Intrapartum & Postpartum Care PDF

1 Intrapartum and Postpartum Care PROF. GREENFIELD OBSTETRICS SPRING 2025  2 Topics u Social Determinants u Postpartum Care u Racial Disparities u Neonate u...

1 Intrapartum and Postpartum Care PROF. GREENFIELD OBSTETRICS SPRING 2025  2 Topics u Social Determinants u Postpartum Care u Racial Disparities u Neonate u Changes of Late Pregnancy u Maternal (Intrapartum) u Anxiety and Depression u Labor u Initial Evaluation u Fetal Station & Heart Tones u Anesthesia u Stages of Labor u Cardinal Movements of Labor  3 Objectives u Identify common signs and symptoms associated with labor and delivery. u Recognize the social determinants of health that can impact health outcomes. u Determine an ongoing approach to the obstetric patient with findings based on history, physical exam, laboratory, or diagnostic exam results throughout the process of labor and delivery. u Provide postpartum education for the new mother and her newborn. u Understand the care provided for the first 24 hrs of a newborn infant’s life. u Identify psychological complications that may develop in the postpartum period and collaborate with other health care specialists as needed.  4 Social Determinants of Health PRE-CONCEPTUAL PERINATAL  5 u “social determinants” of health - non-medical factors that influence health outcomes. Social u Where individuals live, learn, Determinants work, and age, along with socioeconomic status and race, have a tremendous influence on their health. u These determinants shape how people behave.  6 u Stress hypothesis for perinatal outcomes - focuses on 2 types & time periods of psychosocial stress: Stress and u Acute stress during pregnancy Pregnancy u Life-time exposure to stressors prior to conception u Acute perinatal stressors may be pregnancy-related anxiety or major life events (divorce, major illness, or death of a loved one)  7 u Preconceptional stressors: u Major life events that have occurred unrelated in time to the pregnancy u Adverse childhood events Stress and (physical or sexual abuse, death of a parent) Pregnancy u These stressors can be chronic over a significant portion of a woman’s life: u Long-time exposure to poverty u Unemployment u Perceived discrimination u Living in unsafe neighborhoods u Ongoing abuse  8 u Report from Nine Maternal Mortality Review Committees*: u Approx 700 women across the U.S. die each yr due to pregnancy or pregnancy-related complications. Disparities u Non-Hispanic black women experience maternal deaths at a rate 3-4x that of non-Hispanic white women u This disparity is seen across many maternal & infant outcomes. u Nearly 50% of all pregnancy-related deaths were caused by hemorrhage, CV/coronary conditions, cardiomyopathy, or infection. u Leading underlying causes of death varied by race. u Preeclampsia & eclampsia, & embolism were leading underlying causes of death among non- Hispanic black women.  9 u Top 5 underlying causes of pregnancy related deaths among non-Hispanic black pregnancy-related deaths: Disparities u 1. Cardiomyopathy (14.0%) u 2. CV & coronary conditions (12.8%) u 3. Preeclampsia & eclampsia (11.6%) u 4. Hemorrhage (10.5) u 5. Embolism (9.3%)  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