maternal midterm Flashcards
Medical and nursing care given to a pregnant woman
and her family during labor and delivery
intrapartum care
Extends from the beginning of contractions that cause
cervical dilation to the first 1-4 hours after delivery of
the newborn and placenta
intrapartum period
A series of processeLow Progesterone Theory / Progesterone
Deprivation Theorys by which the product of
conception is expelled from the maternal body.
labor
The actual event of giving birth
delivery
Progesterone (uterine muscle relaxant) decreases in
late pregnancy
With corresponding increase in Estrogen (uterine
muscle stimulant), labor starts.
Low Progesterone Theory / Progesterone
Deprivation Theory
The pressure of the fetal head on the cervix in late
pregnancy stimulates the posterior pituitary gland to
secrete oxytocin which causes uterine contractions
oxytocin theory
All these have stimulating effect on uterine
musculature causing uterine motility.
Estrogenic, Fetal Hormone and Prostaglandin
Theories
As the placenta matures more and more pressure is
exerted on the fundal portion, the usual placental site,
and the most contractile portion of the uterus. It is
believed that the resultant diminished blood supply to
the area that causes contraction.
Theory of Aging Placenta
As the uterine muscles get stretched with fetal growth
and increasing amniotic fluid, irritability, and
contraction to empty the contents of the uterus are the
likely results.
Most acceptable theory
Uterine Myometrial Irritability/ Uterine
Stretch Theory
Refers to the adequacy of the pelvis and birth canal in
allowing fetal descent.
Depends to the ability of the uterine segment to
distend, the cervix to dilate and the vaginal canal to
distend.
passageway
cervix, vagina, perineum
soft passage
the pelvis; the true birth canal in labor
bony passage
From lower border of symphysis pubis to sacral
promontory
diagonal conjugate
- Shortest distance
- Usually 11cm
- This is the important pelvic measurements
obstetric conjugate
Measured from upper margin of symphysis pubis
to sacral promontory
True Conjugate or Conjugate Vera
Measures the outlet between the inner borders of
ischia tuberosities and it should be at least 8-9cm.
- We can get the measurement by doing pelvic
exam
Tuber-ischial Diameter/Intertuberous Diameter
Wide and round in all directions
Classic female pelvis
gynecoid
Narrow, heart-shaped
android
Narrow and oval-shaped.
Antero-posterior (AP) diameter is equal to or
greater than the transverse diameter.
Resembles a pelvis
anthropoid
Flattened oval and transverse (side-to-side) shape.
There is growth pelvis with shortened anteriorposterior diameter
It is considered a less common pelvic shape.
Platypelloid
Shallow upper basin of the pelvis
Supports the enlarging of the uterus
false pelvis
Plane dividing upper or false pelvis from lower true
pelvis.
linea terminalis
Consists of pelvic inlet, pelvic cavity, and pelvic outlet
It has bony canal through which the infant will pass
Measurements can significantly influenced the
conduct and progress of labor and delivery
true pelvis
Refers to the fetus and its ability to move through the
passageway
passenger
With seven bones (2 frontal, 2 parietal, 2 temporal and
1 occipital)
fetal head
Thin membranous spaces in between bones or closure
between bones
suture
– longitudinal, between 2 parietal bones
saggital
anterior, between 2 frontal bones.
frontal
posterior, between parietal and occipital
bone.
lambdoidal
anterior, located between the frontal and
parietal bones.
coronal
Points of intersection of cranial bones; membranous
spaces between cranial bones during fetal life and
infancy
fontanels
– formed by 2 frontal and 2 parietal
bones; diamond shaped; measures 2.5 cm by 2.5 cm;
also called as “bregma”. Ossifies or closes in 12 to 18
months.
anterior fontanel
– formed by the union of parietal
and occipital bones; forms junction which sagittal and
lambdoid sutures; triangular shaped; ossifies in 2
months
posterior fontanel
– 12.5 to 13.5 cm; from occiput to the
chin; widest
Occipitomental
12 cm; from occiput to mid frontal
bone
occipitofrontal
9.5 cm; from occiput to the
anterior fontanel; narrowest AP diameter of the head
Suboccipitobregmatic
Fetal Head Diameters
occipitofrontal
occipitomental
suboccipitobregmatic
Posture or habitus.
The relationship of the fetal parts of the trunk or one
another.
The fetus forms an ovoid mass that corresponds to the
shape of the uterine cavity.
fetal attitude
The relation of the long axis of the fetus to the long
axis of the mother.
fetal lie
The fetal head is the presenting part.
- Occurs in about 95% of the cases.
- 4 Varieties
cephalic
occiput
(posterior fontanel) is the presenting part
Vertex (occiput) Presentation –
bregma (anterior fontanel) is the presenting part.
Fetal head is neither flexed nor extended
. Sinciput Presentation (Military Attitude)
. Sinciput Presentation (Military Attitude)
brow presentation
the fetal head is
hyperextended (complete extension). Face is the
presenting part.
face presentation
Occurs 5% of labors at term. When the fetus presents
with the buttocks toward the pelvis
breech
– fetal hips are flexed, and knees
are extended. The buttocks of the fetus present to
the maternal pelvis
frank breech
– the fetal hips and knees are
both flexed, the thighs are on the abdomen, and
the calves are on the posterior aspect of the
thighs. The buttocks and feet of the fetus present
to the maternal pelvis
complete breech
the hips and legs are extended. The
feet of the fetus present to the maternal pelvis.
footling
Also called as ___________ which is extremely rare
presentation.
- Shoulder is usually presenting into the pelvic inlet.
transverse
The relationship of a particular reference point of the
presenting part and the maternal pelvis described
with a series of 3 letters.
fetal position
may be mild, moderate, and strong. With
uterine contractions, these uterine changes occur:
intensity
– uterine contractions
primary power
voluntary bearing down,
abdominal muscle contractions of levator ani muscle
secondary power
the phase of increasing
intensity of contraction; the first phase; the onset.
Increment (crescendo)
– the height of the uterine contractions.
Acme (apex)
– the phase of decreasing
contraction; the last phase; end
Decrement (decrescendo)
pregnant woman’s general behavior and influences
upon her also influence labor progress:
person
Refers to the frequency, duration, and strength of
uterine contractions to cause complete cervical
effacement and dilation
power
– the period from increment to decrement of
the same contraction
duration
– period from the increment of the first
contraction to the increment of the second
contraction.
frequency
– period from the decrement of the first to the
increment of the second contraction
interval
Descent of the fetus and uterus into pelvic cavity
before labor onset.
lightening
the process by which the cervix opens.
dilation
thinning and obliteration of the cervix.
Expressed in terms of shortening of the cervical
length (the average length of the cervix is around 2
cm to 2.5 cm).
Described as “thinning”, “shortening”, or
“narrowing”.
Expressed in Percentage
effacement
Premonitory Signs of Labor
lightening
increased braxton hick’s contractions
show
- Increased maternal energy or burst of energy because of
hormone epinephrine. - Slight decrease in maternal weight by 2 to 3 lbs
. Ripening of the cervix becomes as soft as butter.
- Spontaneous rupture of the BOW or membranes
Progressive fetal descent.
- Increased backache and sacroiliac pressure due to fetal
pressure
cardinal movements
of labor:
: descent,
flexion,
internal rotation,
extension,
external rotation, and expulsion
– mechanism by which the greatest transverse
diameter of the fetal head (biparietal diameter is 9.5 cm)
passes through the pelvic inlet
engagement
– passage of the presenting part through the pelvis;
first requisite for the birth of the baby
descent
when the chin is brought in contact with the chest.
This results to the smallest anteroposterior diameter of the
fetal head (Suboccipitobregmatic diameter of 9.5 cm) to
present
flexion
– turning of the head so that the occiput
moves anteriorly toward the symphysis pubis.
internal rotation
: In primigravida, descent of the fetus into the true
pelvis occurs about _______ days before labor. This descent
is referred to as _____ and results in engagement
10 - 14, lightening
delivery of the fetal head in vertex presentation
extension
– restitution; the movement or the
rotation of the head visible externally due to internal
rotation of the shoulders.
external rotation
birth of the baby
expulsion
involved the superficial vaginal mucosa or
perineal skin but not the underlying fascia and muscle.
first degree
– involved the vaginal mucosa, perineal skin,
deeper tissues, may include fascia and muscles of the
perineum but not the anal sphincter.
second degree
same as 2nd degree but involved the anal
sphincter
third degree
extends through the anal sphincter into the
rectal mucosa
fourth degree
Surgical incision extending from the soft tissue of the
vaginal opening into the true perineum
Episiotomy (Clean Surgical Incision)
An incision from the vaginal opening straight down
toward but not extending into the anus.
Not commonly done and it easily extends to the anal
and region increasing the risk of sepsis.
median epsiotomy
This begins at the midline above the anus but angles to
the left or right.
Mediolateral Episiotomy
Stages of Labor
latent
active
transition
Dilation stage from the onset of the first contraction to
full cervical dilation.
- Power necessary: uterine contractions
First Stage of Labor – Three Phases
First Stage of Labor – Three Phases
External or Indirect Monitoring
– disk over fundus,
secured with belt; provides continuous
record of external pressure created by
contractions, allow measurement of
frequency and duration of contraction
Tocodynamometer –
– at site of loudest
FHR; secured with belt; provides
continuous FHR recording, which is
interpreted in relation to uterine activity.
Ultrasonic Transducer
– applied when
membranes have ruptured, cervix 2 to 3 cm
dilated
Internal or Direct Monitoring
– intrauterine catheter
filled with water is inserted beyond
presenting part; allows measurement of
frequency, duration, and intensity of
contractions
Pressure Transducer
applied to fetal
scalp; allows measurement of FHR, baseline
variability, and periodic changes.
Internal Spiral Electrode
Location of most audible FHR:
– usually above the
umbilicus
Breech Presentation
Location of most audible FHR:
– usually below the
umbilicus
a. Vertex Presentation –
is equal to or less than 100/min.
bradycardia
it is when FHR is more than 170/min.
tachycardia
– periodic decrease in FHR
decelerations
– FHR decreases but not
below 100/min; occurs early before acme;
indicates fetal head compression; it is normal and
requires no nursing intervention.
Early deceleration
FHR decreases rarely below
100/min; occurs late, after acme (usually begins
as contraction peaks); cause by uteroplacental
insufficiency
late deceleration
– due to umbilical cord
compression
variable deceleration
Delivery stage
* From fully dilated cervix to the delivery or expulsion
of the baby
second stage of labor
– progresses from irritability to
participation, eagerness, and excitement.
maternal behavior
From the delivery of the newborn to the delivery of
the placenta.
third stage of labor
Power necessary for third stage of labor
strong uterine contractions to
effect separation; may need maternal pushing to effect
final delivery
power necessary for second stage of labor
primary and secondary powers.
Pushing with contractions; panting at intervals and at
crowning time.
power necessary for first stage of labor
uterine contractions
the delivery of placental with
the side closest to the baby emerging first.
More common; present in 80% of cases.
Placenta is expelled with the shiny “clean” side
first, bluish side.
Inverted umbrella shaped.
Less external bleeding because blood is usually
concealed first behind the placenta.
The type where separation starts from the center
to the edges
Schultze’s Mechanism
less common; present in 20% of
cases.
Roughly “dirty”, reddish maternal side out first.
Umbrella shaped, more external bleeding so it
appears “bloody”.
The amount of blood loss in delivery (whether
placenta is delivered by Schultze or Duncan
Mechanism) is 300 cc with 500 cc as the upper
limit. Bleeding exceeding 500 cc means
hemorrhages.
Inspect the placenta for completeness (first
nursing action after placenta is delivered).
Feel the fundus for contraction or firmness.
The initial activity of the nurse is to massage
fundus until firm. Ice cap may be applied to
further contract the uterus. * The term “soft”,
“boggy” or “non-palpable”, means uterine atony
Duncan Mechanism
Types of Placental Delivery or Presentation:
Schultze’s Mechanism
duncan mechanism
Signs of Placental Separation:
Calkin’s sign
Uterus becomes mobile
Sudden gushing of blood.
- Lengthening of the umbilical cord.
– the 1st sign.
This is when the uterus changes in shape, it
becomes globular, and the consistency becomes
firm.
calikin’s sign
Recovery stage.
* From the delivery of the baby to the first hour after
birth.
Fourth Stage of Labor
Pharmacologic Pain Management:
analgesic
anesthetics
power necessary for Fourth Stage of Labor
uterine contractions to prevent bleeding from
placental site.
drugs that relieve pain or alter its
perception may alter level of consciousness (LOC) and
reflex activity; administer as ordered and monitor
effects;
analgesic
Meperidine – Demerol)
- May initially slow labor, have depressive
effect on neonatal respirations.
- Administered when client in active labor (4 to
5 cm).
narcotics
Produce sedation and relaxation; often given
with narcotics because of potentiating effects;
when given alone, there may be little or no
analgesia; may also cause excitement and
disorientation in presence of pain.
- Examples are promethazine HCI (Phenergan),
hydroxyzine pamoate (Vistaril), promazine
HCI (Sparine) and diazepam (Valium)
tranquilizers
Produce sedation and alter memory.
- Example: scopolamine (belladonna alkaloid).
amnesics (rarely used today)
Produce sedation and alter memory.
- Example: scopolamine (belladonna alkaloid).
anesthetics
3 terms sa anesthetics
general, local, regional
induces sleep
general anesthetics
– used for pain during episiotomy and perineal
repair.
aanesthetics
local
For relief of perineal and uterine pain.
Usually safe for infant unless maternal
hypotension occurs.
anesthetics
regional
A tool to help in management of labor.
Guides birth attendant to identify women whose labor
is delayed and therefore decide appropriate action.
To avoid unnecessary interventions so maternal and
neonatal morbidity are not needlessly increased, to
intervene in a timely matter to avoid maternal and
neonatal morbidity or mortality
partograph
Types of Blocks
paracervical block
peridural block
intradural block
pudendal block
local anesthesia
given in 1st stage active phase;
rapid relief of uterine pain; relieves pain contractions;
has no effect on perineal area and does not interfere
with bearing down reflex.
paracervical block
given in 1st stage active phase or 2nd
stage of labor; produce rapid relief of uterine and
perineal pain; may be given in single doses or
continuously
peridural block
– given in the 2nd stage
intradural block
rapid onset; relieves uterine and
perineal pain; may also cause maternal
hypotension
spinal block
– rapid onset of pain
relief; used for forceps delivery and the client
must remain flat for 8 to 12 hours
saddle block
– given in the 2nd stage of labor; affects
perineum for about ½ hour; safe for newborn; no effect
on contractions.
pudendal block
Four Time Bound Interventions:
immediate drying
early skin to skin contact
properly timed cord clamping and cutting
Non-separation of the newborn from the mother for
early breastfeeding initiation and rooming
– blocks primary nerve pathways in
2nd stage; for delivery and episiotomy; short term
inhibition of pain receptor
local anesthesia
Non-separation of the newborn from the mother for
early breastfeeding initiation and rooming-in –
immediate drying
The first feed provides _____
colostrum
