Week 7 Intrapartal Care Lecture PDF

WEEK 7: INTRAPARTAL CARE (LECTURE) NCMA 217 - CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENT) 2ND YEAR - BS NURSING (MIDTERMS) Padayon, SN. THEORIES OF LABOR ONSET uri...

WEEK 7: INTRAPARTAL CARE (LECTURE) NCMA 217 - CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENT) 2ND YEAR - BS NURSING (MIDTERMS) Padayon, SN. THEORIES OF LABOR ONSET urine production can lead to a weight loss Labor normally begins when a fetus is sufficiently between 1 and 3 pounds. mature to cope with extrauterine life yet not too ○ Braxston Hicks Contraction - woman large to cause mechanical difficulty with birth. usually notices extremely strong Braxton Several theories including a combination of factors Hicks contractions. originating from both the woman and fetus have Ripening of the cervix - At term, been proposed to explain why progesterone the cervix becomes still softer withdrawal begins: (described as “butter-soft”), and it ○ Uterine muscle stretching, which results tips forward. Cervical ripening this in release of prostaglandins (reason why way is an internal announcement u feel pain) that labor is very close at hand. ○ Pressure on the cervix, which stimulates the release of oxytocin from the posterior SIGNS OF TRUE LABOR pituitary. Signs of true labor involve uterine and cervical ○ Oxytocin stimulation, which works together changes. with prostaglandins to initiate contractions. ○ Uterine Contraction - The surest sign that ○ Change in the ratio of estrogen to labor has begun is productive uterine progesterone (increasing estrogen in contractions. Because contractions are relation to progesterone, which is involuntary and come without warning, interpreted as progesterone withdrawal) their intensity can be frightening in early ○ Placental age, which triggers contractions labor. Helping a woman appreciate that at a set point. she can predict when her next one will ○ Rising fetal cortisol levels, which reduces occur and therefore can control the degree progesterone formation and increases of discomfort she feels by using prostaglandin formation breathing exercises offers her a sense of ○ Fetal membrane production of well-being. prostaglandin, which stimulates ○ Show - As the cervix softens and ripens, contraction. the mucus plug that filled the cervical canal during pregnancy (operculum) is expelled. SIGNS OF LABOR The exposed cervical capillaries seep PRELIMINARY SIGNS OF LABOR - Before labor, blood as a result of pressure exerted by a woman often experiences subtle signs that signal the fetus. This blood, mixed with mucus, labor is imminent. It is important to review these takes on a pink tinge and is referred to as with women during the last trimester of pregnancy “show” or “bloody show.” Women need so they can more easily recognize beginning signs. to be aware of this event so that they do ○ Lightening - In primiparas, lightening, or not think they are bleeding abnormally. descent of the fetal presenting part into the ○ Rupture of Membranes - Labor may pelvis, occurs approximately 10 to 14 days begin with rupture of the membranes, before labor begins. This fetal descent experienced either as a sudden gush or as changes a woman’s abdominal contour, scanty, slow seeping of clear fluid from the because it positions the uterus lower and vagina. Early rupture of the membranes more anterior in the abdomen. Lightening can be advantageous as it can cause the gives a woman relief from the fetal head to settle snugly into the pelvis, diaphragmatic pressure and shortness of shortens labor. Two risks associated with breath that she has been experiencing and ruptured membranes are intrauterine “lightens'' her load. infection and prolapse of the umbilical ○ Increase in Level of Activity - This cord, which could cut off the oxygen increase in activity is related to an increase supply to the fetus (Lewis et al., 2007). In in epinephrine release initiated by a most instances, if labor has not decrease in progesterone produced by the spontaneously occurred by 24 hours after placenta. This additional epinephrine membrane rupture and the pregnancy is at prepares a woman’s body for the work of term, labor will be induced to help reduce labor ahead. these risks. ○ Slight loss of weight - As progesterone level falls, body fluid is more easily COMPONENTS OF LABOR excreted from the body. This increase in A successful labor depends on four integrated concepts:  a. A woman’s pelvis (the passage) is of engagement). If the presenting part is above the adequate size and contour. spines, the distance is measured and described as b. The passenger (the fetus) is of minus stations, which range from 1 to 4 cm. If the appropriate size and in an advantageous presenting part is below the ischial spines, the position and presentation. distance is stated as plus stations (+1 to +4). At a c. The powers of labor (uterine factors) are +3 or +4 station, the presenting part is at the adequate. (The powers of labor are perineum and can be seen if the vulva is separated (i.e., it is crowning). strongly influenced by the woman’s position during labor.) d. A woman’s psychological outlook is preserved, so that afterward labor can be viewed as a positive experience. 1. PASSAGE a. The passage refers to the route a fetus must travel from the uterus through the cervix and vagina to the external Fetal Attitude - Attitude describes the degree of perineum. Two pelvic measurements are flexion a fetus assumes during labor or the relation important to determine the adequacy of the of the fetal parts to each other. A fetus in good pelvic size: the diagonal conjugate (the attitude is in complete flexion: the spinal column is anteroposterior diameter of the inlet) and bowed forward, the head is flexed forward so much the transverse diameter of the outlet. At that the chin touches the sternum, the arms are the pelvic inlet, the anteroposterior flexed and folded on the chest, the thighs are diameter is the narrowest diameter; at the flexed onto the abdomen, and the calves are outlet, the transverse diameter is the pressed against the posterior aspect of the thighs. narrowest. This normal “fetal position” is advantageous for birth because it helps a fetus present the smallest anteroposterior diameter of the skull to the pelvis and also because it puts the whole body into an 2. PASSENGER ovoid shape, occupying the smallest space a. The passenger is the fetus. The body part possible. of the fetus that has the widest diameter is A fetus is in moderate flexion if the chin is not the head, so this is the part least likely to touching the chest but is in an alert or “military be able to pass through the pelvic ring. position”. Whether a fetal skull can pass depends on A fetus in partial extension presents the “brow” of both its structure (bones, fontanelles, and the head to the birth canal. suture lines) and its alignment with the Descent - means that the widest part of the fetus pelvis. (the biparietal diameter in a cephalic presentation; Molding is a change in the shape of the fetal skull the intertrochanteric diameter in a breech produced by the force of uterine contractions presentation) has passed through the pelvis inlet or pressing the vertex of the head against the the pelvic inlet has been proved adequate for birth. not-yet-dilated cervix. Fetal Lie - Lie is the relationship between the long Engagement – refers to the settling of the (cephalocaudal) axis of the fetal body and the long presenting part of a fetus far enough into the pelvis (cephalocaudal) axis of a woman’s body; in other to be at the level of the ischial spines, a midpoint of words, whether the fetus is lying in a horizontal the pelvis. (transverse) or a vertical (longitudinal) position. Station - refers to the relationship of the presenting part of a fetus to the level of the ischial spines. When the presenting fetal part is at the level of the ischial spines, it is at a 0 station (synonymous with BATCH 2025 TRANSCRIBED BY: AJ & CM | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 2  TYPES OF FETAL PRESENTATION Fetal presentation denotes the body part that will first contact the cervix or be born first. This is determined by a combination of fetal lie and the degree of fetal flexion (attitude). 1. Cephalic Presentation - A cephalic presentation is the most frequent type of presentation, occurring as often as 95% of the time. With this type of presentation, the fetal head is the body part that will first contact the cervix. The four types of cephalic presentation (vertex, brow, face, and mentum). FETAL POSITION Position is the relationship of the presenting part to a specific quadrant of a woman’s pelvis. For convenience, the maternal pelvis is divided into four quadrants according to the mother’s right and left: (a) right anterior, (b) left anterior, (c) right posterior, and (d) left posterior. POSSIBLE FETAL POSITION Vertex Breech Face Shoulder Presentatio Presentatio Presentatio Presentatio n n (sacrum) n n (acromion (occiput) (Mentum) process) LOA, left LSaA, left LMA, left LAA, left occiput sacroanteri mentoanteri scapula anterior or LSaP, or LMP, left anterior LAP, left mentoposter LOP, left left 2. Breech Presentation - A breech presentation sacroposteri ior LMT, left occipitopost or LSaT, mentum scapula means that either the buttocks or the feet are the erior LOT, posterior left sacrum transverse first body parts that will contact the cervix. Breech left transverse RMA, right RAA, right presentations occur in approximately 3% of births RSaA, right mentoanteri scapula occipitotrans and are affected by fetal attitude. A good attitude sacroanteri or RMP, anterior verse ROA, brings the fetal knees up against the fetal or RSaP, right RAP, right right occiput right mentoposter scapula abdomen; a poor attitude means that the knees are anterior sacroposteri ior RMT, posterior extended. Breech presentations can be difficult ROP, right occiput or RSaT, right births, with the presenting point influencing the posterior right mentum degree of difficulty. Three types of breech ROT, right sacrum transverse presentation (complete, frank, and footling) are occiput transverse possible. transverse 3. Shoulder Presentation - In a transverse lie, a fetus lies horizontally in the pelvis so that the longest fetal axis is perpendicular to that of the mother. The presenting part is usually one of the shoulders (acromion process), an iliac crest, a hand, or an elbow. BATCH 2025 TRANSCRIBED BY: AJ & CM | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 3  transverse one) in line with the wide transverse diameter of the inlet. Extension ○ As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. The head extends, and the foremost parts of the head, the face and chin, are born. External Rotation ○ In external rotation, almost immediately after the head of the infant is born, the MECHANISM OF LABOR (CARDINAL MOVEMENTS) head rotates (from the anteroposterior position it is assumed to enter the outlet) Passage of a fetus through the birth canal involves back to the diagonal or transverse position several different position changes to keep the of the early part of labor. This brings the smallest diameter of the fetal head (in cephalic aftercoming shoulders into an presentations) always presenting to the smallest anteroposterior position, which is best for diameter of the pelvis. These position changes are entering the outlet. The anterior shoulder is termed the cardinal movements of labor: descent, born first, assisted perhaps by downward flexion, internal rotation, extension, external flexion of the infant’s head. rotation, and expulsion. Expulsion Descent ○ Once the shoulders are born, the rest of ○ Descent is the downward movement of the the baby is born easily and smoothly biparietal diameter of the fetal head to because of its smaller size. This within the pelvic inlet. Full descent occurs movement, called expulsion, is the end of when the fetal head extrudes beyond the the pelvic division of labor dilated cervix and touches the posterior vaginal floor. Descent occurs because of POWERS OF LABOR pressure on the fetus by the uterine fundus. The pressure of the fetal head on The second important requirements for a successful the sacral nerves at the pelvic floor causes labor are effective powers of labor. This is the the mother to experience a pushing force supplied by the fundus of the uterus, sensation. Full descent may be aided by implemented by uterine contractions, a natural abdominal muscle contraction as the process that causes cervical dilatation and then woman pushes. expulsion of the fetus from the uterus. After full Flexion dilatation of the cervix, the primary power is ○ As descent occurs and the fetal head supplemented by use of the abdominal muscles. It reaches the pelvic floor, the head bends is important for women to understand they should forward onto the chest, making the not bear down with their abdominal muscles until smallest anteroposterior diameter (the the cervix is fully dilated. Doing so impedes the suboccipitobregmatic diameter) present to primary force and could cause fetal and cervical the birth canal. Flexion is also aided by damage abdominal muscle contraction during Uterine Contraction - The mark of effective pushing. uterine contractions is rhythmicity and progressive Internal Rotation lengthening and intensity. ○ During descent, the head enters the pelvis Phases - A contraction consists of three phases: with the fetal anteroposterior head the increment, when the intensity of the diameter (suboccipitobregmatic, contraction increases; the acme, when the occipitomental, or occipitofrontal, contraction is at its strongest; and the decrement, depending on the amount of flexion) in a when the intensity decreases diagonal or transverse position. The head flexes as it touches the pelvic floor, and the occiput rotates to bring the head into the best relationship to the outlet of the pelvis (the anteroposterior diameter is now in the anteroposterior plane of the pelvis). This movement brings the shoulders, coming next, into the optimal position to enter the inlet, putting the widest diameter of the shoulders (a BATCH 2025 TRANSCRIBED BY: AJ & CM | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 4  Cervical Changes – Even more marked than the changes in the body of the uterus are two changes that occur in the cervix: effacement and dilatation. Effacement - it is shortening and thinning of the cervical canal. Normally, the canal is approximately 1 to 2 cm long. With effacement, the canal virtually disappears. Dilatation refers to the enlargement or widening of the cervical canal from an opening a few millimeters wide to one large enough (approximately 10 cm) to permit passage of a fetus. PSYCHE The fourth “P,” or a woman’s psychological outlook, refers to the psychological state or feelings that a woman brings into labor. For many women, this is a feeling of apprehension or fright. For almost everyone, it includes a sense of excitement or awe. BATCH 2025 TRANSCRIBED BY: AJ & CM | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 5