Intrapartum & Postpartum Care PDF

Changes of Late Pregnancy (Intrapartum) UTERINE CONTRACTIONS CERVICAL EFFACEMENT 10  11 Uterine contractions Mother becomes more uncomfortable as...

Changes of Late Pregnancy (Intrapartum) UTERINE CONTRACTIONS CERVICAL EFFACEMENT 10  11 Uterine contractions Mother becomes more uncomfortable as increase in contractions strengthen strength and Braxton Hicks* contractions frequency Late Pregnancy Shape of the abd changes Sensation that the baby is “Lightening” “lighter” Fetal head descends into the pelvis  12 Ruptured membranes (ROM) – sudden gush of liquid or constant leakage of fluid AKA: “my water broke” Late Bloody show – passage of blood-tinged cervical mucus Pregnancy Occurs when the cervix begins to thin (effacement) Expressed as a % True labor – regular, painful uterine contractions, causing cervical dilation & birth  13 Late Pregnancy Braxton Hicks Contractions True Labor Contractions u Not associated with u Associated with progressive progressive cervical dilation cervical effacement & u Shorter, less intense dilation u Discomfort in lower abd, u Increasingly intense, groin frequent u Relieved by u Felt over uterine fundus with ambulation/hydration radiation to low back & low abd  14 Cervical Dilation and Effacement u Cervical effacement – cervix softens, thins, and shortens u Diagnosed by clinical examination or transvaginal ultrasound u Change in dilation or effacement of at least 1cm or cervix well effaced and dilated (at least 2cm) is considered diagnostic u Normal cervical length is about 4cm u Often accompanied by bloody mucous vaginal discharge aka “bloody show”  15 Cervical Effacement  Labor INITIAL EVALUATION FETAL STATION 16  17 85% of pts undergo spontaneous labor & delivery btwn 37 – 42 wks Pts are instructed to go to the hospital with: Labor Contractions every 5 min, x1 hour Sudden gush of fluid or constant leakage of fluid Suggests rupture of membranes (ROM) Significant bleeding Significant decrease in fetal movement  18 Initial Evaluation u Review prenatal records/ u Abd exam labs u Leopold Maneuvers (fetal lie u Focused Hx and presentation) u Contractions u FH tones u Frequency, duration u Pelvic exam u Spontaneous ROM? u Cervical dilation (in cms) u Bleeding? u % effacement u Station  19 Initial Eval u Leopold Maneuvers u Palpate uterus & fetus thru abd wall u To determine fetal lie, presentation & position  20 Leopold Maneuvers  21 Leopold’s Maneuvers https://www.youtube.com/wa https://www.youtube.co tch?v=jITAO8AcLz0 m/watch?v=gIKfTUrNQQ c  22 Leopold’s Maneuvers u Fetal lie – relation of long axis of fetus to maternal long axis u Longitudinal is most common u Presentation – portion of fetus lowest in the birth canal u Ex; in a longitudinal lie, the presenting part is either breech or cephalic u Position – relation of fetal presenting part to the right or left side of maternal pelvis  23 Examples of Fetal Lie  24 External cephalic version (ECV) u Procedure to manually try and fix breech presentation u Not always successful but increase change for a vaginal delivery u Risk of fetomaternal hemorrhage (2-6%) u Rhogham given  u Fetal Heart (FH) Tones u Reassuring patterns u Baseline FHR 120 -160 bpm u Absence of late or variable decelerations u Moderate variability (6 - 25 bpm) Initial Eval u Nonreassuring patterns u Absent/minimal variability with decelerations or bradycardia u Recurrent late or variable decelerations u Bradycardia: FHR < 110 BPM 25  26 Assessing FH Tones  27 u Management: u Variable decels u Put mom in knee-chest position (gets baby’s head off cord) FH Patterns - u Early decels u Baby is descending into the pelvis, Labor & continue to monitor Management u Accelerations – normal, reassuring u Last for 15+ sec, peaks at 15+ BPM u Late decels – worrisome u Reposition mom, IV fluids u D/C or decrease Oxytocin u Administer a tocolytic to decrease contractions 28 29  30 Initial Eval u Vaginal exam u Determine degree of cervical effacement & dilation u NOT DONE with premature ROM or vaginal bleeding u Cervical dilation (cms) u One finger = 1 cm u Two Fingers = 2 cm u Dilates to 10cm 31  32 Initial Eval u Station u Level of fetal presenting part to level of the ischial spine u Zero station = presenting part has reached the ischial spines (“engaged”) u +1 - +5 station = presenting part is moving into the introitus 33  34 Labor and Delivery u Management: u Pain Management/ Anesthesia u VS every 15 - 30 mins u Non-pharmacologic approaches u Continuous fetal monitoring in high risk pregnancy or following u Epidural block administration of analgesia/ u Spinal anesthesia (single anesthetic injection) u NPO (ice chips allowed) u Combined spinal-epidural u Local block u General anesthesia  35 Pain Management u Epidural Block u Spinal anesthesia u Local anesthetic plus opioid u Administered into the u Administered into the epidural subarachnoid space space using continuous IV u Combined spinal-epidural infusion pumps u Epidural catheter may be activated if delivery has not occurred before intrathecal dose wears off  36 Pain Management u Local Block u Bilat pudendal nerve blocks u A supplement for epidural analgesia u General Anesthesia u Used with complications (ie: shoulder dystocia) u If epidural or spinal is not in place, general anesthesia may be necessary  37 Stages of Labor u Stage I: onset of labor contractions to full cervical dilation (10 cm) u Latent phase – cervical effacement, gradual cervical dilation u Active phase – rapid cervical dilation u Stage II: from full cervical dilation to delivery of the fetus u Passive phase – complete cervical dilation to active maternal pushing u Active phase – from active pushing to actual delivery u Stage III: postpartum to delivery of the placenta u Stage IV: mother is assessed for complications u 1 – 2 hrs post delivery  38 Stages of Labor 39  40 Stages of Labor u Fourth stage u 1st hr post delivery u Repair any lacerations u Highest risk of maternal complications as mother’s body readjusts to non- pregnant state  41 Labor & Delivery Patient Ed Animation: Labor and Vaginal Birth u https://www.youtube.com/watch?annotation_i d=annotation_563008&feature=iv&src_vid=Xath 6kOf0NE&v=ZDP_ewMDxCo x 42 Cardinal Movements of Labor  43 Evaluation of Placenta u Placental expulsion occurs spontaneously u Is examined to make sure it’s intact u Incomplete delivery of the placenta can lead to PP hemorrhage, infection, DIC, or sepsis  44 Evaluation of the Placenta u Examine umbilical cord u 2 arteries, 1 vein u Evaluate maternal blood loss u Palpate uterine fundus for firmness or atony u Inspect & repair lacerations 45 46 47 48