Lecture 3 - Intrapartum Care Flashcards
How does estrogen effect oxytocin receptors on the uterus?
Estrogen induces oxytocin receptors on the uterus
How does oxytocin effect the placenta and uterus during labour?
Stimulates uterus contraction direction
Stimulates placenta to release prostaglandins which also stimulate vigorous contractions of the uterus
How do contractions of the uterus effect oxytocin and placenta prostaglandin release?
Increases both –> Positive feedback loop
A rupture of membranes before labour occurs in what percent of pregnant individuals? When must an induction occur following ROM?
8%
–> Induction will occur 12 hours following ROM
What is meant by “bloody show”?
A loss of mucous plug in combination with small amount of pinkish/blood tinged discharge. Associated with cervical effacement.
How does increased and high stress effect oxytocin release?
Excessive stress can decrease its release
–> Reduces the amount of contractions and the progression of labour
When does a surge of catecholamines occur labour? What is their role?
During 2nd stage of labour
–> Increases strength provide energy/motivation
Relaxin is released by what and has what role during pregnancy?
Released by placenta
–> Relaxes pelvic ligaments and joints and plays role in cervical ripening
What is the role of endorphins in labour?
To ease pain and provide sense of calm
How can true labour contractions can be differentiated from Braxton-Hicks or pre-labour?
True labour contractions will progress cervical dilation and effacement
–> True labour contractions are regular and will not subside, will increase with walking
What are the four stages of labour?
Stage 1
–> Onset of regular contractions that result in cervical changes and ends with complete effacement and dilation
2 Phases
–> Latent: 0-3 cm
–> Active: 4-10 cm
Stage 2
–> Begins with full dilation and effacement and ends with the baby’s birth
2 Phases
–> Passive: Not yet pushing
–> Active: Pushing
Stage 3
–> Starts with birth of the baby and ends with expulsion of placenta
Stage 4
–> Begins with the expulsion of the placenta and lasts until the birthing person is stable in the immediate postpartum period. Usually first 2 hours.
When is it recommended that a person comes to the hospital to be assessed during labour?
5-1-1 Rule
–> Contractions are 5 minutes (or less) apart, and are lasting 1 minute, and have been continuing in this pattern for an hour.
What are the two phases of stage 1 of labour? How long do they last?
Latent: 0-3 cm
–> Variable
Active: 4-10 cm
–> 0.5-1 cm dilation/hour (3-6 hours)
What are the two phases of stage 2 of labour?
Passive: Not yet pushing
Active: Pushing
When does latent labour begin?
The onset of regular contractions
–> q 5-30 mins, lasting 30-45 seconds.
How long does latent labour last?
6-8 hours, very variable
What are the Lamaze International 6 healthy birth practice?
- Let labour begin on its own
- Walk, move, change positions throughout
- Bring loved one, friend, doula for continued support
- Avoid interventions that are not medically necessary
- Avoid giving birth on your back and follow body’s urges
- Keep dyad together
What happens to the cervix during the latent phase of labour?
Lasts for first 1-3 cm dilation
–> More effacement than dilation during this phase
Why is it recommended that someone stay home during the latent phase of labour?
More comfort, less stress
If a person is admitted during latent labour, what nursing interventions should be done?
–> Minimize interruptions.
–> Offer fluids and light snacks.
–> Encourage rest and distraction and offer reassurance.
E.g., watch movie, go for a walk, take a shower or bath to relax, snooze between contractions
–> Remind the birthing person to void.
How frequent are uterine contractions during the active phase of stage 1 labour?
Contractions q 2-5 mins, lasting 40-90 seconds
–> Contractions should be moderate to very strong
How long does the active phase of stage 1 of labour last?
3-6 hours
–> Longer in primapara
What happens to the cervix during the active phase of stage 1 labour?
Dilates from 4-10 cm and effaces to 100%
What assessment must be done during phase 2 of stage 1 (active) labour?
Review OPR, interview.
Systems review, VS, fetal wellbeing, labour progress
Labs and diagnostics
Expressed psychosocial and cultural factors
Birth plan
Notify family and physician/OB
How is labour progress assessed?
Uterine activity, vaginal exam for dilation, ROM, bleeding
Minimize invasive assessments as much as possible, no more than every 2 hours unless otherwise indicated
What blood work will be done when a person is admitted in active labour?
CBC, T&S
GBS, HSV
–> May have already been done
What antibiotics are given for GBS+?
Penicillin G
–> q4h
Can also use clindamycin, baby will not be considered covered.
What are the key components of a FHR assessment?
Baseline FHR (not during contractions)
Accelerations and decelerations
–> Accelerations are a good sign
–> Decelerations may occur simultaneously with contractions
Uterine activity
How often is FHR monitored during labour?
On admission
–> qh
Active phase
–> q15-30 mins
Stage 2
Passive: q15 min
Active: q5 min/after contractions
When is electronic fetal monitoring recommended over intermittent ausculation?
For pregnancies at risk of perinatal outcomes
What are the five factors affecting the process of labour and birth?
Passenger (fetus & placenta)
Passageway
Powers (contractions)
Position (of mother)
Psychological response
What is fetal presentation? What are the most common kinds?
The part of the fetus that enters the pelvic inlet first and will therefore lead through the birth canal
–> 96% cephalic
–> Breech 3-4%
–> Shoulder <1%
How can the presenting fetal part be assessed?
Through cervical/vaginal examination
What are the different kinds of breech presentations?
Complete
–> knees tucked to chin
Frank
–> Legs extended upward
Single/double footling
–> Descended leg
What is fetal lie?
The relationship of the spine of the fetus to the spine of the mother
(longitudinal, transverse)
What is fetal attitude?
The relation of fetal parts to each other - attitude of flexion or extension
Generally, we want an attitude of flexion (fetal position) because extension can make delivery more challenging.
What factors affect the passenger during labour?
Fetal head
–> skull is not yet fused
Fetal Presentation (part)
Fetal Lie
Fetal Attitude
Fetal Position
–> Station
–> Engagement
What shape is the anterior fontanelle? When does it close?
Diamond
-> 18-24 months
What shape is the posterior fontanelle? When does it close?
Triangle
–> 6-8 weeks
What is vertex presentation?
Cephalic presentation with occiput as presenting part
–> ideal
Why is a footling breach the most challenging vaginal delivery?
Cervix may dilate enough for foot/legs to descend, but not enough for the hips and head to descend.
–> Mechanism for dilation is interrupted
What is the suboccipotobregmatic diameter?
9.5 cm
–> Smallest part of the head descending first is deal (with vertex presentation)
What military presentation?
Attitude of moderation extension with occipitofrontal diameter as presenting part
–> 12cm descending
What is meant by fetal position?
The relationship of the presenting part of the fetus to the 4 quadrants of the mother’s pelvis
Fetal position is described with what three letter system?
- Right/Left
- What is the part?
- Direction part is facing (anterior, posterior, transverse)
What is meant by Direct OA?
A direct occipito-anterior positioning of the fetus (not left/right)
–> Ideal for vaginal delivery
What is the station of the fetus?
A measure of the degree of descent of the presenting part in cm
–> The presenting part’s location to the ischial spines
Station 0 is at the ischial spine
What is engagement?
When the largest diameter of the presenting part has passed the pelvic inlet and entered the true pelvis.
The presenting part of engaged with is it at station 0.
When does engagement occur?
Usually 2 weeks before term in nulliparas and just before labour in multiparas
What are the false and true pelvis?
The false pelvis is everything before the inlet.
The true pelvis is everything below the pelvis.
–> Includes inlet, ischial spine, and outlet.
What hormones contribute to the softening of soft tissues in the birth canal?
Progesterone and Relaxin
How does the active segment of the uterus change during labour?
During the second stage of labour the active segments thickens and stops accommodating the fetus.
What are the powers of labour?
Primary: Uterine contractions
Secondary: Bearing down - pushing
How are contractions described?
Frequency
–> 5 contraction/10 mins in active labour/pushing
Duration
–> 1-1.5 mins
Intensity
–> Maternal perception and examiner palpation. not EFM.
Resting Tone
How long is an ideal resting period between contractions during active labour?
At least a minute
–> Risk of hemorrhage after birth
When do we want a person to begin using secondary powers during labour?
After the cervix has fully dilated, because otherwise can cause edema and enlarging.
Most effective once the urge to push is felt and during a contraction.
What position is best when the fetus is in negative station?
Trying to open the inlet
–> External rotation of femur head (toes and knees out)
What position is best when the fetus is in positive station?
–> Internal rotation of femur head (toes and knees in)
What is the usual length of the 2nd stage, passive phase of labour?
60-70 minutes for nulliparous
20-30 minutes for multiparound
How can we support someone in the second stage, passive phase of labour?
Assist with positioning
–> promote fetal descent with position changes, pelvic rock, ambulation, showering
Encourage relaxation
What are two common kinds of pushing?
Open-glottis pushing
Closed-glottis pushing
What is open-glottis pushing?
Not holding breath while pushing
–> Facilitates maternal-fetal circulation, less maternal fatigue, protects pelvic organs from undue pressure, decreased incidences of perineal tears
What positions are best during the pushing phase of stage 2?
Upright and side-lying positions
What is closed glottis pushing?
Person holds breath while pushing
–> Increased intrathoracic and CDV pressure, decreased cardiac output and blood flow.
–> Increased fatigue
–> Cephalgia
For fetus, alterations in perfusion, pH. Can tighten pelvic floor muscles and limit fetal rotation and descent.
Not recommended.
What are the position changes of the fetus during vaginal delivery?
- Engagement
- Descent
- Flexion
–> Resistance from soft tissues and musculature causes attitude of flexion - Internal Rotation
–> Fetal head fits into widest diameter of pelvic cavity - Extension
–> Extension of fetal head passes under symphysis pubis - brow and face emerge - Restitution and external rotation
–> Head realigns with back and shoulder and anterior shoulder extends under symphysis, followed by posterior - Birth
–> Trunk of baby is born
What are some risks of EFM?
May limit ambulation, increase rates of cesarean and instrumental vaginal births
What are the risks of using epidural anaesthesia?
Increased oxytocin administration
Increases length of 2nd stage
Increased need for assisted vaginal births
How can perineal trauma be prevented during delivery?
Warm compresses and upright positioning
What are the four degrees of perineal lacerations?
1st - Mucosal tear
2nd - Perineal muscles involved
3rd - Anal sphincter involved
4th - Rectum mucosa involved
How long does stage 3 of labour last? How does the length of this stage effect risk of hemorrhage?
5-30 minutes
–> Risk increases as length of this stage increases
After 30 minutes, the placenta is considered retained.
How to we prophylactically treat/prevent the risk of retained placenta?
Prophylactic oxytocin administered after birth of anterior shoulder
–> IV rate as ordered
–> IM 10 units
How long will we wait for cord clamping in a term baby?
60 seconds
What are the priorities of care for the birthing person during stage 4?
Promote bonding, rest and relaxation, shower and clean clothes, fluids and food.
Continue to asses VS q15x1 then once during 2nd hour. Assess lochia, fundus, bladder, perineum, pain. Treat pain.
What are the priorities with the newborn during stage 4 of the labour?
Promote bonding, prevent cold stress, observe for complications.
Vit k, weight, ID bands.
Skin-to-skin causes a lower risk of jaundice. Why?
Increased breastfeeding to promote excretion of bilirubin + thermoregulation
What are the four essential elements of labour support?
Physical, emotional, and informational support
Advocacy
When is continuous labour support most effective?
When it is provided by someone outside the mother’s social circle, who is not a member of hospital staff, and who has a moderate amount of training, such as a doula.
What is the acronym for labour pain?
Purposeful
Anticipated
Intermittent
Normal
What causes visceral pain during labour during the first stage?
Caused my uterine contractions, stretching of cervix
–> Ischemia, pressure and traction on adjacent tissues
What kind of referred pain will be felt during the first stage of labour?
Pain the radiated from uterus to the abdominal wall, Lumbosacral area, iliac crests, gluteal area, thighs, and lower back.
What kinds of pain are most felt during the first stage of labour?
Visceral and referred
What kind of labour pain is felt most during the second stage of labour?
Somatic pain
–> intense, sharp, burning
–> Caused by distension and traction on peritoneum and utero-cervical supports during contractions.
What spinal nerves are involved in pain perception during the first stage of labour?
T10-L1
–> Related to visceral and referred pain
What spinal nerves are involved in pain perception during the second stage of labour?
S2-S4
–> Somatic pain
How does informed choice differ from informed consent?
Informed consent - offers opportunity to say yes or no
Informed Choice - Available options are presented
What is the gate control theory of pain?
The idea that a gate open/closes to allow pain impulses through
Small diameter fibers carrying pain can be blocked by large diameter fibers activated by non-painful stimuli - such as counterpressure, massage, temperature
When can cleansing breaths be effective for pain releif?
Before and after a contraction
What is slow paced breathing?
Breathing in through nose and out through mouth - about half of regular resp rate
What is modified paced breathing?
Easy, rhythmical breathing with a frequency of approximately twice your normal respiratory rate.
What are the Rs of labour support?
Relaxation, rhythm, ritual
What can relieve trembling in late active labour?
A warm blanket
What is effleurage?
Light, rhythmic stroking touch
What are some benefits of using a peanut ball during labour?
Reduced length of stage 1 and 2 of labour, reduced C-section rates
Increased patient satisfaction with no adverse neonatal effects
How does the use of hydrotherapy prevent pain during labour?
Softens perineal tissues and promotes circulation, release of endorphins
Related to gate-control theory
What are two things to keep in mind when using hydrotherapy during labour?
Wait until 5cm or more dilated (active labour)
–> Can slow labour in early labour
Water temp should not exceed 37°C (prof disagrees)
–> Decrease risk of hyperthermia and fetal tachycardia
How much SWFI is infected for intradermal water block? What gauge needle is used? What four location are used?
0.5-1 ml with 25g into four areas surround sacrum
How long does ISWB last?
2 hours
–> First accompanied by 20-30 seconds of intense stinging
Why is ISWB effective?
May be gate-control or counter-irritation
What is entonox?
A 50:50 blend of oxygen and nitrous oxide - self administered by mask
CNS depressant + anxiolytic
Peaks in 50 seconds and quickly dissipated
What are some common side effect of entonox?
N&V, light-headedness
Why are systemic opioids not recommended close to delivery?
Risk of respiratory depression in the newborn
Variability in fetal heartrate will also decrease
What is a common side effect of Nubain (nalbuphine)?
Nausea
–> Often administered with Gravol
How long does it take a pudendal nerve block to take effect? How long does it last?
2-10 minute onset with 1 hour duration
Where is an epidural placed during labour?
A cath placed epidurally between 4th-5th lumbar vertebrae
What is spinal analgesia?
A cath (smaller than for epidural) placed in the subarachnoid space, Not continuous.
–> Used for planned c/s
What kind of pain does an epidural relieve during labour?
Relieves pain of contractions but not the pressure of fetal descent in the pelvis.
What are the different kinds of epidurals?
Intermittent
Continuous
PCEA
–> Continuous with PC pump
