Maternal Care: Prenatal Period PDF

CARE DURING ANTEPARTUM PERIOD ○ Older Primigravida: woman >35 years older with first baby Antepartum period: Refers to the duration of ○ Nulligravida: A w...

CARE DURING ANTEPARTUM PERIOD ○ Older Primigravida: woman >35 years older with first baby Antepartum period: Refers to the duration of ○ Nulligravida: A woman who has never pregnancy before the onset of labor and delivery. This been pregnant. critical period is essential for monitoring and promoting ○ Grand Multigravida: six or more maternal and fetal health. pregnancies Aim ○ Para/Parity: Refers to the birth history The primary objective is to ensure the well-being of of the woman at 24 weeks gestation or both the mother and fetus by providing comprehensive later. care and identifying any potential risk factors that could ○ Primipara: given birth to one child complicate the pregnancy. past the age of viability or at least METHODS OF ESTIMATIONS USED DURING weeks alive or dead PREGNANCY ○ Multipara: given birth more than once at 34 weeks of gestation ○ Grand Multipara - given birth to 6 or Calculation of Estimated Date of Delivery more viable deliveries whether dead or (EDD/EDC) alive at birth ○ Age of viability - earliest age fetuses Naegele’s Rule is widely used for calculating the could survive (24 weeks) estimated delivery date based on the last menstrual ○ Abortion - terminates before the age period (LMP): of viability, fetus weighs less than 500 g ○ If LMP is from April to December: ○ Preterm infant - infant born before 37 weeks but more than 24 weeks ○ Subtract 3 months, add 7 ○ Post-term infant - infant born after 42 days, and add 1 year to weeks determine the EDD. ○ Example: For LMP on April 22, DURATION OF PREGNANCY 2021, the estimated delivery date is January 29, 2022. The duration of pregnancy can be measured in ○ If LMP is from January to March: several units: ○ Days: Typically ranges from 267 to ○ Add 9 months and 7 days to 280 days. determine the EDD. ○ Weeks: Represents approximately 37 to 42 weeks. ○ Example: For LMP on January ○ Lunar Months: Duration of pregnancy 20, 2021, the estimated is often considered as 10 lunar months delivery date is October 27, (where one lunar month equals 4 2021. weeks). Determination of Age of Gestation (AOG) TRIMESTERS OF PREGNANCY Formula: AOG can be calculated by taking the total days from the LMP to the date of consultation and dividing that number by 7, converting days into weeks. Pregnancy is divided into three trimesters: ○ First Trimester: Includes the first three months (weeks 1–12). ○ Example: If the LMP is January 1, ○ Second Trimester: Comprises the 2021, and the date of the consultation is August 31, 2021, the total days middle three months (weeks 13–26). would equal 242. Thus, AOG would be ○ Third Trimester: Encompasses the calculated as 34 weeks and 4 days. final three months (weeks 27–40). TERMS TO REMEMBER GOAL OF PRENATAL CARE Key terms in obstetrics include: The main goals of prenatal care include: ○ EDD: Estimated Date of Delivery. ○ Promoting maternal health and ○ EDC: Estimated Date of Confinement. supporting healthy fetal development. ○ EDB: Estimated Date of Birth ○ Enabling early detection and ○ Gravida: Total number of pregnancies management of potential risks or a woman has experienced. complications. ○ Gravidity: total number of ○ Providing education for the mother pregnancies, past and present, about labor, postpartum care, and ○ Primigravida: pregant for the first time infant care, fostering self-efficacy and ○ Multigravida: 2 or more pregnancies preparedness. SCHEDULE OF PRENATAL VISITS Menarche, usual cycle length, and regularity of menses, the interval between periods, amount of menstrual flow menstrual problems and discomforts experienced, past gynecologic The frequency of prenatal visits varies based surgery, and reproductive planning methods on the pregnancy risk level: ○ Normal Pregnancy: ○ First Visit: As soon as possible Obstetrics History after the missed menstrual period. Previous pregnancies, type and outcome, ○ 0-32 weeks: Monthly visits are history of previous miscarriages or abortion, recommended. etc. ○ 32-36 weeks: Bi-monthly visits. Baseline height/weight ○ 36-40 weeks: Weekly visits. ○ High Risk Pregnancy: Vital signs measurement ○ Visits every 2 weeks until 30 weeks AOG. ○ Weekly visits from 30 to 36 Measurement of fundal height, Leopold’s Maneuver weeks AOG. ○ Twice a week from 37 weeks Physical Assessment and Examination until delivery. Vagnal Examination COMPONENTS OF PRENATAL VISIT Evaluation of fetal well-being, fetal heart sounds Initial Interview Health teaching and Prenatal education Establishing rapport with the patient and gathering significant medical and familial history is crucial. Collection of demographic data, including GTPAL System name, age, contact information, insurance details, etc. This classification helps in assessing Demographic Data pregnancy status: ○ G: Gravidity - total pregnancies. Name, age, address, telephone number, ○ P: Parity - pregnancies that have religion, etc. reached viability (greater than 24 weeks). ○ T: Term - full-term births (≥37 weeks). Chief Concern ○ P: Preterm - pre-term births (24-36 weeks). Reason for consult. Documenting the Last ○ A: Abortions - losses occurring before Menstrual Period (LMP) and any signs of early 24 weeks. pregnancy such as nausea, breast changes, etc. is vital for a better assessment. ○ L: Living - total number of living children. ○ M: Multiple gestations may also be Family and Medical History noted for clarity. Example Problems: Assess the mother's support systems and any ○ G4, P3: Indicates four pregnancies, relevant medical history within the family, with three reaching viability. including hereditary illnesses. ○ G6, P4: Indicates six pregnancies, four reaching viability, with detailed History of Past Illnesses outcomes noted. Childhood diseases, allergies, drug sensitivities, STIs, Diabetes, etc. Immunizations, gynecologic disorders, past surgical procedures. Review of Systems Conducting a thorough systematic health assessment from head to toe to identify general health and any specific issues. Gynecologic History CARE OF A WOMAN: ANTENATAL PERIOD (2) detected as irregular granular growth or soft, protruding masses, respectively. Estimating Pelvic Size: Pelvic examination may include a Types of pelvis in women and their characteristics: Papanicolaou (Pap) smear for cellular analysis to detect infections, inflammations, 1. Gynecoid: Typical female pelvis with a and other cellular abnormalities. well-rounded inlet, suitable for childbirth. It has a wide pubic arch. 2. Anthropoid: "Ape-like" shape with a narrow Laboratory examinations transverse diameter. 3. Platypelloid: A flattened pelvis with an - Blood studies include complete blood count, oval-shaped inlet. hemoglobin, hematocrit, VDRL (for syphilis), HIV 4. Android: Resembles a male pelvis with narrow screening, blood typing, Rh factor determination, dimensions, potentially causing complications during and MSAFP (maternal serum alpha-fetoprotein) labor. testing to detect neural tube defects or chromosomal anomalies. Ultrasonography. Fetal Activity Assessment Additional tests: - Indirect Coombs test to check for antibodies in - Daily fetal movement count (DFMC) or “Cardiff Rh-negative women; RhoGAM is administered at 28 count to ten methods” is a test used to check fetal weeks if indicated. well-being starting from the 27th week of pregnancy. - HIV Determination (Western Blot Test, and ELISA or - The fetus typically spends around 10% of the time enzyme-linked immune absorbent assay) moving, with periods of activity lasting 40 minutes and - Antibody titers for rubella and hepatitis B. inactivity about 20 minutes. -Urinalysis to screen for albuminuria, glycosuria, and - Expected movements: 10-12 fetal movements within pyuria. an hour. Warning signs include taking longer than - Tuberculosis screening using the Mantoux test. an hour to reach 10 movements or experiencing fewer than 10 movements within 12 hours. Vaccines for pregnant women Pelvic Examination Influenza vaccine - Before the examination, the bladder should be tetanus-diphtheria (Td) or TDaP (tetanus, emptied, and the client is positioned in a lithotomy diphtheria, and pertussis). TDaP should be position. administered between 27 and 36 weeks of - The physician examines: pregnancy, and a Td booster is recommended - External genitalia for signs of inflammation, every 10 years. irritation, or infection (such as redness, ulceration, or hepatitis A and B, discharge). rabies (if bitten), - Internal genitalia using a vaginal speculum to COVID-19 view the cervix and vagina. Cervical os appearance (Messenger RNA or (mRNA) vaccines are may vary: nulligravida (first pregnancy) is small and offered to pregnant and breastfeeding women, round, while previous pregnancies may result in a especially if at high risk). slit-like cervical appearance. Erosions appear as reddened areas. Psychological changes during pregnancy vaginal inspection and rectovaginal examination Social influences encourage family - A bimanual (two-handed) examination assesses involvement, minimizing anesthetics, and the position, contour, and consistency of pelvic organs. family-centered care. Psychological outlook - Rectovaginal examination can vary based on cultural, familial, and individual experiences. Cultural influences: A woman's cultural Vaginal infections background impacts how actively she participates in her pregnancy and her Trichomoniasis: Profuse whitish, bubbly openness to specific practices. discharge and redness, often with petechial Family influences: beliefs especially if the spots. woman has a positive view of mothering, can Candidiasis (Moniliasis): Thick, white vaginal affect her attitude toward pregnancy. patches caused by yeast (candida albicans). Individual differences: A woman’s coping Gonorrhea: Thick greenish-yellow discharge ability is crucial, helping her resolve conflicts with extreme inflammation, caused by and adapt to the changes pregnancy brings. Neisseria gonorrhea. Syphilis: Caused by treponema pallidum. Chlamydia: Often asymptomatic but can cause complications. Other conditions include cervical cancer/carcinoma and polyps, which may be Psychological tasks during pregnancy - Kegel exercises are encouraged to strengthen the pelvic floor. First trimester: Accepting the pregnancy, where some women may feel unprepared or Discomforts of middle to late pregnancy surprised. Second trimester: Accepting the baby as - Nursing interventions target backache, headaches, part of oneself, driven by the experience of dyspnea, ankle edema, and Braxton Hicks quickening (fetal movement). contractions. Third trimester: Preparing for parenthood, involving activities like arranging baby items, Danger signs of Pregnancy selecting names, and attending prenatal vaginal bleeding classes. Partners are often encouraged to persistent vomiting become emotionally involved during these chills and fever stages. presence of clear fluid abdominal or chest pain Emotional responses during pregnancy pregnancy-induced hypertension (PIC) increase or decrease fetal movement. Ambivalence Grief (as they transition into new roles), Prevention of fetal exposure to teratogens Narcissism Teratogen: any factor, chemical, or physical adversely Introversion or Extroversion affects fertilized ovum, embryo, or fetus Fluctuating body image and boundaries Emotional stressors include the need for Teratogenic Maternal Infections: support, mood swings, and Couvade syndrome (where the partner is Toxoplasmosis involved or attuned to the changes of his Rubella (German Measles) partner, and experiences symptoms like Cytomegalovirus nausea, and fatigue). Herpes simplex Sexual desire may change through the Other viral diseases: trimesters due to factors like nausea, fatigue, Syphilis increased pelvic blood flow, or the physical Lyme disease discomfort of a growing abdomen. Infections cause illness at birth (gonorrhea, candidiasis, chlamydia, streptococcus. B, hepa B) Health Promotion During Pregnancy Potential teratogenicity of vaccines Teratogenicity of Drugs Self-care: Includes regular bathing (no tub Thalidomide effects baths) Narcotics Dental Care: good tooth-brushing Teratogenicity of alcohol Perineal Hygiene: douching is contraindicated Teratogenicity of cigarettes Dressing: wear abdominal support, light Environmental teratogens maternity girdle Metal and chemical hazards Breast care: Washing with clear water and Radiation drying well without soap to protect nipple Hyperthermia / Hypothermia health. Teratogenicity of maternal stress Sexual activity: Generally safe, but women with a history of miscarriage are advised to avoid intercourse early on. Some positions Promoting nutritional health during pregnancy may be more comfortable in later stages. Work and travel precautions: Avoid heavy - Adequate diet ensures fetal growth and lifting, exposure to toxic substances, and development. Expected weight gain ranges from 11.2 standing for extended periods. Travel is to 16 kg. unrestricted in early pregnancy but requires - Essential nutrients include protein, healthy fats, frequent breaks. vitamins, and minerals (such as calcium, phosphorus, Exercise: prevent circulatory stasis in the iodine, iron, fluoride, and zinc). lower extremities - Foods to avoid include caffeine, artificial Sleep: to build new body cells, modified Sim’s sweeteners, and weight-loss diets. position with the top leg - Special dietary considerations apply to adolescents, older women, underweight women, vegetarians, and women with lactose intolerance or Nursing interventions for early discomforts in hyperemesis gravidarum. pregnancy - Common discomforts addressed include breast tenderness, palmar erythema or palmar pruritis constipation, nausea, vomiting, pyrosis, fatigue, muscle cramps, hypotension, varicosities, hemorrhoids, heart palpitations, frequent urination, abdominal discomfort. Preparation for childbirth - Childbirth education classes prepare expectant parents emotionally and physically for childbirth, covering topics such as labor pain management and infant care. - Perineal and abdominal exercises strengthen muscles to aid in delivery and recovery, including: Tailor sitting: Stretches the perineal muscles. Squatting: Useful for stretching perineal muscles. Pelvic floor contraction (Kegel’s exercises): Helps prevent postpartum incontinence and improve perineal healing. Abdominal muscle exercises: Strengthen the abdomen and help prevent constipation. Methods for pain management - Techniques include relaxation, controlled breathing, and distraction to reduce discomfort during labor. - The Lamaze and Bradley methods are commonly taught in classes to focus on relaxation and the support role of the partner. Preparation for cesarean birth Expectant parenting classes: Mother’s Class: Stages of pregnancy, newborn care Sibling education classes Alternative Methods of Childbirth Leboyer Method: Frederick Leboyer: darkened birthing room, warm, soft music, gentle handling of infant, cord cut late, infant placed war,-water bath Hydrotherapy and water bath: contamination is a common problem Antenatal fetal assessment Prenatal monitoring status Amniocentesis: Performed after the 14th week, tests for genetic disorders, Rh sensitization, and fetal lung maturity. Amniotic fluid assessment: Non-stress test (NST): Measures fetal heart rate in response to fetal movements to assess well-being. Nonreactive NST: may indicate fetal hypoxia, fetal sleep cycle Stress test (oxytocin challenge test, OCT): Tests fetal tolerance to contractions by administering oxytocin. Nipple stimulation stress test: Induces contractions naturally to assess fetal well-being. Chorionic villus sampling: Tests a small sample from the placenta to identify genetic disorders, usually done earlier than amniocentesis. Ultrasonography: Provides real-time images to monitor fetal development, detect abnormalities, and assess amniotic fluid. Biophysical profile: Combines tests such as NST, fetal breathing, and amniotic fluid measurement to give an overall assessment of fetal health. INTRAPARTUM PERIOD Components of labor (the "four p’s") Intrapartum period: efined as the period 1. Passage: The maternal pelvis and soft tissues. around labor and delivery, starting from labor 2. Passenger: The fetus, placenta, and membranes. admission through the immediate postpartum. 3. Powers: Uterine Contractions, Primary Power, and Intrapartum care: includes care of women Secondary Power (maternal pushing efforts) forces and their newborns during labor and just after aiding labor. birth. 4. Psyche/Psychological Response: The mother's Labor (parturition): is the series of attitude, which can affect labor progress and duration. physiological and mechanical processes that expel all products of conception, including the Powers of labor fetus, placenta, and fetal membranes. - Uterine Contractions - initiation of effective, Delivery: refers to the actual event of birth. productive, regular, involuntary, uterine contractions - Primary power- involves uterine contractions, originating from the fundus, which are involuntary and Theories of Labor effective for cervical dilation. - Secondary power- involves the voluntary maternal 1. Uterine stretch theory: Labor begins as the uterus pushing after full cervical dilation. distends and muscles stretch beyond normal capacity. 2. Oxytocin stimulation theory: Fetal head pressure Contraction - tightening of the uterine muscles during on the cervix triggers oxytocin release from the labor posterior pituitary, inducing contractions. 3. Progesterone deprivation theory: A decline in Phases of uterine contractions progesterone, a uterine relaxant, leads to uterine contractions. 1. Increment/Crescendo: The building phase of the 4. Prostaglandin theory: Increased prostaglandin contraction. synthesis by fetal membranes initiates contractions. 2. Apex/Acme: The peak intensity of the contraction. 5. Theory of Aging Placenta: Placental aging reduces 3. Decrement/Decrescendo: The phase where the blood supply, initiating contractions. contraction eases, completing the cycle. Premonitory or Beginning Signs of Labor Characteristics of Contractions 1. Lightening: The fetus descends into the pelvis, - Frequency is the time from the beginning of one occurring 10-14 days before labor for first-time contraction to the start of the next. mothers, and closer to labor for others. - Duration refers to the length of each contraction. 2. Braxton Hicks contractions: Irregular, painless - Interval is the rest period between contractions. contractions that do not signify true labor. - Intensity measures the contraction strength, which 3. A sudden burst of maternal energy/activity: Often can range from mild to strong and is assessed by due to increased epinephrine from decreased palpating the fundus. (mild, moderate, and strong) progesterone. 4. Slight decrease in maternal weight: Due to increased urine production from reduced progesterone Cervical changes during labor levels. 1. Effacement: The thinning and shortening of the 5. Softening/ripening of cervix: The cervix softens, cervical canal, expressed in percentages (e.g., 100% preparing for dilation. effaced). 2. Dilatation: The widening of the cervical opening, measured in centimeters up to 10 cm. Signs of True Labor 1. Rupture of the membranes of the bag of water Passenger of labor (the fetus) (BOW): Clear fluid leakage or blood-tinged mucus from the vagina, indicating labor progression. fetal head is the largest and least 2. Bloody show: Indicates cervix softening and mucus compressible part, with various diameters that plug expulsion. affect delivery ease. 3. Painful, regular uterine contractions: Involuntary cranial bones - 2 frontal, 2 parietal, 2 uterine contractions increase in intensity, duration, and temporal, and 1 occipital frequency, starting in the lower back and radiating to sutures - thin spaces in between bones the abdomen. (frontal, coronal, sagittal, and lambdoid), aid in the molding of the fetal skull distinguishing true vs. false labor fontanelles - points of intersections of cranial - True labor involves regular contractions that intensify bones, (soft spot) with movement, cervical dilation, and the presence of a - Anterior fontanelle (bregma) bloody show. diamond shaped, closes when an - False labor has irregular contractions that lessen infant is 12-18 months old with activity or rest, minimal cervical changes, and no - Posterior fontanelle (lambda) - bloody show. triangular shaped, closes when an infant is 6-8 weeks old or 2-3 months old Molding - slight overlapping of the cranial bones due - Footling breech (foot present at the to the force of uterine contractions pressing the head cervix, single and double footling) against the cervix, the skull becomes elongated in Shoulders - transverse lie shape, permitting passage to the maternal pelvis Fetal Station Areas of the fetal skull Ischial Spine - most important landmark of the pelvis occiput - area behind the posterior fontanelle vertex - lies between the 2 fontanelles and Floating (high) - unengaged presenting part extends to the parietal bones Station -3 - 3cm above ischial spines sinciput - in front of the anterior fontanelle Station -2 - 2cm above ischial spines Station -1 - 1 cm above ischial spines Diameters of the fetal skull Station 0 / Engagement - at the level of ischial spines, the largest transverse diameter has entered the true Anteroposterior Diameters pelvis Suboccipitobregmatic- is the smallest and Station +1 - 1 cm below ischial spines narrowest diameter (9.5 cm) when the head is Station +2 - 2 cm below ischial spines in full flexion. Station +3 - at the perineum can be seen if vulva is Occipitofrontal - 12 cm, presenting part if the separated head is in moderate flexion Station +4 - “crowning” Occipitomental - 13.5 cm, widest AP diameter, presenting part if the head is Fetal Position hyperextended - A three-letter code indicates the fetal presenting Transverse Diameters part, such as LOA for left occipitoanterior, which helps Biparietal diameter - is the widest transverse understand fetal orientation. diameter (9.25-9.5 cm) entering the pelvic First letter - right (R) or Left (L) inlet. Second letter - occiput (O), mentum (M), sacrum (Sa), acromion (A), or scapula (Sc) Fetal Presentation and Position Third Letter - anterior (A) or posterior (P) Fetal lie - describes the relationship between fetal and Denominator - part of the presentation used to maternal body axes, either longitudinal (common) or indicate the position transverse (rare). Passageway of labor (the pelvis) Fetal attitude - describes the degree of flexion in fetal posture, ranging from complete flexion (ideal) to - The false pelvis supports pregnancy, while the true extension. pelvis serves as the birth canal. complete flexion - normal fetal attitude moderate flexion - “military position”, chin not Linea terminalis - the imaginary line that separates touching the chest, occipitofrontal diameter the upper or false pelvis from the lower or true pelvis presents partial extension - “brow” presents to the birth Four pelvic bones canal, head moderately extended complete extension - head completely 2 innominate (hip bones) - (ilium, ischium, extended, occipitomental diameter presents, and pubis) face presentation 1 sacrum - sacral promontory (center of the upper border of the first sacral vertebra) Fetal Presentation 1 coccyx - a vestigial tail, (NODDING - the backward movement of the coccyx during Cephalic (vertex)/ head - most common, labor providing more space for the delivery of 96% the fetus) - Occiput/vertex (most common, head fully flexed on chest) Pelvic divisions and planes - Sinciput (moderate flexion, occipitofrontal diameter) - The pelvic inlet (pelvic brim) is the entrance to the - Brow (head moderately extended, true pelvis. forehead is the presenting part) - The midpelvis lies (pelvic cavity) between the inlet - Face (head completely extended) and outlet and is the narrowest part. (transverse or - Mentum (head is hyperextended, interspinous diameter) occipitomental) - The pelvic outlet is the opening through which the Breech/buttocks or feet - either buttocks or fetus emerges. Lies at the level of the ischial feet are the first to come in contact with the tuberosities, the lower border of the symphysis pubis cervix and coccyx - Complete (full) breech (buttocks and tightly flexed feet) - Frank breech (presenting part is the buttocks alone) Important pelvic measurements 1. Diagonal conjugate measures 12.5-13 cm and is the most critical pelvic inlet measurement. 2. Obstetrical conjugate is the shortest anteroposterior diameter, estimated at 10.5 cm. 3. Interspinous diameter is the smallest diameter of the midpelvis, and should be greater than 10.5 cm. 4. Intertuberous diameter is the narrowest diameter of the pelvic outlet, ideally 11 cm. Angle of the Suprapubic Arch - normal is 80-90 degrees, provides adequate room for the upward extension of the fetal head at the delivery time Types of pelvis 1. Gynecoid - normal and classic pelvis, inlet well-rounded/circular, most ideal for childbirth 2. Android is heart-shaped and narrow, often requiring a cesarean section 3. Anthropoid is oval and narrow, allowing spontaneous vaginal birth. 4. Platypelloid is flattened and rare, challenging for fetal rotation. Psychological response of the mother - The mother’s emotional state affects labor progress; a positive outlook and preparedness can shorten labor, while anxiety may prolong it. - Cultural values influence birthing practices, pain expression, and choice of support people. - Factors such as expectations, support, and childbirth preparation are essential to consider. special considerations - Catecholamine release due to stress inhibits uterine contractions and reduces placental blood flow. - Fear and anxiety increase tension, making each contraction and pushing effort more difficult and painful. STAGES OF LABOR & DELIVERY - Narcotics are given when cervical dilation is 6-8 cm and avoided close to delivery to prevent respiratory depression in the newborn. Essential Intrapartum and Newborn Care (EINC) Essential intrapartum care practices during the - Evidence-based standards for safe and quality care first stage for birthing mothers and newborns during the 48 hours surrounding labor and within the first week of life. - Encourage mobility, light carbohydrates for energy, - Includes essential intrapartum care (EIC) for the non-pharmacologic pain relief techniques (e.g., mother and essential newborn care (ENC). effleurage), and companionship. - In December 2009, DOH Secretary Francisco Duque - Use a partograph for labor monitoring starting at 4 cm signed an administrative order mandating EINC dilatation with vaginal examinations every 4 hours protocols in hospitals. The "Unang Yakap" campaign (limited to reduce infection risk). was launched. - Avoid perineal shaving, enemas, IV fluids, fasting, artificial rupture of membranes, and labor-inducing Stages of Labor drugs unless medically indicated. - Stage 1: Cervical dilatation Second stage of labor - fetal expulsion - Stage 2: Fetal expulsion - Stage 3: Placental expulsion - Begins with full cervical dilatation and ends with fetal - Stage 4: Puerperium (recovery period) delivery. - Time duration: Primigravida (30 minutes to 2 hours), Multigravida (20 minutes to 1 hour). Stage durations for first-time mothers - Cardinal movements include engagement, descent, (primigravida) and those with previous births flexion, internal rotation, crowning, extension, and (multigravida) external rotation, ending with expulsion. 1. First stage: Primigravida (10-12 hours), Lacerations and Episiotomy Multigravida (6-8 hours) 2. Second stage: Primigravida (30 minutes to 2 Lacerations - injury or tear in the vaginal canal and hours), Multigravida (20 to 90 minutes) perineum that occurs during delivery of the fetus 3. Third stage: Both primigravida and multigravida (up to 30 minutes) Laceration degrees: 4. Fourth stage: Both primigravida and multigravida (1 to 4 hours) First degree: Tear of the fourchette and vaginal mucosa. First stage of labor - cervical dilatation Second degree: Involves fascia and muscles. Third degree: Extends to the anal sphincter. - Begins with true labor contractions and ends with full Fourth degree: Involves the rectum. cervical dilatation (10 cm). - Dilatation rates: Primigravida (1.2 cm/hour), Episiotomy (surgical perineal incision) is either Multigravida (1.5 cm/hour). midline (easy to repair, but may extend to rectum) or - Effacement (shortening and thinning of the cervix) mediolateral (avoids rectum but causes more pain). expressed as a percentage: fully effaced (100%), partially effaced (25%, 50%, 75%). Episiorraphy - repair of perineal laceration or of episiotomy Phases of the first stage of labor essential intrapartum care practices during the - Latent phase: Dilatation 0-3 cm, contractions last second stage 20-40 seconds, intervals of 5-10 minutes, mild - Allow spontaneous pushing, encourage semi-upright intensity, minimal discomfort, excitement, and control positions, and limit episiotomy to cases where over pain. necessary. - Active phase: Dilatation 4-7 cm, contractions last 40-60 seconds, intervals of 3-5 minutes, moderate to Third stage of labor - placental expulsion strong intensity, increasing discomfort, restlessness, and anxiety. - Begins after delivery of the fetus and ends with - Transition phase: Dilatation 8-10 cm, contractions placental delivery, ideally within 30 minutes. last 60-90 seconds, intervals of 2-3 minutes, strong intensity, significant discomfort, nausea, and an urge to Signs of Placental Separation push. Calkin’s sign - earliest sign, uterus becoming Pain management during first stage firm, round, globular again Sudden gush of blood - Analgesics like Meperidine (Demerol), Nalbuphine Lengthening of the umbilical cord (Nubain), and Fentanyl (Sublimaze) are common. Firm contraction of the uterus Meperidine has sedative and antispasmodic effects, Appearance of the placenta at the vaginal typically given intramuscularly (onset 30 minutes) or opening intravenously (onset 5 minutes), lasting 2-3 hours. Types of Placental Presentation progress of labor (partograph part 2) - Cervical dilatation is plotted from 4 cm until full Schultz presentation (fetal side first): "Shiny dilatation, using the alert line (indicating expected side" and common. progress) and action line (prompting intervention if Duncan presentation (maternal side first): labor slows). "Dirty side" and less common. - Uterine contractions recorded every 30 minutes, with intensity measured by duration and frequency. Mild Techniques for placental expulsion contractions are less than 20 seconds, moderate between 20-40 seconds, and strong over 40 seconds. Crede's maneuver (manual pressure on the fundus) maternal condition (partograph part 3) Brandt-Andrews maneuver (controlled - Records maternal pulse, blood pressure, traction). temperature, and urine output throughout labor. - Monitoring includes protein and ketone levels in urine to detect complications like pregnancy-induced Active Management of Third Stage (AMTSL) hypertension or gestational diabetes. - Ensure no second baby is present before administering oxytocic drugs (e.g., oxytocin, ergotrate). - Massage the uterus gently to ensure it remains contracted and prevent excessive bleeding. Fourth stage of labor - Immediate Postpartum Period - First 1-4 hours post-delivery, focused on stabilization. - Monitor uterine firmness and prevent atony by gently massaging the uterus if necessary, monitoring for signs of uterine relaxation. - Check vital signs every 15 minutes for the first hour, then at 30-minute intervals, ensuring no signs of excessive bleeding, swelling, or infection. Assessment of Lochia - Lochia is the postpartum discharge containing blood, mucus, and tissue. Monitor lochia flow by counting soaked pads and assessing color, odor, and consistency. - Bright red lochia lasting over two weeks suggests placental retention or incomplete uterine healing. Monitoring maternal condition - Ensure that the fundus remains firm, there is no bladder distention, and that vital signs remain stable. - Encourage nourishment, provide warmth, and support bonding through early breastfeeding initiation. partograph - tool for labor monitoring - Graphical tool to assess labor progress, fetal condition, and maternal health during labor. - Records start from the active phase (4 cm dilatation) to monitor for abnormal labor progression. - Objectives include early detection of abnormal labor, preventing prolonged labor, and assisting with decision-making on interventions if needed. fetal condition (partograph part 1) - Tracks fetal heart rate, membrane status, amniotic fluid condition, and molding of the fetal skull bones. - Fetal heart rate is recorded every 30 minutes during the first stage and every 5 minutes in the second stage, with adjustments if meconium-stained amniotic fluid is present. - Molding (overlapping of fetal skull bones) assessed initially and every 4 hours, indicating fetal descent and fit within the maternal pelvis.