The 5 P’s in labor
- Power
- Passenger
- Passage
- Placenta
- Psyche
- uterine contractions (needs oxytocin)
* maternal pushing
Power
1st P
how fetus is oriented to mother’s spine •longitudinal–most common, parallel •transverse–at right angles to mother •oblique–somewhere in between
Lie
Passenger - 2nd P
fontanels allow for…
molding
how is the fetus flexed.
•Prefer chin on chest, arms and legs flexed toward body
Attitude
Passenger - 2nd P
fetal part that enters the pelvis first
•cephalic/vertex–head first
•breech – butt/feet first
•transverse–shoulder or side
Presentation
Passenger - 2nd P
buttocks with feet at shoulders
Can deliver this way
Frank Breech
buttocks with legs flexed upon abdomen
Complete breech
foot or feet presenting part
Footling
Breech causes placenta to be planted in lower uterus or it doesn’t perfuse well so…
Baby is not ready
how a reference point on presenting part is oriented within pelvis
•cephalic/vertex use occiput
•breech use sacrum
Position
ROA
Right Occiput Anterior
LSA
Left Sacrum Anterior
- Mother’s bony pelvis
* Soft tissue–cervix, vagina, perineum
Passage
3rd P
•Placement •Ability to sustain fetus during labor •At 40+ weeks it is wearing out and breaking down Towards end it doesn't produce much progesterone Should be in upper Posterior
Placenta
4th P
- Mother’s psychological response to labor process
- Coping skills
- Support system
- Expectations for labor
- Knowledge base
Psyche
5th P
- Braxton-Hicks contractions–occur throughout pregnancy but do not affect dilation of the cervix
- no progressive cervical dilation
- amniotic membranes usually intact
False Labor
After 4 cm you see ….
1 cm per hour
•Progressive dilation and effacement of cervix
•membranes may or may not be ruptured
•bloody show may be present (“mucous plug” from cervix that falls out when it gets bigger)
•uterine contractions are regular with intervals between shortening
and intensity increasing
Signs of True Labor
•Physical activity intensifies
•Mild sedation does not affect strength or pattern
•Pain/discomfort in abdomen and back
•Nausea and vomiting may occur in true labor
Morphine doesn’t work in true labor
What Effects Uterine Contractions in True Labor
•Bloody show–thick mucus mixed with pink or dark brown blood, may occur several days before labor begins
•Spontaneous rupture of membranes
•SROM
•must go to hospital even if no other signs of labor!
Infection can occur when it breaks
Signs of approaching Labor
- Risk for infection
- open pathway for microorganisms into uterus
- prophylactic IV antibiotics during labor if prolonged time of rupture
- Risk for prolapsed umbilical cord
- emergency C-section
- position mother to relieve pressure
SROM
settling of presenting part into pelvis
can breath easier since baby is dropping
Lightening
- Ruptured membranes
- Contractions strong and regular q 5-7 min for 1-2 hours for primips, q 10 min for 1 hour for multips
- Bleeding greater than bloody show
- Decreased fetal movement–no movement felt for > 2-3 hours
when to go to hospital
- Admission charting
- Fetal monitoring to check FHR and variability (FIRST THING - makes sure baby is stress free)
- Maternal Vital signs
- Vaginal exam–dilation, effacement, position. Nitrazine tape (will be blue if ruptured) for SROM•Review prenatal record
- Routine UA (look for nitrates, albumin)
- Complete blood count
- Blood type and antibody screen
- IV site established, IV fluids per orders
Do upon admission
- Descent–station
- Engagement
- Flexion
- Internal rotation
- Extension
- External rotation •Expulsion
Labor process
- “Stage of Dilation”
- onset of labor to full dilation
- Primiparas 8-10 hours •Multiparas 6-8 hours
First stage of labor
Latent phase
0-3 cm - lasts the longest
Active phase
4-7 cm - more rapid
transition phase
8-10 - short intense pain - must to be complete to push
- “Stage of expulsion”
- Complete dilation until birth of babe through vagina
- Primiparas 1 1/2 - 3 hours
- Multiparas 20-45 minutes
- Strong urge to push, may need guidance to push effectively
- Fetal head molds to pass through pelvis/vagina
- Crowning–head visible at perineum
Second Stage of Birth
•From the birth of the baby to expulsion of the placenta
•Approximately 5 -30 minutes
•Usually “shiny Schultze” (fetal side) side presents
•Manual exam with forceps by examiner to check for retained
placenta or tissue
•May give Oxytocin IV or IM to contract uterus, fundal massage or breastfeed
Third Stage of Labor
- Period of stabilization and recovery from birth process– 1-4 hours
- Uterus firm, grapefruit sized, at midline
- Chilling, involuntary shaking
- Perineal discomfort
- Important time for breastfeeding and bonding
Fourth stage of labor
- Monitor the fetal oxygen status - do kick counts
- Promote adequate fetal oxygen - if mom BP is low the uterus doesn’t perfuse well - turn to left side
- Take corrective action as needed
- Notify MD of fetal oxygenation problems
- Document
Nurse responsibilities for fetal monitoring
beginning of one contraction to the beginning of next
measuring the start of hills
frequency
beginning of end of one contraction to other
how long It lasts
duration
how strong contraction is, internal tocotransducer is the most accurate
•mild–uterus easily indented (tip of nose)
•moderate-uterus firm, indent slightly, (chin)
•strong- very firm, can’t indent, (forehead)
Intensity
- period of relaxation between contractions
- External – Palpation - soft •Document: Present or Absent
- IUPC – 5-25 mmHg
- Pressure of uterus should be
Resting Tone
4 things to look for contractions
- Frequency
- Duration
- Intensity
- Resting tone
- Need to evaluate in conjunction with contractions to determine pattern
- Baseline–rate between contractions, 110-160 bpm at full term
- Determine mean and round 0-5
Fetal heart patterns
Most effective labor pattern that allows baby to perfuse….
2-3 minutes apart
60-90 seconds duration
strong intensity with positive resting tones
irregular fluctuations in the baseline •Minimum 0-5 bpm (baby sleeping) •Moderate 6-25 bpm •Marked >25 bpm (mom had burst of energy and went to baby) want this so we know the baby has energy
Variability
rate increases 15 bpm for at least 15 seconds in a 10 min strip–Reassuring sign
Accelerations
bible verse 2
rate decreases from baseline
•early - need interventions
•variable - nursing judgment if ok
•late - never good
decelerations
rate decrease during contraction that returns to baseline by the end of contraction. Normal sign *caused by compression of head
head is being compressed
towards transition and when she’s pushing
early decels of decelerations
rate change begins and ends abruptly. V, W, or U shaped. Not always in conjunction with contraction. Indicates cord compression
vary in size, shape and frequency
*cause is cord compression
Variable decels of decelerations
resemble early but don’t return to baseline until after contraction ends
•Indicates not enough O2 to infant by placenta–uteroplacental insufficiency
late decels of decelerations
- Reposition mother to left side
- O2 per face mask
- Increase IV fluids
Intervention for fetal distress
bible verse 3
- Turn off Pitocin (if applicable)
- Notify the provider
- Document
intervention for fetal distress
bible verse 4
- Nitrazine paper - cobalt blue
- Ferning
- Pooling
SROM
artificial rupture of membranes (AROM) using sterile disposable Amnihook.
•Assess FHT
•Note time and condition of fluid
AROM
- Record color, odor, and amount of fluid
- green–meconium. Note if thick or watery (babies 1st stool)
- yellow, cloudy, foul odor–infection
- large quantity of fluid–at risk for prolapsed cord.
- Monitor FHR at least 10 minutes after ROM to detect prolapsed cord or compression
Amniotic fluid
take temp every 2 hours if elevated or ROM
Pulse, BP and respiration every 1 hour
fetal monitoring
- Vaginal exams check:
- effacement, dilation, station of fetus
- Check when contractions increase in frequency, intensity, woman’s behavior changes
- Always use sterile technique
Monitor labor progress
initiation of labor before it begins naturally
last longer
induction
stimulation of contractions after they have begun naturally (ROM, Pitocin)
augmentation
- Prostaglandin gel (Cervidil) or misoprostil (Cytotec) inserted vaginally to soften cervix.
- May induce labor by itself or be used with oxytocin
cervical ripening
- “Pit induction”–artificial stimulation of uterine contractions with IV oxytocin (Pitocin)
- Oxytocin diluted in IV solution and piggybacked into mainline IV. Always regulated with infusion pump
- Slowly increased until desired contraction pattern established
- Continuous EFM
types of oxytocin and augmentation
- Drugs are avoided during latent phase of labor–slow or stop labor
- Meds can cross placental barrier (if 8 cm, opioids cross placenta)
- Goal of pain meds is to reduce pain to tolerable level (doesn’t take away all pain)
- IV most frequent route
Pain meds - Analgesics
- Most commonly used
- Do not give if delivery in 1 hour or less
- Butorphanol (Stadol) - 1-2 hours, slows baby heartrate
- Fentanyl (Sublimaze) - 1 hour, respiratory depression
- Naloxone (Narcan) –antagonist
Narcotics in pregnancy
- Promethazine (Phenergan)–reduces N/V - makes fentanyl work better - cause drowsiness
- Diphenhydramine (Benadryl)–reduces itching
Adjunct Medications
numb specific area, but still feel pressure
Any meds that end in -caine
Local infiltration: injection of perineal area for epistomy before delivery or for repair
injection of pudendal nerves 10-20 mins before delivery, nubs lower 2/3 of vagina (saddle part that’s numb)
•Epidural block
– injection into epidural
space
• Blocks transmission of pain impulses to
brain
•No sedation of mother/fetus
•May affect ability to push
Regional Anesthetics
•Catheter and infusion pump to deliver continuous dose •may be used for c-section •Single dose of epidural opioids administered prior to removal of catheter can last 24 hours
Epidural
•Spinal Block --injection through lumbar interspace into subarachnoid space •Used for C -sections •Level of anesthesia from nipples to the feet
Regional Anesthetics (2)
•Not used for vaginal births
•Used for emergency C
-sections
C-section when epidural or intrathecal contraindicated or refused by woman
Use when you have 3 minutes to get baby out
General Anesthetic
- Does not harm mother and fetus
- Does not slow labor
- No risk of allergy or adverse reaction
- May not provide adequate pain relief when used alone
- Most methods need to be practiced before labor begins–education
Non-pharmacological pain management
•Relaxation - 1 job is to provide smooth environment •Skin stimulation a) effleurage - gate control theory b) sacral pressure c) thermal stimulation •Positioning •Mental stimulation A) focal point B) imagery C) music D) Meditation E) TV
Techniques for labor
perineal incision to enlarge vaginal opening •midline •mediolateral •lateral
episiotomy
tearing of perineal tissue
•Classified by how far it extend from the
vagina to the anus
1. 1st degree
—through the skin
2. 2nddegree–through the muscle
3. 3rd degree–extends into the rectal sphincter
4. 4th degree-extends through rectal sphincter
Laceration
instruments with curved blades that fit around the fetal head
•Pull on infant as mother pushes
•Use if woman is exhausted, pushing ineffectively
•Use if fetus in distress at end of labor
•May injure tissue
Forceps
used suction
applied to fetal scalp to pull as mother pushes
• Does not enter pelvic cavity like forceps
• Causes circular edema to infant’s scalp that subsides after birth
Vacuum extraction
surgical birth of fetus through incisions in the mother’s abdomen and uterus •32.2% of all deliveries (2014 CDC)
C-section
- Abnormal labor
- Cephalopelvic disproportion (CPD)– baby doesn’t fit
- PIH
- Previous c-section or uterine surgery
- Fetal compromise
- Placenta previa (its implanted in cervical opening or lower uterine segment) or abruptio placentae (pulling away so not good perfusion)
C-section indications
Types of C-Section
- planned (breech, repeat)
- Unplanned
- Emergency
- Low transverse or Pfannensteil–preferred, less chance of uterine rupture in next pregnancy
- Low vertical–allows delivery of larger fetus
- Classic– vertical, rarely used, higher incidence of rupture in subsequent pregnancy
Types of c-section incisions
•Emotional support– disappointment, guilt, anger,
anxiety
•Post-op vital signs
•Assess fundus and lochia - healing and not bleeding
•I & O –IV and Foley until next a.m.
•Dressing changes, assess incision
•Pain management – epidural or PCA
• Teach CDB cough and deep breath
•Encourage ambulation
Nursing care for c-section
•Meconium in amniotic fluid
•Fetal Heart Rate (FHR) decreasing below 110 bpm
between
contractions
•Large amount of bleeding from vagina more than 1 TBSP – Placental
shearing
•Maternal HR > 100bpm (sign of infection)
•increased temperature
•cardiac decompensation, circulatory alterations
•Maternal BP 20 mmHg above baseline
•Cord presents at or near vaginal outlet
•Contractions are > 90 seconds duration, > 2 minutes in frequency
•Irregular fetal or maternal heartrate
•Elevated maternal temperature
•Extreme maternal headache
– increased risk for seizures or stroke
•Failure to dilate in 24 hours
Danger signs in labor
•Difficult labor r/t fetus, uterine contractions, birth canal, maternal position during labor, placenta and
psychological responses of the mother
Dystocias of Labor
head delivered but shoulders stuck above
symphysis pubis – fractures
Shoulder dystocia
problems with fetus (passenger)
•Fetal anomalies -- hydrocephalus (too much fluid = big head) • Abnormal Presentation •breech •face or brow (emergency c) •Abnormal Positions •LOP or ROP -- face up, back labor •repositioning mother on hands/knees may rotate to OA •Multifetal pregnancy •Overdistention of uterus and ineffective contractions •Abnormal presentation of one or more fetuses Often delivered by C-section
passenger
- Contractions too weak
* usually diminish during active phase
Hypotonic labor dysfunction
•contractions are frequent, cramplike with poor coordination, very painful •occur during latent phase •Administer mild sedation to promote rest •Tocolytics reduce contractions -- Terbutaline (Brethine) •Hydrate
Hypertonic labor dysfunction
Causes increase in heartrate
If mom’s heart rate is high you cannot give it
Terbutaline (Brethine)
•Ineffective maternal pushing
•Weak abdominal wall
•allows uterus to rotate forward and
prevent fetus from aligning with birth canal
•put mother in upright position, abdominal
pressure
Power
- Contractures of the pelvic diameters
- congenital anomalies
- maternal malnutrition
- neoplasms - benign tumors
- lower spinal disorders
- young maternal age
Problems with birth canal (passage)
- Soft tissue dystocia
- Full bladder or rectum
- Placenta Previa (grows in lower uterus)
- Uterine fibroids
- Ovarian tumors
- Edematous cervix
Passage
- Abruption/Previa
- Infarcts - dead tissue=poor perfusion from smoking/drugs
- Postdate - older placenta
Problems with placenta
- Diabetes
- Hypertensive disorders
- Smoking
- Taking cocaine or other drugs
- Malnutrition
- Maternal age
- Multiple births
- Blood clotting disorders
- Trauma
- Prior placenta issue
conditions that cause Add to dictionary insufficiency
- Fetal Kick Count - 10 kicks per hour
- Fetal Movement
- Fetal Monitoring - look for contractions, baseline, variability
- Ultrasound - 20 weeks to check for amniotic fluid if it’s too much or little
- Post delivery assessment
placenta assessments
•Prolonged labor --> 24 hours •Can result in maternal and/or fetal infections •Exhaustion •Postpartum hemorrhage
abnormal labor
completed in less than 3 hours •Abrupt onset, quickly intensifies, frequent and intense contractions •Higher risk for injury to mother and fetus
Precipitous labor
- Occurs after 20 weeks and before 37 6/7 weeks
- Signs:
- contractions or cramping
- constant backache
- pelvic pressure
- change in vaginal discharge
- general ill feeling
duration of pre-term labor
- Bed-rest
- Hydration
- Tocolytics–Brethine, MgSO4 - muscle relaxant, only give in hospital so you can monitor because it causes respiratory labor and stops contractions
- Treat UTI if present
- Steroids given IM to mature fetal lungs
- betamethasone - cause production of surfactant- give to mom to give to baby
- dexamethasone
preterm labor treatment
