B. INTRAPARTUM INTRAPARTUM CARE refers to the medical and nursing care given to a pregnant woman and her family during labor and delivery Extends from the beginning of contractions that cause cervical dilation to the first 1 to 4 hours after delivery of the newborn and placenta. •
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1.
Facto Factors rs affec affectin ting g labor labor and and delive delivery ry
a.
Passageway – refers refers to the adequacy adequacy of the pelvis pelvis and birth canal allowing fetal fetal descent; factors include:
i.
Types of female pelvis (INSERT PICTURE) A. Gynecoid – typical female pelvis with a rounded inlet B. Android – normal male pelvis with a heart shaped inlet C. Anthropoid – is an “apelike” pelvis with an oval inlet D. Platypelloid – is a flat, female-type pelvis with a transverse oval inlet
ii. ii.
Stru Struct ctur ure e of of Pel Pelvi vis s False pelvis vs. true pelvis A. FALSE PELVIS - Superior half formed by the ilia. Offers landmark for pelvic measurements. Supports the growing fetus into the true pelvis near the end of gestation TRUE PELVIS - Inferior half formed by the pubes in front, the ilia and the ischia on the sides and the sacrum and coccyx behind.
iii.
Adequa Adequate te deli deliver very y diame diameter ter A. Pelvic Inlet diameter Inlet – entrance way to the true pelvis. Its Transverse Transverse diameter is wider than its anteroposteror diameter. Also known as pelvic brim. B.
Pelvic Outlet diameter Outlet – inferior portion of the pelvis, bounded on the back by the coccyx, on the sides by the ischial tuberosities and in front by the inferi inferior or aspect aspect of the the symphy symphysis sis pubis pubis and the the pubic pubic arch. arch. Its Its anteroposterior diameter is wider than its transverse diameter. *Engagement*Engagement- refers to settling of the presenting part of the fetus into the pelvis to be at the level of the ischial spine, a midpoint of the pelvis. - descent to this point means the pelvic inlet is proven adequate for birth - “Floating”- a presenting part that is not engaged. - “Dipping”- one that is descending but has not reached the ischial spine *Station- or degree of engagement; refers to the relationship of the presenting part of a fetus to the level of the ischial spines - minus minus stati station ons s (-1 to -4)= -4)= prese presenti nting ng part part above above ischia ischiall spine spine,, measurement measurement in cm - plus plus statio stations ns (+1 to +4)= +4)= presen presentin ting g part part below below ischia ischiall spine spine,, measurement measurement in cm - station 0= presenting part engaged - station -4= presenting part is floating - statio station n +4= +4= prese presenti nting ng part is at outlet outlet or it is crown crowning ing (the encirclement of the largest diameter of the fetal head by the vulvar ring)
C.
Ability of the uterine segment to distend, the cervix to dilate and the vaginal canal and introitus to distend. o DILATATION Enargement of the external cervical os from 0 to 10 cm
o
b.
As a result of uterine contractions contractions and additionally as a result of pressure on the presenting part
EFFACEMENT Shortening and thinning of cervical canal from 0 to 100%
Primigravida – effacement effacement occurs before dilatation
Mutligravidas Mutligravidas – dilatation may precede effacement
Passenger This refers to the fetus and its ability to move through the passageway. i. Fetal sk skull Size Size of the fetal fetal head and capab capabilit ility y of the the head head to mold to the the passageway. o Molding- change in shape of fetal skull produced by force of contract contraction ion pressing pressing the head against against the not-ye not-yett dilated dilated cervix Parents are reassured that molding only lasts a day or two and is not a permanent condition No molding when fetus is breech. The fetal skull is the most important part of the fetus because: It is the largest part of the body o o It is the least compressible of all parts It is the most frequent presenting part o Fetal lie or presentation The part of the fetus that enters the maternal pelvis first; the body part that will be born first or contact the cervix first •
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A. Cephalic = head first; ideal presentation presentation for NSVD because because the bones of the skull are capable of molding so effectively to accommodate the cervix and may actually aid in cervical dilation
a.
B.
C.
b. c.
Vertex Vertex – head is sharply flexed, making the parietal bones the presenting parts Face Brow
d.
Chin or mentum
Breech – either buttocks or feet first; difficult birth; can be delivered NSVD a. Complete Complete breech breech – thighs thighs are are flexed flexed on on the abdomen abdomen and and legs legs are on thighs b. Fran Frank k bree breech ch – thig thighs hs are flexe flexed d and and legs legs are exten extende ded, d, resting on the anterior surface of the body c. Footling i. Doub Double le – legs legs unfl unflex exed ed and and exte extend nded ed;; feet feet are are presenting parts ii. Single – one leg flexe flexed d and extended extended;; one foot foot is the presenting part iii. Shoulder presentation- presenting part can be one of the shoulders (acromion process, an iliac crest, a hand or an elbow; CS delivery)
iii. Fetal LieLie- relationship between the long axis of the fetal body and the long axis f the woman’s body (cephalocaudal) a. Hori Horizo zont ntal al (tra (trans nsve vers rse) e) b. Vertica Verticall (longitud (longitudinal) inal)-- cepha cephalic lic or breech breech
iv. Fetal Attitude The relationship of fetal parts to one another; degree of flexion a fetus assumes during labor
GOOD ATTITUD ATTITUDEE- if in complete complete flexion; flexion; the spinal column is bowed forward, the the head is flexed forward so much that the chin touches the sternum, the arms are flexed and folded on the chest, the thighs are flexed onto the abdomen and the calves are pressed against the posterior aspect of the thighs MODERATE ATTITUDE- if chin is not touching the chest but is in alert or military position POOR ATTITUDE- the back is arched, the neck is extended and a fetus is in complete extension v. Fetal position The relationship of presenting part and the maternal pelvis which is divided into 4 quadrants: 1. 2. 3. 4.
Righ Rightt an anterior rior righ rightt post poste erior rior lef left ante nterior rior lef left pos postterio rior
Four parts of the fetus have been chosen as point of direction 1. 2. 3.
Occipu Occiputt -= in in verte vertex x presen presentat tation ion Chin Chin (men (mentu tum) m) – in in face face prese presenta ntatio tions ns Sacrum Sac rum – bre breech ech presen presentat tation ions s
4.
Scapula (acromion) – in shoulder presentations.
Possible fetal positions: LOA (left occipitoanterior)- most common fetal position (birthing is fast) LOP (left occipitoposterior)- difficult delivery; more painful LOT (left occipitotransverse) occipitotransverse) ROA (right occipitoanterior)- second most frequent (birthing is fast) ROP (right occipitoposterior)- difficult delivery, delivery, more painful ROT (right occipitotransverse) occipitotransverse) *Posterior positions may be more painful for the mother, because the rotation of the fetal head puts pressure on the sacral nerves causing sharp back pain. Other fetal positions found in p. 497
c.
Power refers to the frequency, duration and strength of uterine contractions to cause complete cervical effacement and d ilatation. Labor monitoring/ monitoring uterine contractions: > fingers should be spread lightly over the fundus > three phases of uterine contractions: contractions: i. crescendo/increment - intensity of the contraction increase. This phase is longer than the other two phases combined. ii. acme/apex- the height or peak of the contraction iii. decresenco/ decrementdecrement - intensity of the contraction decreases
Duration of contractions “How Long” From From the the beginn beginning ing of one contrac contractio tion n to the the end end of the same o contraction Duration during early labor- 20-30 seconds Duration in late labor- 60-70 seconds Should never be longer than 60-70 seconds because any muscle that is contract contracted ed does not have any blood supply supply and so will jeopardize the fetus
Interval o
From From the the end end of one contrac contractio tion n to the the beginn beginning ing of the the next next contraction Interval during early labor- 40-45 minutes Interval in late labor- 60-70 seconds
It is an import importan antt aspec aspectt of conta contacti ction on becaus because e it is during during this this relaxatio relaxation n period period when when the uterine blood vessels vessels refill themselves themselves with blood to supply the fetus with adequate oxygen
2.
Frequency “How Often” o From the beginning of one contraction to the beginning of the next contraction. T o Three to four contractions are timed to get a good picture of the frequency.
Intensity “How Strong” o The strength of contraction; may be mild, moderate, strong or severe o Measured by the consistency of the fundus at the acme of the contraction o When When esti estima mati ting ng inte intens nsit ity y, chec check k fund fundus us at conc conclu lusi sion on of contraction to determine whether it relaxes. o More strong: more pain
d.
Psyche refers to the client’s psychological state, available support systems, preparation for childbirth, experiences and coping strategies. strategies.
e.
Placental factors refer to the site of placental insertion.
Premonit Premonitory/ ory/prel prelimina iminary/ ry/ prod prodroma romall signs signs of labor labor
a.
Lightening – is the descent of the fetus and uterus into the pelvic cavity 2-3 weeks before the onset of labor. Effects of lightening Shooting pains down the legs because of pressure on the sciatic nerve Increased lordosis as the fetus enters the pelvis and falls further forward Increased amount of vaginal discharges Resurgence of sign of pregnancy like urinary frequency, as the gravid uterus impinges on the bladder Relief of abdominal tightness and diaphragmatic pressure • • • •
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b.
Loss Loss of we weigh ight 2- 3 lbs is loss 2 days prior to onset of labor, probably due to loss of appetite and decrease in progesterone level that leads to fluids excretion thus causing loss weight. Progesterone – is known to cause fluid retention
c.
Burst of energy or Increased tension and fatigue “Nesting behavior” behavior ” – may occur right before the onset of labor. Sudden burst of energy is due to increase in epinephrine in response to the stress brought about by the approaching delivery. Pregnant woman should be caution not to use this energy to carry out household chores because it is meant to prepare the body for the labor.
d.
Braxton Braxton Hicks Hicks contract contraction ion irregular irregular intermitt intermittent ent contract contractions ions that have have occurred occurred throughout the pregnancy, become uncomfortable and produce a drawing pain in the abdomen and groin; painless uterine tightening Also known as practice contraction.
e.
Cervical changes include softening “ripening” describe as butter soft and effacement of the cervix that will cause expulsion of the mucous plug (bloody show).
f.
Rupture of amniotic membranes or “the bag of water” may water” may occur before the onset of labor l abor.. •
Its rupture rupture may be seen seen as a sudde sudden n gush, gush, or a sca scant nty y, slow slow seepi seeping ng of amniotic fluid from the vagina.
It is important to remember that once membranes (BOW) have ruptured; Therefore labor is inevitable. Labor pains will set in within the next 24 hours. •
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g.
Since the integrity of the uterus has been destroyed, infection can easily set in. Thus, ASEPTIC Thus, ASEPTIC TECHNIQUE TECHNIQUE should be observed in doing perineal care. Doctors do less of the IE and enema s no longer given. Check for any umbilical cord compression and or cord prolapsed especially in breech presentation) presentation) o A woman seeking admission claims that her BOW has ruptured. FIRST NURSING ACTION : Put her to bed right away, then take the fetal heart tones. She should be allowed to remain in the standing position or sittin sitting g positi position on becau because se if its true true that that BOW BOW has has ruptu ruptured red,, the the possibility of cord compression is high. o If a woman in labor says that she feels a loop of the cord coming out of her her vagin vagina a (cord (cord prolap prolapse se), ), IMMEDIATE ACTION: Place Place her in trendelenberg trendelenberg position – to reduce pressure on the cord. REMEMBER: only 5 minutes of cord compression can already lead to CNS damage or even death Apply Apply a warm saline saline saturated saturated OS on the cord cord to prevent prevent crying of the cord. Color should be noted o Normal: Normal: clear clear, almost almost colorless colorless and contains white specks specks of vernix vernix caseosa. Abnormal: o green staining – amniotic fluid has been contaminated with meconium which signifies fetal distress if the fetus is in a nonbreech presentation yellow staining – may mean blood incompatibility Pink stain – may i ndicate bleeding If labor does not occur within the next 24 hours, the woman will have to be induced to go into l abor by administering intravenous drip of oxytocin (Pitocin).
Show This Show This is the blood-tinged mucus discharged from the vagina because of pressure of the descending descending fetal fetal part on the cervical capillaries, capillaries, causing their rupture. rupture. Capillary Capillary blood mixes with mucus when operculum is release that is why SHOW than a pinkish vaginal discharge. Show should be distinguished from bright red vaginal bleeding because the later is a danger sign during this phase of pregnancy.
ONSET OF LABOR Labor normally begins when a fetus is sufficiently mature to cope with extrauterine life, yet not to large to cause mechanical difficulties with birth. •
h.
Onse Onsett of labo labor r theo theori ries es
Possible Causes of the Onset of Labor Maternal Factor Theories Uterine Stretch Theory Uterine Uterine muscles muscles stretch stretch to capacity capacity,, causing causing release of prostaglandin
Fetal Factor Theories Theory of Aging Placenta Placen Placental tal aging aging and deter deterior iorati ation on trigg triggers ers initiation of contraction. contraction.
Oxytocin stimulation Theory Pressure on the cervix stimulates nerve plexus, caus causin ing g rele releas ase e of oxyt oxytoc ocin in by mate matern rnal al poste posterior rior pituit pituitary ary gland. gland. This This is known known as Ferguson reflex. reflex .
Fetal cortisol, produced by the fetal adrenal glands glands,, rises rises and acts on the placent placental al to reduce progesterone formation and increase prostaglandin.
Prostaglandin Theory Oxyt Oxytoc ocin in stim stimula ulati tion on in circ circul ulat atin ing g bloo blood d incr increa ease ses s slow slowly ly durin during g preg pregna nanc ncy y rises rises dramatically during labor, peaks during second stag stage. e. Oxyt Oxytoc ocin in and and pros prosta tagla gland ndin in work work together together to inhibit inhibit calcium calcium binding binding in muscle muscle cells, cells, raisin raising g intrac intracell ellula ularr calciu calcium m and thus thus activating contractions. contractions.
Prostaglan Prostaglandin din produced produced by fetal fetal membran membranes es (amn (amnio ion n and and chor chorio ion) n) and and the the decid decidua uas s stimulat stimulates es contract contractions. ions. When When arachidon arachidonic ic acid stored in fetal membranes is released at term, it is converted to prostaglandin.
Progesterone Deprivation Theory Estrogen/progesterone Estrogen/progesterone ratio shift----estrogen shift----estrogen excites the uterine response, and progesterone quiet quiets s the the uterin uterine e respon response. se. A decre decrease ase of progesterone allows estrogen to stimulate the contractile response of the uterus
3.
Differenti Differentiatio ation n betwee between n true true and and false labor labor False Labor Pains Remain irregular
True Labor Pains May be slight slightly ly irregul irregular ar at first first but become become regular and predictable within a matter of hours
Generally confined to the abdomen.
First felt in the lower back and sweep around to the abdomen in girdle-like fashion Increase in duration, frequency and intensity
No increa increased sed in durati duration, on, freque frequency ncy and and intensity
Continue no matter what the woman’s level of activity
Often disappear if the woman ambulates
Acco Accomp mpan anie ied d dilatation
by
cerv cervic ical al
effa efface ceme ment nt
and and
Absent cervical changes
4.
. Stag Stages es of La Labor
a.
First stage ( Stage of Dilatation) begins with the onset of regular contractions which cause cause progre progressiv ssive e cervi cervical cal dilation dilation and efface effaceme ment. nt. It ends ends when when the the cervix cervix is completely effaced and dilated. 1. Late Latent nt phas phase e - 1-4 1-4 cm 2. Acti Activ ve pha phase se - 4-7 4-7 cm 3. Transit ransition ional al phas phase e - 7-10 7-10 cm cm •
Power/Forces at work: involuntary uterine contracts
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PHASES
I.
Latent phase – early time in labor Regular contraction Cervical dilation – 1 to 4 cm Intensity: mild to moderate Uterine Uterine contract contractions ions occur occur Q15-30 Q15-30 minutes minutes and are 15-30 15-30 seconds in duration and of mild intensity Mother is talkative and eager to be in labor
II.
Active Phase – Cervical dilation 4-7 cm Uterin Uterine e contr contract action ions s occ occur ur Q3-5 Q3-5 minut minutes es and and are 30-60 30-60 seconds in duration
Contra Contracti ction: on: modera moderate te to strong strong,, freque frequent, nt, longer longer more more painful Mother may experience feeling of helplessness and becomes restless and anxious as contractions intensifies Woman fears losing control of herself
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III III..
b.
Tran Transit sitio iona nall Phase Phase Cervical dilation 8-10 cm Uterine contractions occur every 2-3 minutes and are 45-90 seconds in duration and of strong intensity Mother becomes tired, is restless and irritable and feels out of control Mood change AMNIOTOMY (if not yet ruptured) Gaping (bulging) of vagina or anus or perineum AMNIOTOMY AMNIOTOMY is not done if the station is still negative because because this can lead to cord compression
Second Second Stage( STAGE STAGE OF EXPULSI EXPULSION) ON) – Begins Begins with complete complete dilatation dilatation of the cervix and ends with delivery of the newborn. Duration may differ among primiparas (longer) and multiparas (shorter), but this stage should be completed within 1 hour after complete dilatation.
*Powe *Power/F r/Forc orces es at work: work: INVOLU INVOLUNT NTARY ARY UTERI UTERINE NE CONTRA CONTRACT CTION IONS; S; CONT CONTRAC RACTIO TIONS NS OF THE DIAPHRAGMATIC AND ABDOMINAL MUSCLES i. Contrac Contractions tions are are severe severe at at 2-3 minut minute e interva intervals, ls, with with a durat duration ion of 50-90 50-90 seconds ii. Cervic Cervical al dila dilatio tion n is comple complete te iii. iii. Progre Progress ss of labor is measure measured d by desce descent nt of fetal fetal head head thru the the birth canal canal (change in fetal station) iv. iv. Uterine Uterine contract contractions ions occur occur every 2-3 minutes, minutes, lasting lasting 60-75 60-75 seconds, seconds, and the intensity is strong. v. Increa Increase se in bloody bloody show show vi. Mot Mothe herr feels feels the the urge urge to to bear bear down down The newborn exits the birth canal with the help from the following cardinal movements, or mechanisms of labor (D FIRE ERE) DESCENT- fetus goes down the birth canal (preceded by engagement) FLEXION- pressure on the pelvic floor causes the fetal chin to bind towards the chest INTERNAL ROTATION – from antero-postero to transverse then AP to AP EXTENTION EXTENTION – as the head comes out, the back back of the neck stops beneath beneath the pubic arch. The head extends and the forehead, nose, mouth and chin appear EXTERNAL ROTATION ROTATION (also known as restitution) – anterior shoulder rotates externally to the AP position so that it is just behind the symphysis pubis EXPULSION – the delivery of the rest of the body
Episiotomy
Prevent prolonged & severe stretching of the muscles Natural anesthesia (synchronized with pushing of the woman)
Done to facilitate delivery and avoid laceration of the perineum Reduce duration of second stage Enlarge outlet in breech presentations or forcep delivery
TYPES OF EPISIOTOMY Median Mediolateral Application of Ritgen’s Maneuver is the best method for delivery As soon as crowning is taking phase, cover anus with sterile towel to exert.
c. Third Stage (Placental Expulsion) - Begins with the delivery of the and ends with the delivery of the placenta.
baby
Placental separation and expulsion occur Placental birth occur 5-30 minutes after birth of baby. baby.
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Placental Separation(Mechanisms) Separation(Mechanisms)
o o
SCHULTZE SCHULTZE MECHANISM: center portion of placenta separates first and its its shin shiny y feta fetall surf surfac ace e emer emerge ges s from from the the vagi vagina na.. SHIN SHINY Y AND AND GLISTENING DUNCAN MECHANISM: margin of placenta separates, and the dull, red, rough maternal surface emerges emerges from the vagina. DIRTY, RAW, RAW, RED AND IRREGULAR WITH THE RIDGES OR COTYLEDONS
Signs of P lacental Separation Separation o uterus becoming globular (calkin’s sign) o Fundus rising in abdomen o gushing of blood Lengthening of the cord o Contractions of the uterus controls uterine bleeding and aids with placental separations and delivery. Generally, oxytocic drugs (oxytocin 10-20 units) are administered to help the uterus contract (after placenta out)
METHERGINE PROMOTES UTERINE CONTACTION AND PREVENTS POSTPARTUM HEMORRHAGE PRODUCE STRONG AND EFFECTIVE CONTRACTION ASSESS VITAL SIGNS (BP) DO NOT ADIMINISTER IF BP IS 140/90 mmHg LEADS TO HYPERTENSION
DISCONTINUE: MARKED VASOCONSTRICTION (COLDNESS, PALENESS, NUMBNESS OF THE FEET AND HAND); NOTIFY THE PHYSICIAN
OXYTOCIN INCREASES UTERINE CONTRACTION MINIMIZED UTERINE BLEEDING INCREASES BLOOD PRESSURE (VASOCONSTRICTION)
d. Fourth Stage ( Recovery and Bonding)- From the delivery of the placenta until the postpartum condition of the woman woman has become stabilized (usually after 1 hour after delivery). – – – –
the period of time from 1-4 hours after delivery the mother and newborn recover from the physical process of birht The maternal organs undergo initial readjustment readjustment to the nonpregnangt state The newborn baby systems begins to adjust to extrauterine life and stabilize
Monitoring the Blood Pressure Blood Pressure should not be taken during a contraction as it tends to INCREASE, because no blood supply goes to the placenta during contraction. All the blood is in the periphery, which explains the increased BP during contraction BP taking should be taken at least every half hour during active labor Whenever a woman complains of a HEADACHE, remove the blood pressure apparatus from the arm right away (pr iority intervention) 5. A.
Mana Managi ging ng Disc Discom omfo fort rts s Dur in ing La Labor
1.
Physical Assessment. Assessment. General physical examination, Leopold’s maneuvers and/or internal examination are done.
2.
Bath. Bath is advisable if contractions are still tolerable or are not too close to one another another. Bathing Bathing will not only ensure ensure cleanline cleanliness ss but will also provide provide comfort comfort and relaxation.
3.
Perineal Preparation. Perineal Perineal flushing flushing is done to prevent prevent contaminat contamination ion of the birth canal and reduce possibilities of postpartum infection.
4.
Ambulation. Unless contraindicated (by medications, intravenous infusion or ruptured membranes), ambulation is advised during the latent phase of labor in order to help shorten the first stage of labor.
5.
Diet . Solid a) b) c)
6.
Enema Administration. Administration. Enema is not a routine procedure for all women in labor but may be done for the fol lowing reasons: a) A full full bowe bowell hind hinder ers s labo laborr prog progre ress ss;; enem enema a incr increa ease ses s the the spac space e avail availabl able e for passag passage e of the the fetus fetus and and improv improves es freque frequency ncy and and intensity of uterine contractions. b) Enema Enema decrease decreases s the possibilit possibility y of fetal conta contamina mination tion of the the perineum perineum during the second stage of labor. c) A full bowel bowel can add to the discom discomfor fortt of the imme immedia diate te postpa postpartu rtum m period. Contraindications Contraindications of enema: a) Vagin aginal al blee bleedi ding ng b) Prem Premat atur ure e labo laborr c) Abnor Abnormal mal fet fetal al presen presenta tatio tion n or posit position ion d) Rupt Ruptur ured ed memb membra rane nes s e) Crowning
or liquid foods are avoided for the following reasons: Diges Digestio tion n is delay delayed ed during during labo laborr. A full full stomach stomach interfere interferes s with proper proper bearing bearing down. down. Aspiratio Aspiration n may occur occur during during the reflex reflex nausea nausea and and vomiting vomiting of the the transitio transition n phase or when anesthesia is used.
7.
Voiding. The woman in labor should be encouraged to empty her bladder every 2-3 hours because: a) full full bladde bladderr retard retards s fetal fetal des descen cent. t. b) urinary urinary stasis stasis can can lead lead to urinary urinary tract tract infection infection.. c) a full full bowel bowel may may be be traum traumatize atized d during during delive delivery ry..
8.
Breathing Technique. The woman in the 1st stage of labor should be instructed not to push or bear down during contractions because it will not only lead to maternal exhaustion but, more importantly, unnecessary bearing down can lead to cervical edema bacause of the excessive pounding of the fetal presenting part of the pelvic floor, thus interfering with labor progress. To minimize bearing down, down, the patien patientt should should be advise advised d to do abdomi abdominal nal breat breathin hing g during during contractions.
9.
Position. Encourage the woman in labor to assume Sim’s position because: a) It favor favors s anteri anterior or rotat rotation ion of of the head. head. b) It promotes promotes relaxatio relaxation n betwee between n contr contractio actions. ns. c) It preve prevent nts s Supine Supine Hypote Hypotensi nsive ve Syndr Syndrome ome..
The inferior vena cava, the blood vessel which carries unoxygenated blood back to the heart, lies just above the spinal column. When a pregnant woman lies flat on her back, the inferior vena cava is caught between the gravid uterus and the spinal column, causing a drop in arterial blood pressure, which leads the woman to complain of dizziness.
10. Contractions.
Uterine contractions are monitored every hour during the latent phase of labor and every 30 minutes during the active phase by spreading the fingers lightly over the fundus.
11. Vital
Signs. Signs. Blood Pressure (BP) and Fetal Heart Rate (FHR) are taken every hour during the latent phase and every 30 minutes during the active phase. Definitely, BP and FHR should never be taken during a contraction. During uterine contractions, contractions , no blood goes to the placenta. The blood is pooled to the peripheral peripheral blood vessels which results results in increase increased d BP. BP. Therefor Therefore, e, the blood pressure should be taken in between contractions contractions and whenever the mother in labor complains of a headache. headache.
12. Danger Signals. The nurse must be aware of the foll owing danger signals during labor and delivery. delivery. a) Sign Signs s of of fet fetal al dis distr tres ess s 1) Tachycardia achycardia (FHR (FHR more more than 180)B 180)Brady radycardi cardia a (FHR less less than 100) 2. Meconium-stained Meconium-stained amniotic fluid in non-breech presentation presentation 3. Fetal Fetal thrashing thrashing or hyperact hyperactivity ivity due to fetal fetal struggling struggling for more oxygen b) Sign Signs s of mate matern rnal al dist distre ress ss 1. BP over 140/90, or a falling BP associated with clinical signs of shock (pallor, restlessness or apprehension, increased respiratory and pulse rates) Bright red vaginal bleeding or hemorrhage(blood loss of more 2. than 500 cc) 3.
Abnormal abdominal contour (may be due to uterine rupture or Bandl’s pathological ring, a condition wherein the muscles at the physio physiolo logica gicall retra retracti ction on ring ring becom become e very very tense tense,, gripping the fetus causing possible fetal distress)
13. Administration of Analgesics.
Narcotics are the most commonly used analgesics, specifically Demerol (meperidine hydrochloride). Demerol acts to suppress the sensory portion of the cerebral cortex. A dose of 25-100 mg is given and it takes effect within 20 min when the patient experiences a sense of well being and euphoria. Demerol, being also an antispasmodic, should not be given very early in labor because it will retard labor progress.
It should not also be given when delivery is less than an hour away because it can cause respiratory depression in the newborn. It is , therefore, preferably preferably given when cervical dilatation is around 5-8 cm.
14. Administration of Anesthetics.
Regional anesthesia is preferred over any other form because it does not enter the maternal maternal circulation and therefore therefore does not retard labor contractions nor cause respiratory depression in the newborn.
15. Transfer of Patients.
A sure sign that the baby is about to be born is the bulging of the perineum. In general, multiparas are transported to the delivery room when cervical dilatation is about 7-9 cm, while primiparas are transferred to the delivery room at full dilatation with perineal bulging when crowning is taking place.
B.
Duri During ng Deli Delive very ry
1.
Positioning on the Delivery Table. When positioning the woman on lithotomy on the delivery table, the legs should be put up slowly at the same time on the stirrups in order to prevent trauma to the uterine ligaments and backaches or leg cramps. The same should be done when putting the legs down from the stirrups after delivery.
2.
Bearing Down Technique. Technique. At the beginning of a contraction, the woman is asked to take two short breaths, then to hold her breath and bear down at the peak of contraction. She should also be told to use blow-blow breathing pattern to prevent pushing between contractions.
3.
Care of the Episiotomy Wound. Episiotomy, Episiotomy, a perineal incision done to facilitate the birth of the baby, is made by the doctor primarily to prevent lacerations. No anesthesia is necessary during episiotomy b/c the pressure of the fetal presenting part against the
perineum perineum is so intense intense that the nerve endings for pain are momentari momentarily ly deadened deadened (natural anesthesia). anesthesia).
4.
Breathing Technique. Technique. As soon as the head crowns, the woman is instructed not to push any longer because it can cause rapid expulsion of the fetus. Instead, she should be advised to pant (rapid and shallow breathing).
5.
Ritg Ritgen en’s ’s Mane Maneuv uver er.. a) Suppor Supportt the the perine perineum um during during crowning crowning by applyi applying ng pressur pressure e with with the palm against the rectum. This will not only prevent lacerations of the fourchette but will also bring the fetal chin down the chest so that the smallest diameter of the fetal head is the one presented at the birth canal. b) in order to to prevent prevent rapid rapid expulsion expulsion of the the fetus fetus which could could result result not only only in lacerations, abruptio placenta, and uterine inversion but also to shock because of sudden decrease in intraabdominal pressure, the head should be pressed gently while it slowly eases out.
6.
Time of Delivery. Take note of the time the baby is delivered.
7.
Handling of the Newborn. Immediately after delivery, delivery, the newborn should be held below the level of the mother’s vulva so that blood from the placenta can enter the infant’s body on the basis of gravity flow.
The newborn should be held with his head in a dependent position to allow drainage of secretions. A newborn newborn is never never stimulat stimulated ed to cry unless he has been drained drained of his secretions secretions because he can aspirate these secretions into his lungs. The newborn newborn should be immediate immediately ly wrapped wrapped in a clean diaper diaper to keep him warm because chilling increases the body’s need for oxygen. He should then be placed on his mother’s abdomen so that the weight of the baby can help contract the uterus; a noncontracted noncontracted uterus can l ead to death due to hemorrhage
8.
Cutting Cutting of the cord. Cutting of the cord is postponed until pulsations have stopped because because it is believed believed that 50-100 50-100 ml of blood is flowing from the placenta placenta to the newborn at this time. It is then clamped twice, an inch apart, and cut in between.
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Initial Contact. Contact. Maternal-infant Maternal-infant bonding is initiated as soon as the mother has eye-to-eye eye-to-eye contact with her baby. The mother is informed of her baby’s sex and helped to hold and inspect her baby if she wishes.
Nursing Diagnosis • • • •
Fear r/t uncertainty about the outcome of the birth process Acute Pain r/t uterine contraction, cervical dilatation and fetal descent Health Health seeking seeking behaviors behaviors:: Informat Information ion about about the fetal monitor monitor r/t an expresse expressed d desire desire to understand equipment used Readiness for enhanced family processes r/t opportunity to incorporate newborn into the family
Fetal Heart Monitoring Goal: to detect signs that identifies fetal distress in its early stages PARAMETERS Baseline heart rate 120-160 bpm Tachycardia Moderate 161-180 bpm Marked >180 bpm Bradycardia Moderate 100-119 bpm Marked <100 bpm Acceleration >15 bpm for >15 sec Deceleration Early Late Variable
10-40 bpm 50-60 bpm 10-60 bpm
INTERPRETATION Normal Nonreassuring Abnormal Non reassuring Abnormal Stimulation Maternal fever Head compression Hypoxia/acidosis Cord compression Non reassuring
Severe bradycardia- FHR less than 80 bpm Persistent severe bradycardiabradycardia- severe bradycardia that persists for longer than 5 minutes Accelerations FHR increases than 15 bpm for more than 15 seconds Appear as smooth patterns on electronic fetal monitoring Good indicators of fetal well-being Triggered in the normal mature fetus by fetal body motions, sounds stimulations of the fetal scalp and other stimuli Early decelerations decelerations Normal and common Deceleration Deceleration pattern matches the contraction with the most deceleration occurring at the peak of the contraction FHR rarely goes below 100 bpm Cause: head compression during uterine contraction Late decelerations Decrease in FHR from the baseline rate with a lag time of greater than 20 seconds from the peak of contraction First appear at or after the peak of the uterine contractions. The FHR improves only after the contraction has stopped. May be mild or severe based on how low the FHR goes and how long it takes for the FHR to recover Caused by reduced blood flow to the uterus and placenta during contraction Associat Asso ciated ed with uteroplacent uteroplacental al insufficien insufficiency cy and is a conseque consequence nce of hypoxia hypoxia and metabolic metabolic abnormalities Variable deceleration Common type of FHR deceleration in labor Cause by umbilical cord compression Significance depends on how low the heart rate drops and how long the episode lasts Classified severe if they last more than 60 seconds or to a FHR of less than 90 bpm Interventions Interventions for late or variable decelerations decelerations lasting more than 60 seconds: 1. Repo Reposi siti tion on the the pat patie ient nt 2. Admini Administe sterr oxyge oxygen n by face face mask mask 3. Disc Discon onti tinu nue e oxyt oxytoc ocin’ in’ 4. IV fluid fluids s to incr increa ease se mate materna rnall volume volume 5. Noti Notify fy phys physic icia ian n 6. Vagin Vaginal al exam exam to chec check k for prola prolapse psed d of cord cord 7. Prepar Prepare e for emerg emergenc ency y caesar caesarean ean sect section ion TYPES OF CHILDBIRTH: 1. Vagin aginal al deli delive very ry A natural process that usually does not require significant medical intervention NSVD- normal spontaneous vaginal delivery Forceps Forceps delivery delivery-- vaginal vaginal delivery with the use of obstetri obstetric c forcep forcep (an instrument instrument designed to extract the baby’s head) Indications: o Uterine inertia or poor uterine contraction and the second stage has gone pass two hours Face presentation; presentation; OA in flat pelvis, OP position Relative CPD Cardiac and pulmonary disorders of the mother, maternal exhaustion Late decelera deceleration tion pattern, pattern, excessive excessive fetal fetal movement movement,, meconium meconium stained in cephalic presentation presentation • • •
2.
Lebo Leboy yer met method hod Postulated that moving from a warm, fluid-filled intrauterine environment to noisy air filled, brightly lit birth room creates a major shock for newborn •
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He proposed that birthing room should be darkened, kept pleasantly warm, soft music is played, infant is gently handled, cord is cut late and placed immediately into a warm water bath Advantage: Advantage: ideal for most birthing institution Disadvantage: o warm bath could reduce spontaneous respiration and high level of acidosis; late cutting of the cord causes excess blood viscosity in newborn o
Hydrot Hydrothe herap rapy y and and Water Water Birth Birth Baby is born underwater and immediately brought to the surface for a first breath Advantage: Advantage: reduce discomfort in labor Disadvantage: o Contamination Contamination of bath water with feces expelled o Aspiration of bath water by fetus: pneumonia o Maternal chilling • • •
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4.
Uterine infections- pushing efforts in 2 nd stage of labor
Caes Caesar area ean n birt birth h Latin word “caedore” means to cut Birth accomplished through abdominal incision into the uterus, after 28 weeks AOG Emergency procedure (under general anesthesia) or elective procedure (under spinal) Indications : o CPD o Placenta previa o Abruption placenta o Malpresentation Malpresentation or malposition o Preeclampsia/eclapmsia o Fetal distress o Cord prolapsed o Previous CS o Cervical dystocia o Cancer of the cervix o Other factors: poor obstetrical history, vaginoplasty, vesico-vaginal fistula • • • •
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Complications o Uterine rupture in subsequent pregnancy o Postop infection o Injury to urinary system o Injury to uterine vessels o Embolism Types: o
Classic caesarean section Incision made vertically through the abdominal skin and uterus Advantage: incision is made high on the uterus to avoid cutting the placenta and be used with placenta previa Disadvantage: Leaves a wide skin scar Scar could rupture during labor and not be able to have a subsequent vaginal birth Low segment incision Lower segment transverse caesarean section (LSTCS) Made horizontally across the abdomen over the cervix Referred to as pfannesteil incision or bikini incision Advantage: Less likely to rupture in subsequent subsequent labours Less blood loss- easier to suture Decrease postpartal infections Less possibility of GI complications Disadvantage: Longer procedure No assurance for small skin incision and small uterine incision • •
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