Intraparta Period Lecture Notes PDF

INTRAPARTAL PERIOD EDWIN B. DEL ROSARIO, CCRN, ACNP, AGNP THEORIES OF LABOR ONSET LESSON 1 progesterone  OXYTOCIN STIMULATION THEORY Oxytocin produced by - posterior pituitary gland during pregnancy nears term  UTERINE STRETCH THEORY Increasing size of the Prost...

INTRAPARTAL PERIOD EDWIN B. DEL ROSARIO, CCRN, ACNP, AGNP THEORIES OF LABOR ONSET LESSON 1 progesterone  OXYTOCIN STIMULATION THEORY Oxytocin produced by - posterior pituitary gland during pregnancy nears term  UTERINE STRETCH THEORY Increasing size of the Prostaglandin fetus release Stretched Uterine muscle of contraction the uterus PROGESTERONE DEPRIVATION THEORY Aging placenta Decreased progesterone production Uterine contraction PROSTAGLANDIN THEORY Fetal membrane Arachidonic acid Uterine produce Prostaglandin contraction arachidonic acids  THEORY OF AGING PLACENTA Aging Uterine placenta contraction progesterone prostaglandin  FETAL ADRENAL RESPONSE THEORY Fetal adrenal Progesterone Release fetal Uterine and pituitary cortisol contraction gland prostaglandin COMPONENTS OF LABOR PROCESS AND THE SIGNS OF LABOR LESSON 2  FOUR P’S OF LABOR Passage Passenger Powers Psyche Pelvis Fetus Uterine Psychological contraction state  PASSAGE Refer to the route the fetus must travel from uterus via vaginal canal to perineum Soft passage : muscles, cartilages, joints Hard passage : Pelvis  PELVIS Cavity that contains the female internal reproductive organs Serves as a birth canal through which the fetus must pass during labor Made up of 4 united bones: 2 innominate or hip bones Ilium Ischium Pubis Articulation/joints Sacroiliac Symphysis pubis PELVIS Division ▪Linea Terminalis ▪True Pelvis ✔Pelvic inlet/brim ✔Pelvic outlet ✔Pelvic cavity ▪False pelvis  FOUR TYPES OF PELVIS Gynecoid Anthropoid Android Platypelloid Normal pelvis Ape-like Triangular Rarest Well-rounded pelvis pointing Flat pelvis Longer towards Spines not Wide side front-to-back mother front prominent to side Oval shaped Male pelvis Wide pubic arch AP > Heart shaped Bowl-like transverse Narrow pubic Transversely arch oval MEASUREMENTS 13 Inlet Diagonal conjugate 13 True conjugate Obstetric conjugate Traverse Oblique Outlet Transverse anteroposterior  PASSENGER Head – most important part ✔Largest ✔Least compressible Bones (Cranium) FETAL HEAD: SUTURES Sagittal – 2 parietal bones Frontal – 2 frontal bones Coronal – frontal and parietal Lambdoidal – parietal and occipital  FONTANELLES Anterior fontanelle or Posterior fontanelles bregma intersection of sagittal, intersection between coronal and frontal sutures sagittal and lambdoidal AP: 3-4 cm; transverse 2-3 sutures cm (bigger) 2 cm Diamond shape triangular Closes at 12-18 months closes by 2-3 months  DIAMETERS OF THE FETAL HEAD Transverse diameter Biparietal Bitemporal Bimastoid  DIAMETERS OF THE FETAL HEAD AP Diameters Suboccipitobregmatic (SOB) Occipitobregmatic Occipitomental FETAL PRESENTATION AND POSITION Attitude ✔ Relation of the fetal parts to the other parts ✔Degree of flexion, fetus assumes during labor 1. Complete flexion (vertex presentation) 2. Moderate flexion (sinciput presentation) 3. Partial extension (brow presentation) 4. Complete extension (face presentation)  PRESENTATION Denotes the body part that will first contact the cervix or will deliver first ▪ Cephalic presentation : head ▪ Vertex ▪ sinciput ▪ Brow ▪ Mentum/face ▪ Breech ▪ Complete ▪ Footling ▪ frank  TYPES OF CEPHALIC PRESENTATIONS LIE ATTITUDE DESCRIPTION VERTEX LONGITUDINAL GOOD (FULL Head is sharply flexed FLEXION) Most common presentation Allows SOB diameter to present to the cervix Brow Longitudinal Moderate (military) Brow/sinciput is the presenting parts Face Longitudinal Poor Fetus extends the head to make face presents to cervix Risk: extreme facial edema/distortion Mentum Longitudinal Very poor Fetus completely hyperextends the head Occipitomental diameter presents to cervix Risk: C-section, vaginal delivery is impossible FETAL POSITION relationship of the presenting part to specific quadrant of the woman pelvis ✔ Fist letter : laterality R/L ✔ Middle: fetal landmark ✔ Third: anterior, posterior, transverse (lie) Four quadrants ✔ Right: anterior/posterior ✔ Left: anterior/posterior Four fetal landmarks ✔ Occiput ✔ Sacrum ✔ Chin ✔ shoulder  FETAL PRESENTATION Station Relationship of the presenting part of the fetus at the level of ischial spine Engagement Settling of the presenting part of the fetus far enough into the pelvis at the level of ischial spine Descent Downward movement of the biparietal diameter of the fetal head to pelvic inlet STATION  MECHANISM OF LABOR Descent Flexion Internal Rotation Extension Rotation Expulsion  MECHANISM OF LABOR https://youtu.be/dYu-0rOnLpA  POWERS OF LABOR Force supplied Uterine Cervical Expulsion of by the fundus contraction dilatation fetus of the uterus PHASES: Increment Acme Decrement Characteristics Frequency Duration interval  CERVICAL CHANGES Effacement ▪ Shortening/thinning of the cervical canal Dilatation Enlargement/widening of the cervical canal an opening PSYCHE Psychological state of the mother COMPONENTS OF LABOR PROCESS AND THE SIGNS OF LABOR LESSON 2  Signs of Labor Lightening descent of the fetal presenting part into pelvis, “baby drop” ✔ Primipara – occurs 10-14 days before labor begins ✔ Multipara – occurs before labor onset  LIGHTENING Relief of Leg pain Increase Decrease Urinary respiratory muscle vaginal in fundic frequency discomfort cramps discharge height  Signs of Labor Ripening of Increase in Braxton Hick’s Rupture of Lightening Bloody show cervix level of activity contractions membrane “baby drop” Prepares the Irregular Gush of clear mother for painless vaginal fluid labor contraction  FALSE LABOR TRUE LABOR CHARACTERISTI Painless, irregular Begins irregular and becomes more CS regular and predictable LOCATION Initially, abdominally and remain Initially, in the lower back and confined to abdomen and groin LOCALIZES to the abdomen RELIEVER Disappears with ambulation No relief sedatives or sleep ACIIVE LABOR Increase in duration, intensity and frequency EFFACEMENT/ present DILATATION/ BLOODY SHAW ENGAGEMENT PRESENT  VAGINAL EXAMINATIONS DURING LABOR 1. Wash hands. Explain procedure to the patients 2. The examiner places a hand on the outer edges of the vulva and spread the labia 3. Note fluid escaping from vagina : amniotic fluid 4. Cervix ✔ Cervical consistency, dilatation, effacement ✔ Dilatation : 1 fingerbreadth = 1 cm ✔ Effacement: ✔ Normal thickness : 2-2.5 cm ✔ 1 cm = 50 % effaced 5. Locate ischial spine : station 6. Determine Fetal position INVASIVE AND NON-INVASIVE ASSESSMENT OF FETAL WELL-BEING FETAL HEART RATE  FETAL MOVEMENT: Mother observes and Mother observes and records records the time interval to fetal movement feel 10 fetal movements Normal: 10 movements in 1 Normal: minimum of twice hour or less every 10 minutes or average Warning signs 10-12/hr. ✔ More than 1 hour to Report: fewer than 10 reach 10 movements movements x 2 consecutive ✔ Less than 10 movements hours in 2 hours ✔ Longer time to reach 10 Cardiff Sandovsky method FMs than on previous method days (count-to-ten) ✔ Movements are weaker , less vigorous  NON STRESS TEST (FHR VS. FETAL MOVEMENTS ) When fetus moves = FHR increases about 15 beat per minutes and be elevated for 15 seconds (ACCELERATION – REASSURING) Results ✔Reactive: 2 or more accelerations of FHR of 15 bpm lasting for 15 seconds or ore with each fetal movements in a 20-minute period ✔Non-reactive: no acceleration of FHR of 15 bpm lasting for 15 seconds ✔Unsatisfactory: quality of FHR recording is not adequate for interpretation NST RESULTS  CONTRACTION STRESS TEST (FHR VS. UTERINE CONTRACTION ) Stimulation ✔ Oxytocin ✔ Nipple stimulation, EFFLURAGE, using BELL Basis ▪ Healthy fetus: oxytocin stimulation --- decrease in oxygen supply --- withstand the stress ▪ Fetal distress : demonstrate fetal deceleration ---- uteroplacental insufficiency Requirements 3 contractions with 40 seconds or more duration within 10 minute period CST: RESULTS  INCIDEN STAGE OF LABOR NADIR 0F ETIOLOGY INTRVENTION CE DECE;ERATI ON EARLY Uncommo Late 1st/2nd stage Peak of Head Observe n contraction compression Benign Monitor for labor progress LATE 8-10% Any After peak Uteroplacental Reposition of insufficiency Oxygen support contraction (ominous sign) Hydration: IV fluids Turn off oxytocin Fetal Resuscitation Call MD : immediate delivery VARIAB 85-90% Any variable Cord Repositioning LE commo compression n FETAL BIOPHYSICAL SCORING DIAGNOSTIC PROCEDURES Ultrasound Purpose : ESTIMATE AOG (EARLY ULTRASOUND) ✔ Diagnose pregnancy as early as 6 weeks gestation ✔ Confirm presence, size and location of placenta and amniotic fluid ✔ Detect fetal anomalies ✔ Sex determination ✔ Measures biparietal diameter of the head = 8.5 cm = 40 weeks AOG = > 2500 grams Preparation ✔ Full bladder  AMNIOCENTESIS Amniocentesis- aspiration of amniotic fluid from pregnant uterus for examination. Can be done as early as 16-18 weeks : (+) AFP – neural tube defect Done 34-42 wks. to determine fetal well-being and maturity. First, ultrasound is done to determine location of placenta, amniotic fluid pocket and fetal position. Lung maturity ✔ lecithin:sphingomyelin ratio = 2:1 STAGES OF LABOR, RELATED DISCOMFORTS AND NURSING INTERVENTIONS LESSON 4 STAGES OF LABOR:  LATENT ACTIVE TRANSITIONAL CERVICAL DILATATION CERVICAL EFFACEMENT 0-5 CM 6-8 8-10 INTERVAL 6-10 minutes 3-5 minutes 2-3 minutes DURATION 20-30 SECS 40-60 secs 60-70 secs NURSING CONSIDERATION May continue to Bloody show, feeling of loss of walk spontaneous control, anxiety, Deep breathing rupture of panic Epidural anesthesia membrane may be given Left lateral position CARE OF WOMAN DURING THE FIRST STAGE OF LABOR active phase: VS every 30 minutes MECONIUM STAINING  SECOND STAGE OF LABOR Positioning : sitting, squatting EPISIOTOMY  THIRD STAGE OF LABOR Placental stage Begins with the birth of the infant and ends with the delivery of placenta Phases ✔ Placental separation ✔ Placental expulsion sign SIGNS OF PLACENTAL SEPARATION A sudden gush The placenta is The uterus Lengthening of of vaginal visible at the contracts and the cord. blood occurs vaginal opening feel firm again METHODS OF PLACENTAL SEPARATION PLACENTAL EXPULSION naturally by bearing down effort by the mother manually by gentle pressure on the contracted uterine fundus by physician or nurse-midwife DEGREE OF LACERATIONS Vaginal mucosa submucosa Anal sphincter rectum  EPISIOTOMY EPISIOTOMY https://youtu.be/9Wb2BlQltn0 EPISIORRHAPY https://www.youtube.com/shorts/3rdGjb6gbts?feature=share CARE OF WOMAN ON THE FOURTH STAGE OF DELIVERY  OXYTOCIN Promotes uterine contraction Decrease bleeding Nursing ✔ Check Blood pressure prior to administration and during treatment ✔ Must be administered after placental separation/delivery DANGER SIGNS OF LABOR LESSON 6 MATERNAL DANGER SIGNS MATERNAL DANGER SIGNS  FETAL DANGER SIGNS Fetal Fetal Meconium Hyperactivity Acidosis tachycardia bradycardia staining MATERNAL RESPONSES TO LABOR LESSON 6  PHYSIOLOGIC EFFECTS OF LABOR ON THE MOTHER: Decreased blood Increased Uterine supply to peripheral contraction uterus resistance Pressure Increased Increased against blood in SBP 15 uterine systemic mmHg arteries circulation  PHYSIOLOGIC EFFECTS OF LABOR ON THE MOTHER Temperature Hematologic Respiratory Fluid balance regulation leukocytosis Increased O2 Slight Increased consumption elevation of insensible temperature water loss Concentrated urine  PHYSIOLOGIC EFFECTS OF LABOR ON THE MOTHER Neurologic/sensory Musculoskeletal Gastrointestinal response Relaxin Slow digestion Pain Soften pelvic Delayed gastric Fatigue cartilage emptying Fear Fairly inactive during labor THANK YOU “ THE LORD IS MY SHEPHERD”