INTRAPARTAL PERIOD
From onset of contractions, dilation of cervix up to first 4 hours after delivery
All products of conception are expelled
(baby, placenta and fetal membranes)
Intrapartum Care…care during labor and delivery
Intrapartum…
Fetal expulsion along with products of conception due to:
regular, progressive & frequent
uterine contractions
Parturient – woman in labor Puerpera – woman who gave birth
LABOR…
LABOR ONSETa. Stretching of uterine musclesb. ↓ progesteronec. Release of oxytocind. Maturity of placentae. ↑ prostaglandin
↓Contraction of Uterus
↓Expel products of conception
Preliminary Signs of Labor
a. Lighteningb. Weight lossc. Braxton Hicks Contractiond. Apprehension & Restlessness
RegularRegular , ↑↑ frequencyfrequency, ↑ , ↑ intensity & Shorter IntervalShorter Interval of contractions
Rupture of Rupture of amniotic amniotic membranesmembranes
Effacement and Dilatation
TRUE LABOR Pain = Pain = Back Back
discomfortdiscomfort radiating to abdomen & legs
IntensifiedIntensified by Walking
Bloody showBloody show
Contractions persistpersist during sleep & sedation
4 Stages of Labor1. First Stage – onset of true labor to complete dilation
2. Second stage – complete cervical dilation to delivery
3. Third Stage – placental stage
4. Fourth Stage – first 4 hours after delivery of placenta
Maternal Factors Affecting
Labor Process(5 P’s)
a. Passageway (pelvis)b. Passenger (Fetus & Placenta)c. Power d. Placentae. Psychologic response of mother
› maternal pelvis› Route of fetus when
leaving the uterusIschial spines
= degree of descent (station) of fetal headAbove ischial spine - station
Floating (unengaged)Ischial spine
station 0; engagedBelow ischial spine
+ station
1. Passageway (Pelvis)
Pubis
= front portion
= 2 pubic bones meet at symphysis pubis
Estrogen & Relaxin = Relaxes the symphysis pubis
Slight separation allowing room
for the fetal head
Pelvic Types…1. Gynecoid- Normal female pelvis- Round & wide- Good vaginal
delivery
2. Anthropoid- Narrow, oval- Like ape pelvis- Good Vaginal Delivery
3. Platypelloid- Flat- Poor vaginal
delivery4. Android- Heart-shaped - like male pelvis- Poor vaginal
delivery
› Refers to fetus
› Fetal head consists of :
vault, face & brow
2. Passenger BROW From nose to
anterior fontanel
FACE From chin &
neck to root of nose
2 Frontal Bonesforehead
2 Parietal Bones crown of head
2 temporal Bones
side of head 1 Occipital
Bonesback of head
Vault of fetal head is composed of:
Bones meet at suture lines Allow bones to overlap
(molding/overlapping)
MOLDING - Due to uterine contractions- Head is pressing against
the cervix
Making skull to ↓ in size Easier passage thru birth
canal
Anterior Fontanel - Posterior Fontanel› Bregma
› Large, diamond shape
› Membranous floor
› Formed by 4 bones (2 frontal & 2 parietal)
› ossified by 1 ½ years of age (12-18 mo)
› Lambda
› Small, triangle shape
› Bony floor
› Formed by 3 bones (2 parietal & 1 occipital bones)
› ossified at full term (6-8 wks = 2-3 mo)
3. POWER Force of uterine contractions Refers to:
IntensityDuration
FrequencyInterval
of uterine contractions to result in cervical effacement & dilation
PRIMARY POWER SECONDARY POWER
Uterine contractions
Maternal bearing down
(readiness for pushing)
Intra-abdominal pressure
a. Uterine Contractions (primary power) - wavelike manner
Phases of Intensity: Increment – intensity ↑ - builds up & longest phase Acme – contraction is at its strongest - peak of contraction Decrement – intensity ↓ - letting down phase
Monitor contractions
Rest a hand onwoman’s abdomen at the fundus of uterus
Sense the gradual tensing andupward rising of fundus thataccompanies a contraction.
Strength of contraction during acme Determined by palpation
Mild – minimally tense. - indented easily with fingertips
Moderate – feels firm; fundus is difficult to indent
Strong – so intense; uterus feels hard as wooden board at peak of contraction - Fundus is firm, can’t be indented with fingers
.
Duration – beginning to end of same contraction
- Seconds - Report if more than 90 sec - During transition phase (2nd stage of
labor)
Frequency - beginning of 1 contraction to beginning of next
contraction. - Minutes; Report if less than 2 minutes
2 parts: 1. Duration of contraction 2. Period of relaxation
Interval – From decrement of first to increment of 2nd contraction
You are ready to push if:
- Cervix is 10 cm dilated & 100% effaced
Dilatation – Widening of cervical canal - Advances from 0 – 10cm- As cervical canal opens = resistance ↓- This eases fetal descent- 10 cm = fully dilated
Effacement… Thinning, shortening of cervical canal Expressed in % 100% effaced cervix = cervical canal is
paper thin or absent 75% = cervix is ¼ of its original length 50% = cervix is ½ of its original length
b. Intra-abdominal pressure This is another secondary power
As the woman pushes, the intra-abdominal pressure increases
Patient Monitoring… Void Frequently
- Full bladder hinders fetal descent
- Cause dysfunctional labor
- If bladder is distended = it is palpable, notify physician
- Catheterization may be necessary
4. Placenta Placental Separation
Calkin’s sign = Uterus becomes globular & firm
Fundus of uterus rises in the abdomen
Umbilical cord lengthening
Gush of blood from the vagina
Placental Expulsion
Natural bearing down of the mother
Gentle pressure on contracting uterus
(Crede’s maneuver)
Brandt andrews maneuver downward sideways gentle controlled cord traction
Crede’s Maneuver
Brandt Andrews Maneuver
Schultze placenta (80%)
Separates at center & fold
(inverted umbrella)
fetal surface exposed Shiny & glistening
Less external bleeding; blood is concealed behind the placenta
Duncan placenta (20%)
Separates at its edges
Umbrella shaped
Maternal surface exposed
Rough, red, raw & irregular from ridges
More external bleeding
Appears bloody
Stages: cont’d
Third stage Placental separation Placental delivery
Fourth stage 1-4 hours
After placenta is delivered= veins in the place of attachment
at decidua is 7cm dilated = mother is prone to hemorrhage
MUST promote contraction after delivery
Average blood loss = 250-300 ml 500 ml or above = postpartal
hemorrhage (maternal mortality)
5. Psyche/ Psychologic Response of Mother
Psychological state
Feelings women bring to labor
Experience & coping mechanisms.
•Amniocentesis - couvade syndrome •Pap smear - placenta•FHR - probable sign•Leopold’s - amniotic fluid•Pregnancy test - fetal distress•Prenatal visit - smoke – effect to NB•Primipara & primigravida - TT•Morning sickness - foods rich in folic acid•Hyperemesis gravidarum - exercise for back pain•Quickening - iron supplement•Uti - foods rich in iron•Weight gain - varicose veins
•Leg cramps - dyspnea•Constipation - Johnson’s rule•Iodine rich foods - bartholomew’s rule•Heartburn/pyrosis - naegele’s rule•Anemia - haase’s rule•Kegel’s exercise - mc donald’s rule•Clothes for pregnant women - incidence of twins•Vaginal secretions/leukorrhea - lightening•Urinary frequency - mesoderm•Alcohol - products of conception•Teratogen - sequence of conception•Type of exercise - implantation
•Cocaine - dilation•AVA - effacement•Fetal attitude - break BOW•Fetal presentation - VBAC•Fetal position - types of placenta•Fetal station - advantage of episiotomy•Pelvic shape - breech presentation•Position for vaginal delivery - types of breech•Cardinal movements of labor - intensity, duration,•Crowning interval, frequency•Laceration - TPAL•Placental separation - 4 stages of labor
Pain Management During Intrapartum Period
Pain during labor accompanies:uterine contractions
cervical dilatation & effacement fetal descent
Response to pain:↑ VS & muscle tension
Hostility, fear or depressionGroaningSweating
Nonpharmacologic measures
Read Method Slow abdominal
breathing in 1st stage of labor:
1 breath/minute (30 sec inhalation & 30 sec exhalation)
Use of panting to prevent pushing until needed
Bradley Method Husband-coached Modification of
Read method
Lamaze Method breathing, effleurage,
relaxation
Blocks recognition of pain
Lamaze breathing techniquescontrolled chest breathing
Slow = inhale thru nose = exhale thru mouth/nose = 6 – 9 times/min
Pant-blow = rapid, shallow breathing thru the mouth only during contractions
Leboyer Method environment Room is darkened Pleasantly warm with soft
music playing
Focusing, Relaxation & Positioning
obstruction Concentrate on
photograph or object during contractions
Imagery
Mental concentration on person, place or thing
Sound = aids in maintaining her concentration on the image
Effleurage Light abdominal massage
woman traces a pattern on the skin – repeating it over and over
For mild to moderate discomfort
Distraction Diversion of attention - early labor Playing games or recalling pleasant
experiencesYoga
Deep-breathing exercises, body stretching postures and meditation
helping the body relax and possibly releasing endorphins
a. Acupuncture – stimulation of trigger points with
needles- release of endorphins to reduce
pain
a. Acupressure – finger pressure or massage at
the same trigger point
a. Opioidsb. Sedativesc. Anesthetics:
EpiduralSpinalLocal
Pharmacologic measures
a. Opioids Commonly used drugs include: Meperidine (Demerol) Butorphanol (Stadol) Nalbuphine (Nubain) Maternal adverse reaction: Respiratory depression Nausea & vomiting Drowsiness Transient hypotension
b. Sedatives Barbiturates - used in early latent
phase of labor secobarbital (seconal) pentobarbital (Nembutal)
Benzodiazepines – midazolam (Versed)
c. Regional Aesthesia Block specific nerve pathways blocking of nerve conduction
Lumbar Epidural Anesthesia Injection into epidural space
Can cause hypotension Can slow down labor process- patient awake & cooperative in delivery- Provides analgesia for the 1st & 2nd stages of
labor & anesthesia for birth
Epidural animation
Spinal Anesthesia injected at cerebrospinal fluid (CSF) at Lumbar 3-
4 Hypotension can occur Spinal headache Increase incidence of urinary retention
Local anesthesiaLocal anesthesia during actual birth of the fetus• injection into perineal nerves• receives relief from discomfort only at receives relief from discomfort only at
delivery not during labordelivery not during labor
Nursing Interventions Know type of anesthesia (Drug Rights)
Allay anxieties; answer questions
Assist in preparation & administration
monitor patient and fetus
adverse reaction = notify physician & have emergency equipment available
Fetal Factors Affecting the Labor
Process:(5 F’s)
Fetal Lie Fetal Attitude Fetal Presentation Fetal Position Fetal Station
1. FETAL PRESENTATION Describes fetal body part to pass
thru cervix and be delivered
The part felt on IE
I. CephalicII. Breech
III. ShoulderIV. Compound
Abnormal Animation(Jot Down Notes)
I. Cephalic Presentation – Head presents first at the cervix
Vertex presentationSinciput/forehead presentation
Brow presentationMentum/Face presentation
Vertex Sinciput/ForeheadSinciput/Forehead
› head is sharply flexed
› posterior fontanel (lambda)
› Chin touches the sternum
› Fetal Attitude: complete/full flexion
chin is not touching the chest
alert or military position
Anterior fontanel (bregma)
Fetal Attitude: Moderate flexion
Brow Brow Mentum/Face
head is moderately extended
brow enters first
Fetal Attitude: Partial extension
› fetal head is hyperextended
› chin presents first
widest diameter
› Fetal Attitude: Complete extension
During labor, the fetal skull press cervix becomes edematous from continued pressure against it.
This edema is called CAPUT SUCCEDANEUM.
II. Breech Presentation – either buttocks/feet are
first to contact the cervix
3 Types: Complete Frank Footling
Complete Breech Presentation…
Thighs are tightly flexed on abdomen
buttocks & flexed feet to present first
Frank Breech Presentation… fetal hips are
flexed but legs are extended, resting on chest
buttocks to present first
Footling Breech Presentation…
1 or both extremities are the presenting part
Most difficult
Cord prolapse is common because of the extended leg
Cesarean birth may be necessary
In breech presentation =
passage of meconium is not a sign of fetal distress
PINARD MANEUVER
MAURICEU MANEUVER
PRAGUE MANEUVER
Breech delivery Video(Jot Down Notes)
III. Shoulder Presentation presenting part is the shoulder, iliac crest,
hand or elbow
abdomen have an abnormal shape –wider horizontally & shorter vertically
transverse lie fetus must be turned before delivery;
successful if fetus is small or preterm
Cesarean birth = to reduce risk of fetal or maternal mortality
IV. Compound Presentation
An extremity prolapses alongside the major presenting parts
2 presenting parts appear at pelvis
2. Fetal Lie Relationship of (spine) of the
fetus to the (spine) of the mother
Can be:I. LongitudinalII. TransverseIII. Oblique
I. Longitudinal Lie Fetal spine parallel
to maternal spine
Fetus is lying top-to-bottom
Can be classified as cephalic or breech
perpendicular to maternal spine
The fetus is lying side-to-side
If labor progresses, the presenting part may be a shoulder, iliac crest, hand or elbow
II. Transverse Lie
TransverseLongitudinal
III. Oblique Lie The fetal spine is 45° angles to
maternal spine
midway between transverse and longitudinal lies
abnormal if fetus maintains this position
Fetal Lie Video(Jot Down Notes)
Degree of flexion
Could be:I. Complete/Full Flexion
II. Moderate FlexionIII. Partial Extension
IV. Complete Extension
3. Fetal Attitude
I. Complete/Full Flexion Most common
Neck is completely flexed
chin touching sternum
vertex presentation
ideal attitude
occupies smallest space in the uterus
II. Moderate Flexion 2nd most common military position
Straight head appear to be “at attention”
Neck is slightly flexed chin doesn’t touch chest
sinciput/forehead presentation
III. Partial Extension IV. Complete Extension
brow presentation
Neck is extended
Head is moved backward
cause a difficult delivery
face presentation
may need cesarean delivery
Head & neck are hyperextended
occiput touching the upper back
Back is usually arched
A – Vertex presentation & Complete flexionB – Forehead presentation & Moderate flexionC – Brow presentation & Partial extensionD – Face presentation & Complete extension
4. Fetal Position Relationship of presenting part
to the mother’s pelvis
Landmarks - QuadrantsO = Occiput, vertex
presentationM = Mentum, face presentationSa = Sacrum, breech presentationA = Scapula/ acromion process, shoulder presentation
R = rightL = leftA = anteriorP = posteriorT = transverse
(center)
Fetal position is described by using 3 letters
1st letter = if presenting part facing mother’s R or L
2nd letter = presenting part of fetus
3rd letter = if presenting part is pointing to A, P or T of mother's
pelvis
Vertex Presentations… ROA ROT ROP LOA LOT LOP
Right occiput anterior Right occiput transverse Right occiput posterior Left occiput anterior Left occiput transverse Left occiput posterior
Face Presentations… RMA RMT RMP LMA LMT LMP
Right mentum anterior
Left mentum anterior
Breech Presentations… RSaA RSaT RSaP LSaA LSaT LSaP
Right sacrum anterior
Left sacrum anterior
LOA & ROA – occiput is towards the front; face is down; favourable delivery position
LOP & ROP – occiput is towards the back; face is up; much back discomfort, labor is slow
5. Fetal Station Relationship of
presenting part to ischial spines of mother’s pelvis
Determined (IE)
Station 0 = level of the ischial spines
engagement occurs
Floating (High) – unengaged
above ischial spines “minus station”
(-1 to -4 cm)
below ischial spines “plus station” (+1 to +4 cm)
If at +4 cm, known as crowning
Relationship between the passage and the fetus
Engagement Station Fetal position
Phase Station Contraction
Phase 1 0 to +2 2 – 3 min apart
Phase 2 +2 to +4 2 – 2.5 min apart with urgency to
bear down
Phase 3 +4 to birth 1 – 2 min apart; fetal head visible
increased urgency to bear down
Fetal Station Video(Jot Down Notes)
Stages of Labor1. First Stage – onset of true labor to complete dilation
2. Second stage – complete cervical dilation to delivery
3. Third Stage – placental stage
4. Fourth Stage – first 4 hours after delivery of placenta
1. First Stage of Labor (Dilatation Stage)
From true labor to complete dilation of cervix
6-18 hours = primipara 2-10 hours = multipara
Divided into 3 phases:I. LatentII. Active
III. Transitional
Phase Dilatation Duration/Interval IntensityLatent Phase
0 – 3 cmMild & short20-40 secQ10 min
6 hrs – primipara4-5 hrs – multipara
Encourage walkingChest breathingEncurage to void q2-3 hours
Active Phase
4 – 7 cmModerate to strong40-60sec q3-5 min
3 hrs – primipara2 hours multipara
Meds should be readyAssess vsAbdominal breathingOral care
Transition Phase
8 – 10 cmVery Strong
60-90 secQ 2-3 min
Cervical dilation TiredInform progress of laborRestless, support her with breathing techniques,
- Take history
vital signs Assess cervical dilation & effacement by IE maintain effective breathing patterns ambulation, if desired & tolerated void every 1-2 hours
Quiet surroundings
comfort measures:
Back rubs Pillow support
Position changes Offer liquids/ice chipsProvide ointment for dry lips
rest between contractions update regarding progress of labor Provide privacy Monitor contractions by palpation/ progress of
labor (frequency, duration & intensity)
Assess color of amniotic fluid; meconium staining = fetal distress
Perineal preparation
Render enema if ordered: to prevent infection, retardation of labor progress
2. Second Stage of 2. Second Stage of LaborLabor› Expulsive stage› complete cervical dilation to delivery of
the newborn› Contractions: strong› Duration: 60 – 90 seconds› Frequency: every 2-3 minutes› Primipara: 40 minutes average 20 contractions› Multipara: 20 minutes average 10 contractions
› Fetus moves along the birth canal by cardinal movements of labor
Increase in bloody show “The baby is coming” “I need to push.”
Pushing will ↑ uterine contractions
Bulging of perineum & crowning of head – hallmark of 2nd stage
bear down only during contractions
Monitor FHR
Monitor contractions: frequency, duration & intensity
Check for rupture of membranes: time, color, odor, amount and consistency of amniotic fluid
Assess signs of hypotensive supine syndrome
- If BP falls, position patient on her Left side
- Increase IV flow rate - Administer O2 through
face mask at 6-10 L/min
When to transfer patient to delivery room? Primigravida: Cervix 10cm with bulging & contractions Multigravida: Cervix 8-9cm
Assist mother in positioning:dorsal recumbent – for bearing downlithotomy – if with position
Check for prolapsed cord an check FHR after rupture of membranes
ProlapsedCord
Prepare for birth & maintain sterile technique
Place legs simultaneously in stirrups
Perineal preparation: front to back
After delivery, cord is clamped and cut within 15~20 seconds.
Delayed cord clamping can result in hyperbilirubinemia = additional blood is transferred to NB.
Cardinal Movements of Labor…
7 movements occur: (ED FIRE ERE)
I. EngagementII. DescentIII. Flexion
IV. Internal RotationV. Extension
VI. External RotationVII. Expulsion
I. Engagement presenting part at
ischial spines
Station 0
downward movement of fetus
Fetal head passes the dilated cervix
II. Descent
III. Flexion head bends
forward
chin is pressed to the chest
rotation of head to pass thru ischial spines
head rotates about 45°
Fetal head is against the front of her pelvis
IV. Internal Rotation
V. Extension delivery of head outside
pelvis
Occiput at vagina Crowning
back of neck is under symphysis pubis
causes the head to extend
extension is controlled by the physician.
An episiotomy may be done
Promoting Gradual Extension:
Ritgen’s maneuver = gradual
extension= exert pressure on
the chin;
Panting & not pushing during crowning
VI. External Rotation VII. Expulsion
After extension, neck is twisted
head needs to externally rotate to realign with the spine
the anterior shoulder descends first
Final birth Delivery of fetal
body
head is raised to deliver shoulder and entire body
When entire body emerges = birth is complete
time of birth recorded and entered in the birth certificate
PD 651 registration with Civil registrar of all births within 30 days
birth certificate = legal document must be complete & accurate, devoid of
any erasures
procedures employed to present trauma/reduce hazard to mother and or infant during the birth process.
First degree: vaginal epithelium or perineal-skin.
Second degree: subepithelial tissues of the vagina/perineum & muscles of the perineum
Third degree: anal sphincter
Fourth degree: rectal mucosa
Episiotomy… A surgical incision of perineum
used to enlarge the vaginal outlet
prevent perineum from tearing
release the pressure on fetal head that accompanies birth
repaired easily & heals faster
Method Done during contraction as the
baby’s head pushes against perineum and stretches it.
Blunt scissors are used
Client is usually on anesthetic, local or inhalation
Type of Episiotomy:a. Midline episiotomy - center of perineum toward anal
sphincter - Easier healing, decreased
blood loss & decreased postpartum discomfort
- Danger of extension into anal sphincter
b. Mediolateral episiotomy - midline and then angled (45°)
to 1 side away from the rectum - Decreased risk of rectal
mucosa tearing Blood loss is greater Healing process is quite painful Incision is harder to repair
OB Forceps Video(Jot Down Notes)
Forceps delivery… Forceps are steel instruments to
assist with delivery and relieve fetal head compression
2 blades connected together; blades are slipped into position one at a time
Commonly used forceps: Kjelland’s, Elliot, Piper, Tucker-
McLean, Simpson’s
For forceps delivery to be performed, the ff must be present:
Ruptured membranesFully dilated cervix
Empty bladderFetal head engaged in maternal pelvis
FHT present before and after forcep application
Absence of cephalopelvic disproportion It shortens 2nd stage of labor
Indications: Fetal distress Poor progress of fetus through
the birth canal Failure of the head to rotate Maternal disease or exhaustion Client is unable to push(with
regional anesthesia)
Types:Low or Outlet – presenting part on perineal
floor
Midforceps – presenting part below or at the level of the ischial spine
High forceps – presenting part above the ischial spine (not engaged). This procedure has been replaced by cesarean birth.
Disadvantage… ↑ perinatal morbidity & mortality ↑ neonatal birth trauma &
depression ↑ incidence of perineal
lacerations, postpartum hemorrhage & bladder injury
Forceps Video(Jot Down Notes)
Vacuum extraction… An alternative to forceps delivery Facilitates descent of fetal head A plastic vacuum cup is applied
to the fetal head, negative pressure is exerted & traction is applied to deliver the head
Advantages… Lower incidence of vaginal,
cervical & laceration Less maternal discomfort because
the cup does not occupy additional space in the birth canal
Little anesthesia needed Neonate born with less respiratory
depression
Disadvantages… Marked caput succedaneum of
neonate’s head lasting as long as 7 days after birth
Preterm neonates is problematic because of extreme softness of their skulls
3. Third Stage of Labor3. Third Stage of Labor› Placental stage
› From delivery of neonate to delivery of placenta
› After delivery, contractions cease for several minutes
Duration: 5 – 30 minutes
Placental Separation Calkin’s sign = Uterus
changes from discoid to globular & from soft to firm
Fundus of uterus rises in the abdomen
Umbilical cord lengthening
Gush of blood from the vagina
Placental Expulsion
Natural bearing down of the mother
Gentle pressure on contracting uterus(Crede’s maneuver)
Brandt andrews maneuver downward sideways gentle controlled cord traction
Schultze placenta (80%)
Separates at center & fold
(inverted umbrella)
fetal surface exposed Shiny & glistening
Less external bleeding; blood is concealed behind the placenta
Duncan placenta (20%)
Separates at its edges
Umbrella shaped
Maternal surface exposed
Rough, red, raw & irregular from ridges
More external bleeding Appears bloody
Stages: cont’d
Third stage Placental separation Placental delivery
Fourth stage 1-4 hours
After placenta is delivered= veins in the place of attachment
at decidua is 7cm dilated = mother is prone to hemorrhage
MUST promote contraction after delivery
Average blood loss = 250-300 ml 500 ml or above = postpartal
hemorrhage (maternal mortality)
Placenta Video(Jot down notes)
wait for signs of placental separation
DO NOT do fundal pressure with pull at the cord if uterus is relaxed
= could cause hemorrhage
Gradual delivery of placentamake sure placenta is intact &
complete
Complete cotyledons (oxygen reserve during 2nd stage of labor to prevent fetal distress)
Complete cord vessels: 2 arteries & 1
vein Complete membranes Monitor maternal vital signs inspect cervix and vagina for
laceration
Feel fundus for contractions or firmness. soft, boggy & non-palpable = uterine atony
massage fundus until firm Ice cap to contract uterus
20 units oxytocin IV or p.o. as ordered to enforce contractions
Introduce NB to patient & her partner
Allow to breast-feed Provide essential newborn care/unang
yakap
1. Immediate & thorough drying2. Skin to skin contact3. Properly timed cord clamping
& cutting4. Early BF
Umbilical cord/funis AVA 53-55cma. Short cord –
abruptio placenta
b. Long cord – cord coil or cord prolapse
c. 2 vessel cord – congenital heart problem; check for AVA
Cord Care Animation(Jot down notes)
Episiotomy Repair Animation
(Jot down notes)
4. Fourth Stage of 4. Fourth Stage of LaborLabor› Recovery & bonding stage› after delivery of placenta› First hour after delivery› Stabilizing NB & helping him adapt
to extrauterine life› maternal-neonate bonding› Uterine contractions prevents
bleeding from placental site
Interventions… Asses mother:
Every 15 min = 1st fourEvery 30 minutes = another hour
Every hour = 2 hours
Ice cap to contract uterus
Apply ice pack to perineum if with episiotomy or laceration, swollen
uterine massage to keep it firm
Assess & document lochia
Perineal pad saturated in 15 minutes or blood pooling under buttock
= excessive blood loss
Bright red lochia = laceration of cervix or vagina
Check perineum for edema, bruising & rectal pain
MIO
Parameter Rubra Serosa AlbaAppearance Mostly
bloodySerosangui-neous
Creamy white
Color Red Brownish White
Amount Moderate Scanty Slight
Time present
1-3 days 4-10 days (7 days – average)
11-14 days (maximum of 21 days
Duration of LaborLabor Stage
First Stage: true labor – full dilatation
1. Latent phase (0 – 3cm) 2. Active phase (4 – 7cm) 3. Transitional (8-10cm)
mild & short (20-40 sec)
6 hrs - primi4-5 hrs -
multi
Encourage walkingChest breathingEncourage to void q2-3 hours
Second stage: (full dilatation – to birth)
Most difficult for fetus
50 minutes= 1 hr
Third Stage: (placental expulsion)
5 – 15 minAve. 5 min
Fourth stage: (recovery/ immediate postpartum)Dangerous for the mother- Due to hemorrhage
1 – 2 hoursMaximum: 4 hours
INDUCTION OF LABOR
Artificial initiation of Labor
Deliberate initiation of labor or uterine contractions before spontaneous onset
192
• Condition before Induction Fetus in Longitudinal lie Cervix is ripe or ready for birth
Presenting part is engaged No CPD
Fetus is mature, mother at or near term
No contraindications for use of oxytocin like CS scar, placenta previa
193
Ways of Induction of Labora. Administer Pitocin – synthetic substitute for uterine contractions
b. Artificial ROM (amniotomy)
Prepare amniotomeCheck FHT after BOW is ruptured
194
Management- on bedrest- VS & FHT every 15 minutes - IV – 10”u” Pitocin add D5W piggybacked to main line
-Stop oxytocin if: - FHT is more than 170 bpm - less than 120 bpm - Meconium passage - Maternal hypotension
IF FETAL DISTRESS DEVELOPS:a. Stop oxytocinb. Turn client to the left sidec. Administer oxygen per maskd. Refer to the physician
Cesarean Birth Removal of NB from uterus thru abdominal &
uterine incision
Indicated for: CPD
Uterine dysfunction Malposition
Previous uterine surgery Placenta previa
DM, cardiac disease Prolapsed umbilical cord
Fetal distress
Types of Incisiona. Low Segment Transverse incision - bikini incision - above pubic hairline
- Blood loss is minimal - less likely to rupture during future labors
due to minimal active contractions at the area
- Vaginal delivery may be possibleVBAC
b. Classic/vertical incision - vertical incision
- used if with previous CS exist
- fetus is in transverse lie
- chance of vaginal birth is low - because incision’s location is in the active contracting portion of uterus
PRE-OPERATIVE Regular preparation
for abdominal / pelvic surgery
POST-OPERATIVE Ensure airway
(suction & oxygen)
VS q15 min until stable
Check dressing & perineal pad for bleeding, lochia
MIO - Bleeding & urine
Clear liquids after flatus
Oxytocic drugs = ensure firm fundus
Analgesic = relief of pain
Antibiotics = prevent sepsis
Assess signs of infection & thrombophlebitis
Regular positioning
Early exercise
Passive then active leg exercises
(Foot & leg exercise, abdominal tightening, pelvic rocking)
Danger Signs Thrombophlebitis:
- Local redness (rubor)
- Warm to touch (calor)
- Swelling (tumor)- Pain (dolor)
Validate by eliciting Homan’s sign (calf pain upon
dorsiflexion)
Effects of Anesthesia Trauma to nerve root or spinal cord
(paresthesia)
Postdural puncture headache (flat on bed)
Hematoma in spinal canal (ischemia)
Diminished uterine contractions (bleeding)
Hypotension
Cesarean Birth Animation
Evaluation During Labor
Leopold’s maneuver
Cervical effacement & dilation
Patient monitoring:Signs of dehydration
ContractionsUrinary elimination
Partograph
Partograph = advocated by WHO
= to assess progress of labor
= Components:
Progress of laborFetal conditionMaternal condition
Alternative Birthing Experience
Birthing Centers Maternity facilities Hospital or institution
close to a hospital Warm, homelike
environment
Families take more responsibility for birth experience
NOT for high-risk deliveries
Care provided by nurse-midwives
Home births Inadequate medical back-
up Woman must ensure the
home is prepared for birth must be in good health
6 Cleans (WHO)- Clean hands- Clean delivery surface- Clean tie for the cord- Clean blade- Clean cloth for mother- Clean cloth for baby
Water birth sitting or reclining in warm
water bath NB is born under water and
brought out of the water for the first breath
Relaxation occurs due to warm water
Risk of fecal contamination May lead to uterine
infection & neonatal aspiration of water