Intrapartum Assessment and Interventions Flashcards
intrapartum period
begins with the onset of regular uterine contractions (UCs) and lasts until the expulsion of the placenta.
Labor triggers
inflammatory process
genetic component
and or biomarkers in cervicovaginal fluid
Maternal factors to labor
●Uterine muscles are stretched-release of prostaglandins and oxytocin that stimulate contractions
●pressure on cervix stimulates release of oxytocin which causes contractions
● progesterone withdrawn, estrogen stimulates contractions
● Oxytocin stimulates myometrial contractions.
Fetal factors labor
●placenta deteriorates, triggering contractions
● Prostaglandin synthesis and the decider stimulates contractions
● Fetal cortisol reduces progestrogen
progesterone
quiets uterine
Lightening
descent of the fetus into the true pelvis approximately 2 weeks before term in first-time pregnancies
Braxton-Hicks
These contractions are irregular UCs that do not result in cervical change and are associated with “false labor.”
bloody show
brownish or blood-tinged cervical mucus discharge
Cervical changes
The cervix ripens, becomes soft, and may become partially effaced and begin to dilate. The woman may lose her mucous plug or have a change in discharge.
Nesting
a burst of energy or feel the need to put everything in order, which is sometimes referred to as nesting.
Less common signs of labor
1- to 3-pound weight loss and others experience diarrhea, nausea, or indigestion
Five Ps affecting labor
● Powers (the contractions)
● Passage (the pelvis and birth canal)
● Passenger (the fetus)
● Psyche (the response of the woman)
● Position (maternal postures and physical positions to facilitate labor)
Powers- contractions
involuntary UCs of labor and the voluntary pushing or bearing-down powers that combine to propel and deliver the fetus and placenta from the uterus
Leopolds maneuver
systematic way to determine the position of a fetus inside the woman’s uterus
True labor
- Pain from lower back and radiates to abdomen
- Regular contractions, intensity increases
- True signs of labor- cervical dilation
lochia rubra
is the first discharge after birth Composed of blood, shreds of fetal membranes, decidua, vernix caseosa, lanugo and membranes
Hemorrhage after labor- nursing actions
massage
have her get up if she can
straight cath if she can’t get up
Low Fluid signs
low bp
high pulse
high resp
primary causes of postpartum hemorrhage
Tone- uterine atony
Tissue- placenta problems
Trauma- rupture
Thrombin- coagulation problems
Uterine contractions
resting phase or uterine relaxation period that allows the woman and uterine muscle a pause for rest
causes dilation of cervix until 10cm
contraction phases
increment
acme
decrement
Dilation and effacement
during the first stage of labor when UCs push the presenting part of the fetus toward the cervix, causing it to open and thin out as the musculofibrous tissue of the cervix is drawn upwards
Effacement
shortening and thinning of the cervix
before dilation in first pregnancy, at the same time with following
Bearing-down powers
once the cervix is fully dilated (10 cm), and the woman feels the urge to push; she will involuntarily bear down
Ferguson reflex
The urge to push
stretching of uterus and cervix pressure causes oxytocin to release causes contractions
passage
bony pelvis and the soft tissues of the cervix, pelvic floor, vagina, and introitus (external opening to the vagina)
passenger
fetus
Molding
ability of the fetal head to change shape to accommodate/fit through the maternal pelvis
Fetal attitude or posture
relationship of fetal parts to one another, noted by the flexion or extension of the fetal joints
Fetal lie
long axis (spine) of the fetus in relationship to the long axis (spine) of the woman.
Cephalic
head first)
Breech
pelvis first
presenting part
specific fetal structure lying nearest to the cervix.
Cephalic presentations
The presenting part is the head
Vertex/brow presentation
chin up
face presentation
face first
fetal position
relation of the denominator or reference point to the maternal pelvis
Culture influences
● Who is with the woman in labor, their role, and who participates in decision making
● Preferences for use of pharmacological and non-pharmacological pain management in labor
● Who the woman wants to care for her in relation to gender and modesty
● Response to labor
expectations
● Unrealistic expectations can cause an increase in maternal anxiety.
● Women who have experienced a negative previous birthing experience are at risk for increased anxiety; women who experienced a positive previous birthing experience have lower anxiety levels.
● Current pregnancy experience with difficulty conceiving, an unplanned pregnancy, or a high-risk pregnancy may increase a woman’s anxiety and fears.
● Expectations for the birth experience are related to how childbirth is viewed by the woman
effects of support
- Shorter labor
- Decreased use of analgesia/anesthesia
- Decreased operative vaginal births or cesarean births
- Decreased need for oxytocin/uterotonics
- Increased likelihood of breastfeeding
- Increased satisfaction with the childbirth experience
supportive care for adolescents
- Respectful nurse caring
- Assistance with pain control
- Nursing support of the adolescent’s support person
- Childbirth guidance
support- nursing actions
● Serve as an advocate
● Offer comfort measures
● Provide emotional support
● Provide information about labor progress and advice regarding coping techniques.
● Encourage her to do normal, distracting activities and rest as needed.
Adoptive Parents
birth mother decides if adoptive parents are there
mother goes through grief
mother some times needs alone time afterwards to make peace
counseling may be needed
Gestational Surrogacy
business agreement
Everyone involved in surrogacy may need early and ongoing support, education, care options, and counseling
When the adoptive parents have contact with the newborn is the decision of the birth mother in most situations.
Labor Support First theory
During labor, women may be uniquely vulnerable to unfamiliar environmental influences; current obstetric care frequently subjects women to institutional routines, high rates of intervention, unfamiliar personnel, and lack of privacy, resulting in stress
Labor support second theory
Second theory describes two pathways: enhanced passage of the fetus through the pelvis and soft tissues, and decreased stress response
freedom of movement
allowing the woman to labor in the position she finds most comfortable
Helps cope with labor
1st stage of labor position
upright position (walking, sitting, kneeling, or squatting) and/or a lateral position is encouraged
2nd stage of labor position
the upright position has been shown to increase the pelvic outlet and better aligns the fetus with the pelvic inlet
most used in births in the United States is the lithotomy position, which allows for provider visualization and control during the delivery process.
True labor
contractions bring about changes in cervical effacement and dilation.
False labor
characterized by irregular contractions with little or no cervical change
pontaneous rupture of the membranes (SROM)
Once the membranes have ruptured, the protective barrier to infection is lost, and ideally the woman should deliver within 24 hours to reduce the risk of infection to herself and her fetus.
Ferning
During a sterile speculum exam, a sample of fluid in the upper vaginal area is obtained, placed on a slide, and assessed for “ferning pattern” under a microscope
Nitrazine paper
The paper turns blue when in contact with amniotic fluid.
AmniSure testing kit
ROM Test is a rapid, non-invasive monoclonal immunoassay that detects PAMG-1, an amniotic protein that appears in vaginal secretions if ROM has occurred
SROM nursing actions
- assess FHR
- assess amniotic fluid for color, amount, and odor. (if meconium stained fetus may be compromised)
- Document the date and time of SROM, characteristic of fluid, and FHR.
woman should go to the birthing center immediately when:
● The membrane ruptures, or water breaks.
● She is experiencing intense pain.
● Bloody show increases.
Care Practices That Support and Promote Normal Physiologic Birth
- Labor begins on its own: Support the normal physiologic process.
- Freedom of movement throughout labor: Allow women to move around and adapt positions of their choosing.
- Continuous labor support from family, friends, doulas, or nursing staff.
- Minimize interventions to allow healthy labor progress.
- Spontaneous pushing in non-supine positions.
- NO separation of mother and baby.
first stage of labor
● It begins with onset of true labor and ends with complete cervical dilation (10 cm) and complete effacement (100%).
● Stage 1 is the longest stage, typically lasting 12 hours for primigravidas and 8 hours for multigravidas.
● There are normally tremendous variations in lengths of labor
● The bag of waters or fetal membranes usually ruptures during this stage.
● The woman’s cardiac output increases.
● The woman’s pulse may increase.
● Gastrointestinal motility decreases, which leads to increase in gastric emptying time (Mattson & Smith, 2011).
● The woman experiences pain associated with UCs that result in the dilation and effacement of the cervix.
● The first stage has three phases: the latent, active, and transition phases
Nursing actions first stage
diet and hydration activity and rest elimination comfort support and family involvement education safety documentation of labor admission and progression
Latent Phase
5-9 hours
● Cervical dilation from 0 to 4 cm with effacement from 0% to 40%.
● Mild intensity contractions occur every 5 to 10 minutes, lasting 30 to 45 seconds. Women often describe them as feeling like strong menstrual cramps.
Nonpharmacological Strategies for Nurses and Comfort Measures in Labor
emotional support physical support informational support advocacy support of the partner and family
Latent stage assess
● Maternal vital signs
● FHR
● Uterine contractions
● Cervical dilation and effacement; and fetal presentation, position, and station by performing a sterile vaginal examination
● Status of membranes
● Amniotic fluid for color, amount, consistency, and odor
● Vaginal bleeding or bloody show for amount and characteristics of vaginal discharge
● Fetal position with Leopold maneuver
● Deep tendon reflexes
● Signs of edema
● Heart and lung sounds
● Emotional status
Latent stage nursing actions
● orient woman to unit
● review prenatal record and give info to mother
● labor and delivery admission form
● review birth plan and discuss expectations
● teach/reinforce relaxation
● obtain labs as needed
● IVs or saline lock if ordered
● Review the woman’s report of onset of labor.
● Review laboratory results
● Review GBS status
● Document allergies, history of illness, and last food intake.
● Encourage fluid intake; food may or may not be restricted.
● Provide comfort measures.
● Encourage the woman to walk as much as possible
● Review the labor plan with the woman and her partner.
Group B streptococci (GBS)
can cause perinatal morbidity and mortality. Between 10% and 30% of pregnant women are colonized with GBS in the vagina or rectum.
Cervical dilation
This measurement estimates the dilation of the cervical opening by sweeping the examining finger from the margin of the cervical opening on one side to that on the other.
Cervical effacement:
This measurement estimates the shortening of the cervix from 2 cm to paper-thin measured by palpation of cervical length with the fingertips
Position of cervix:
Relationship of the cervical os to the fetal head and is characterized as posterior, midposition, or anterior.
Station
Level of the presenting part in the birth canal in relationship to the ischial spines. Station is 0 when the presenting part is at the ischial spines or engaged in the pelvis.
Presentation
Cephalic (head first), breech (pelvis first), shoulder (shoulder first)
Fetal position
Locate presenting part and specific fetal structure to determine fetal position in relation to the maternal pelvis.
Teamwork and Collaboration: Leading Health Care Organizations Issue Recommendations for Quality Patient Care in Labor and Delivery
- Ensure that patient-centered care and patient safety are organizational priorities that guide decisions for policies and practices.
- Foster a culture of openness by promoting the active communication of good outcomes and opportunities for improvement.
- Develop forums to facilitate communication and track issues of concern.
- Provide resources for clinicians to be trained in the principles of teamwork, safety, and shared decision making.
- Develop methods to systematically track and evaluate care processes and outcomes.
- Facilitate cross-departmental sharing of resources and expertise.
- Ensure that quality obstetric care is a priority that guides individual and team decisions.
- Identify and communicate safety concerns and work together to mitigate potential safety risks.
- Disseminate and use the best available evidence, including individual and hospital-level data, to guide practice patterns.
active phase
● nulliparous and parous woman dilate at a similar rate between 4-6 cm
● Fetal descent continues.
● Contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds.
● Discomfort increases; this is typically when the woman comes to the birth center or hospital if she has not done so already.
tandard Of Practice. AWHONN Position Statement: Nursing Support Of Laboring Women
● Assessment and management of the physiological and psychological processes of labor
● Facilitation of normal physiologic processes, such as the women’s desire for movement in labor
● Provision of emotional support and physical comfort measures, informational support, and advocacy
● Evaluation of fetal well-being during labor
● Instruction regarding the labor process
● Patient advocacy and collaboration among members of the health care team
● Role modeling to facilitate family participation during labor and birth
● Direct collaboration with other members of the health care team to coordinate patient care
transition phase
● Cervical dilation from 8 to 10 cm with complete (100%) effacement
● Intense contractions every 1 to 2 minutes lasting 60 to 90 seconds
● Exhaustion and increased difficulty concentrating
● Increase of bloody show
● Nausea and vomiting
● Backache: Woman complains of back pressure, hand goes over hip, rubbing and pressing on area.
● Trembling
● Diaphoresis, especially upper lip and facial area
● May have a strong urge to bear down or push, more vocal with primal noises and facial expressions.
Second Stage
10cm dilation to birth of baby
Latent or resting phase
characterized by a period of rest and relative calm. The urge to bear down is usually not well-established
Descent or active phase
increasing intensity of uterine contractions and strong urges to bear down with the activation of Ferguson’s reflex.
Characteristics of active phase
● Typically lasts 50 minutes for primigravidas and 20 minutes for multigravidas, although a second stage of several hours is normal.
● Woman may feel an intense urge to push or bear down when the baby reaches the pelvic floor.
● Contractions are intense, occurring every 2 minutes and lasting 60 to 90 seconds.
● Bloody show increases.
● The perineum flattens and the rectum and vagina bulge.
Directed pushing
instructions from care providers to the woman concerning how to push and often
Closed glottis (involuntary)
refers to spontaneous pushing against a closed glottis
Closed glottis (voluntary)
involves a voluntary directed strenuous bearing-down effort against a closed glottis for at least 10 seconds
Nondirected pushing
refers to care providers encouraging the woman to choose whatever method she feels is effective to push her baby out
Open glottis
spontaneous, involuntary bearing-down accompanying the forces of the uterine contraction and is usually characterized by expiratory grunting or vocalizations.
episiotomy
an incision made in the perineum — the tissue between the vaginal opening and the anus — during childbirth.
Perineal Stretching
application of warm compresses, gentle perineal massage and stretching, and perineal massage with warm oil during the second stage of labor.
Nursing actions second stage
● Instruct the woman to bear down with the urge to push.
● Monitor for fetal response to pushing; check FHR every 5 to 15 minutes or after each contraction.
● Explain the need for vaginal examinations and the pressure and/or pain sensations anticipated.
● Provide comfort measures and allow woman to be in position of comfort.
● Provide reassurance, empathy, and encouragement to the woman
● Attend to perineal hygiene as needed
● Validate and explain the physical sensations
● Encourage rest between contractions
● Review and reinforce pushing technique
● Advocate on the woman’s behalf for her desires of the delivery plan.
● Evaluate the father’s, partner’s, or labor coach’s knowledge
● Assist the support person and partner
third stage of labor
begins immediately after the delivery of the fetus and involves separation and expulsion of the placenta and membranes
Signs that signify the impending delivery of the placenta include:
● Upward rising of the uterus into a ball shape
● Lengthening of the umbilical cord at the introitus
● Sudden gush of blood from the vagina
normal blood loss for vaginal birth
500 ml within 24 hours.
Inaccurate measurement of postpartum blood loss has the following implications:
- Underestimation can lead to delay in delivering lifesaving hemorrhage interventions.
- Overestimation can lead to costly, invasive, and unnecessary treatments such as blood transfusions that expose women to unnecessary risks.
ways to measure blood loss
collect blood in calibrated, under-buttocks drapes for vaginal birth.
weigh blood-soaked items and clots.
Oxytocin (Pitocin)
Actions: Stimulates uterine smooth muscle that produces intermittent contractions. Has vasopressor and antidiuretic properties.
Methylergonovine (Methergine)
Actions: Directly stimulates smooth and vascular smooth muscles causing sustained uterine contractions.
Carboprost—Tromethamine (Hemabate)
Actions: Contraction of uterine muscle
Misoprostol (Cytotec)
Actions: Acts as a prostaglandin analogue causes uterine contractions.
Nursing actions third stage
● Administer uterotonic per protocol after delivery of the placenta.
● Assess maternal vital signs every 15 minutes.
● Encourage the woman to breathe with contractions and relax between contractions.
● Encourage mother-baby interactions by providing immediate newborn contact, if the newborn is stable.
● Complete documentation of the delivery
● Explain all forthcoming procedures.
● Stay with the woman and her family.
fourth stage
after delivery of the placenta and typically ends within 4 hours or with the stabilization of the mother
first-degree laceration
perineal skin and vaginal mucous membrane
second-degree laceration
skin, mucous membrane, and fascia of the perineal body
third-degree laceration
skin, mucous membrane, and muscle of the perineal body and extends to the rectal sphincter
fourth-degree laceration
extends into the rectal mucosa and exposes the lumen of the rectum
