Intrapartum Part 1 Flashcards
Intrapartum
During labor until a few hrs after delivery
Clinical Pelvimetry
False pelvis (above pelvic brim) True pelvis represents bony limits of birth canal: most important in childbirth
3 subdivisions of true pelvis
Bony limits of birth canal:
pelvic inlet
midpelvis
pelvic outlet
Pelvic types
Gynecoid: prognosis good, best pelvic type for delivery
Anthropoid: good prognosis
female bony pelvis
four bones: 2 innominate (hip bones) ilium, ischium, pubis sacrum coccyx
pelvic floor
musculature to overcome force of gravity
pelvic diaphragm
-dilation during pregnancy
-returns after birth
Premonitary signs of labor
braxton hicks lightening increased vaginal secretions bloody show/ mucous plug energy spurt
phone triaging a pt
- what is your EDD
2. what time did the membranes rupture
True vs. False labor
progressive dilation and effacement
false labor management
pain can be relieved by ambulation, changes of position, resting or hot bath or shower
RN responsibilities admission to the birth center
therapeutic relationship
imminence of birth
fetal and maternal status
admission assessments
ROM
ferning
nitrazine paper turns blue if amniotic fluid is present
vaginal pH < 4.5
amniotic fluid pH 7.0-7.5
uterus changes during birth
contractions
Cervical changes during birth
effacement
dilation
cardiovascular changes during birth
check vitals between contractions
remember about positioning
respiratory changes during birth
hyperventilation
GI changes during birth
motility decreased
thirst
GU changes during birth
reduced sensation of full bladder
hematopoietic system changes during birth
SVD 500 ml, C/S 1000 ml
H/H
WBC increased up to 25000/mm3
increased clotting factors
decreased fibrinolysis
psychosocial considerations
readiness preconceived ideas about birth birth plan factors associated w/ positive birth support system
4 P’s of birth process
powers passage passenger psyche the 4 P's are interrelated and must all work together
powers
physiologic forces of labor- uterine muscular contractions
-frequency & intensity
pushing during second stage of labor
passage
size of maternal pelvis
type of maternal pelvise
ability of cervix to dilate, efface
ability of vaginal canal to descend
Passenger
fetal head
fetal lie
fetal attitude
fetal presentation
fetal head
overlapping bones- molding
sutures- allow for molding
fetal lie
longitudinal- vertical
transverse- horizontal
fetal attitude
posture of fetus to conform to uterine cavity
normal attitude: head flexed, chin on chest, arms crossed over chest, legs flexed at knee, thighs on abdomen
Fetal presentation
b
fetal malpresentation
breech (frank, footling, complete) transverse lie (shoulder presentation)
Station
presenting part vs. imaginary line between the ischial spines
presenting part moves from negative to positive
psyche
culture individual values education/ support birthing experiece impact of technology pain, fatigue and fear
Stages of Labor
- Cervical dilation: 0-10 cm
- Birth of baby “pushing”
- placental delivery
- Recovery
1st stage- 1st phase
cervical dilation
latent phase:
- beginning cervical dilation and effacement
- no evident fetal descent
- contractions increase, mild-regular intensity
- excited, talkative, smiling
1st stage-2nd phase
cervical dilation
active phase
- dilation 4-7 cm
- progressive fetal descent
- contractions increase in freq and intensity
- increased anxiety
1st stage- 3rd phase
cervical dilation
transition phase
-dilation 7-10 cm
progressive fetal descent
-contractions increase in freq and intensity
-woman more likely to withdrawal into self
second stage
“pushing”
complete dilation 10 cm ends with birth of baby spontaneous birth positional changes of fetus "urge to push"
recommendation time for 2nd stage
2 hrs for mulitparous woman w/ anesthesia and 3 hrs for nullipara w/ anesthesia
-after this time period, c-section is recommended
open glottis pushing
grunt without holding breath and bear down spontaneously
push no more than 8 seconds, no more than 3 times per contraction
closed glottis
valsalva manuver
no longer recommended
3rd stage
“placental”
begins with birth of baby, ends with expulsion of placenta
placental separation
- signs!!
- delivery
- retained (placenta breaks in pieces)
- schultz and duncan mechanisms
Uterine Inversion
Medical Emergency
placenta doesn’t detach or is ripped from cervix
4th stage
“recovery”
begins with delivery of placenta, ends when mother is stable 1-4 hrs after birth physiologic readjustment thirsty and hungry shaking bladder is hypotonic uterus remains contracted
Amniotomy
Sterile procedure- rupture of membranes
Have ready: amnio-hook, sterile gloves and lubricant, clean chux, blankets, washcloth
when the membranes are rupture the mother feels pain, baby’s head is no longer cushioned
RN assesments before and after amniotomy
assure the presenting part is engaged prior to procedure to prevent cord prolapse
monitor FHR before and after
monitor color, amount and smell of the fluid
Prolapsed cord
medical emergency
when a cord comes out before the baby
Prolapsed cord management
priority is to relieve pressure off the cord
birth by stat C/S unless vag birth is imminent
position hips higher than head
with gloved hand, push fetus upward
give O2
RN care during labor
promote placental functioning
-maternal position, IV fluids, relaxation and pain relief
provide comfort measures
-lighting, temp, mouth care, bladder (empty q 2 h)
Pain during labor
…
Non-pharmacologic pain relief
relaxation techniques visualization thermal stimulation focal point massage music
Breathing Techniques
…
Pharmacologic pain management
remember any drug taken by the woman is taken by the fetus
….
Common drugs used in labor
- Opioids-
- Adjunctive drugs-
- Narcotic Antagonists-
Labor induction
the chemical or mechanical initiation of uterine contractions
- bishop score is used to assess readiness and predict success of induction augmentation
Labor Augmentation
improving the quality of uterine contractions once labor has started
- bishop score is used to assess readiness and predict success of induction augmentation
Factors of Bishop Score
cervical dilation cervical effacement fetal station cervical consistency cervical position
Max score 13
cervical ripening
Prostaglandin E2
intravaginal insert
left in posterior vagina-slow release
easily removed
cervical ripening
Misoprostol
…
contraindications to cervical ripening
…
Pitocin
used to induce contractions
Assess maternal pelvis and fetal position before starting infusion
RN responsibilities during induction or augmentation
Observe the uterine response for hyper-stimulation and high resting tone (we don’t want these sxs)
observe the fetal response
pain assessment
documentation
Monitoring uterine contractions (UC)
palpation
external- tocodynamometer
internal- intrauterine pressure catheter
Internal EFM
Fetal scalp electrode (FSE) cervix must be dilated at least 2 cm membranes ruptured electrode attached to presenting part continuous recording infection risk
FHR patterns
interval between heartbeats (continually monitored) baseline variability accelerations decelerations
baseline FHR
the rate at which the baby stays while at rest between UCs mean FHR during 10 min period rounded to 5 bpm must be observed for 2 mins FHR decreases w/ gestational age
FHR Variability
most important indicator of an adequatley oxygenated fetus
moderate 6-25 bpm (normal)
episodic changes in FHR
not associated w/ uterine contractions
periodic changes in FHR
associated w/ uterine contractions
FHR Accelerations
a breif temp increase of at least 15 beast above baseline, lasting 15 seconds
usually associated w/ fetal movement, vaginal exams, contractions, fetal scalp stem, etc.
considered a sign of well being
FHR decelerations
a periodic decrease in FHR below the baseline
FHR early decelerations
normally reassuring, the onset and return of deceleration coincide with the start and end of the contraction
FHR variable changes
variable in duration, intensity and timing, not usually concerning UNLESS:
less than 70 bpm
lasts > 60 seconds
slow return to baseline
FHR late decelerations
immediate interventions: position change increase IV fluids O2 face mask stop IV Pitocin in infusing notify MD, CNM
Guidelines for management: prolonged decelerations
perform vag exam to r/o cord prolapse
maintain maternal position on L side
d/c oxytocin
report findings and document, provide explanation to pt
increase IV fluids
administer tocolytic as ordered
anticipate intervention if FHR previously abnormal, deceleration lasts > 3 min
Reassuring FHR patterns
Baseline 110-160
moderate variability
accelerations > 15x15
no concerning decelerations
Non reassuring FHR patterns
tachycardia bradycardia decreased or absent variability late decelerations severe variable decelerations any prolonged decelerations
RN interventions for non reassuring FHR
- identify the cause
- stop or decrease oxytocin infusion per unit policy
- increase placental perfusion (L side then increase IV fluids)
- increase maternal O2 sat (face mask, 8-10 L/min)
- reduce cord compression
- Call MD
what are factors that might cause minimal variabiliy and lack of accels on a FHR?
hypoxia
maternal narcotic admin
magnesium sulfate
CNS abnormalities
RN actions for minimal variability and lack of acels on FHR
MAXIMIZE PLACENTAL PERFUSION
lateral position
oxygen
maintain BP
testinf to determine abnormal FHR significance
fetal scalp stimulation
vibroacoustic stimulation
fetal oxygen saturation monitor
fetal scalp blood sampling
