Intrapartal Period PDF

INTRAPARTAL PERIOD THEORIES OF LABOR ONSET  UTERINE MYOMETRIAL  Progesterone IRRITABILITY (UTERINE deprivation( low STRECTH) progesterone theory) When the uterine muscles stretch with fetal growth and...

INTRAPARTAL PERIOD THEORIES OF LABOR ONSET  UTERINE MYOMETRIAL  Progesterone IRRITABILITY (UTERINE deprivation( low STRECTH) progesterone theory) When the uterine muscles stretch with fetal growth and When progesterone level increasing amniotic decreases and uterine fluid, it results to muscle stimulants irritability and increase in late contractions to empty pregnancy, labor will the contents of the start. fetus. The most acceptable Progesterone is a uterine muscle theory. relaxant  OXYTOXIN THEORY  ESTROGENIC, FETAL HORMONE, The pressure of the AND fetal head on the PROSTAGLANDIN cervix in late THEORIES. pregnancy stimulates the All these have posterior pituitary stimulating effect gland to secrete on uterine oxytocin which musculature causes uterine causing uterine contractions. contractility.   Summary:  THEORY OF AGING Fetus uterine muscle Placenta PLACENTA to stretch Amniotic fluid  Progesterone level As the placenta decreases matures, it is  Oxytocin level increases increase believed that the  Estrogen, fetal hormone and uterine resultant prostaglandin level increases contractility diminished blood  Placenta matures supply to the area causes contraction. As placenta aged, more pressure labor/delivery is exerted on the fundal portion ( the usual placental site and the most contractile portion of the uterus). PREMONITORY SIGNS OF LABOR  1. Lightening :  c. signs of lightening descent/dipping, dropping of the a. relief of dyspnea presenting part to the b. relief of abdominal true pelvis. tightness a. engagement is not c. increased frequency of exactly the same as urination, varicosities, pedal lightening. edema because of pressure b. onset on bladder and pelvic girdle -primigravida: lightening occurs earlier, 2 weeks d. shooting pains down the before labor legs because of the - multigravida: lightening pressure on the sciatic occurs either a day nerves before labor or on the e. increased amount of day of the labor. vaginal discharge 2. Increased braxton 3. Increased maternal hicks contractions 3 energy/burst of energy to 4 weeks before because of hormone labor epinephrine a. false labor contractions: irregular 4. Slight decrease in b. do not dilate the maternal weight by 2 – 3 cervix pounds, 1 to 2 days before labor. c. abdominal discomfort 5. Show d. relieved by 6. Ripening of the cervix walking, enema 7. Rupture of the bag of e. generally painless waters but may be quite 8. Progressive fetal descent uncomfortable  CRITERIA TRUE LABOR FALSE LABOR Contractions Regular, progressive Irregular, non- progressive Discomfort Lumbo-sacral Abdominal radiating to the front;increasing intensity Cervix Dilated: most No dilatation important sign Walking Intensifies No effect on contractions contraction Enema Intensifies No effect on contractions contraction Show Present and Absent increasing TRUE VS. FALSE LABOR PHYSIOLOGIC ALTERATIONS IN LABOR  Dilatation : progressive, opening/widening of the cervical os  Effacement : thinning and obliteration of the cervical canal.  Physiologic retraction ring: the separation of the active, shorter, thicker upper uterine segment and passive, longer and thinner lower segment.  Bandl’s ring: pathologic retraction ring; formed when the upper uterine segment is as active as the lower segment, seen as “ abdominal indentation ring” signifying rupture of the uterus if not managed. COMPONENTS OF LABOR PROCESS 1. PASSAGEWAY. This   d. Pelvic outlet diameters refers to the adequacy of the pelvis and birth canal in allowing fetal e. Ability of the uterine descent. segment to distend the cervix to dilate, and the virginal A. Soft passages: cervix, vagina, canal and introitus to distend. perineum; may be affected by laceration. B. Bony passage: the pelvis a. Type of pelvis 1. gynecoid 2. android 3. anthropoid 4. platypelloid b. Structure(division) of pelvis 1. true pelvis 2. false pelvis c. Pelvic inlet diameters  a. Suture; thin spaces in between  2. PASSENGER. bones/line of junction or clossure between bones.  This refers to the fetus and a. Sagittal suture-longitudinal, its ability to move through midline suture between 2 the passage way, which is parietal bones; most important based on the following: suture (overrides/overlaps in labor which reduces the 1. Size of the fetal head( has 7 biparietal diameter of the head bones: 2 frontal, 2 by 0.5-1 cm. parietal, 2 temporal, and b. Frontal suture- anterior suture 1 occipital) and capability between 2 frontal bones. of the head to mold the c. Coronal suture- anterior suture passageway. between frontal and parietal bones. d. Lambdoidal suture- posterior suture between parietal and occipital bones.   B. fontanels- points of C. fetal head diameters intersection of cranial a. anteroposterior (AP) bones; membranous diameters: wider than the spaces between cranial transverse diameters of the bones during fetal life head and infancy. 1. occipitomental; 12.5 – 13.5 cm from occiput to the chin, a. anterior fontanel widest AP diameter. ( bregma) formed by 2 frontal bones and 2 2. occipitofrontal; 12 cm from occiput to midfrontal bone. parietal bones: diamond shaped, 3.suboccipitobregmatic: 9.5 cm from below the occiput to measures 2.5 cm x 2.5 the anterior fontanel, cm, ossifies ( closes) in narrowest AP diameter of the 12 to 18 months. head. b. posterior fontanel b. transverse diameters ( lambda)-formed by 1. biparietal diameter; 9.5 cm, union of 2 parietal and widest transverse occipital 2. bitemporal diameter; 8 cm bones:triangular- shaped, ossifies in 6-8 3. bimastoid diameter; 7 cm wks or 2-3 months  c. Fetal attitude – the relationship of fetal parts to one anther. d. Fetal position – the relationship of a particular reference points of the presenting part and the maternal pelvis, described with a series of three letters (side of maternal pelvis [L, left; R, right; T, transverse], presenting [O, occiput; S, sacrum; Sc, scapula; M, mentum], and the part of the maternal pelvis (A, anterior; P, posterior) FETAL PRESENTATION  Cephalic a. vertex b. sinciput c. brow d. face  Breech a. complete b. incomplete c. footling d. shoulders FETAL POSITION  Choosen  Assessment of fetal landmarks/denominators position: a. occiput (o) b. mentum (m) a. leopold’s manuever c. sacrum (s) b. vaginal d. acromiodorso (ad) examination  4 imaginary quadrants a. left anterior b. left posterior FETAL STATION c. right anterior d. right posterior  Left occipitoanterior ( LOA)  Occiputposterior (OP) THE POWER  Primary power: Purposes: UTERINE  Propel presenting part CONTRACTIONS downward/forward. Characteristics:   Effacement of the cervix involuntary, rhythmical, regular  Dilatation of the cervix activity of uterine musculature Effects of contractions:  Occurs intermittently  Increased maternal BP. by allowing period of relaxation between  Decreases uteroplacental contractions, circulation. promoting uterine and  Fetal hypoxia maternal rest and  Cervical dilation during the restoration of 1st stage. uteroplacental  Expel the fetus and the circulation which sustains fetal placenta during the 2nd and oxygenation. 3rd stages of labor.  Phases of uterine  A. Duration – the period form contractions: the beginning of increment to 1. Increment the completion of decrement ( cresendo)-” of the same contraction. building up” of  B. Frequency – the period contraction, longest from the beginning of one phase. contraction to the beginning 2. Acme (apex)- of the next contraction; expressed in every minutes. height/peak of contractions  C. Interval – the period from decrement of the 1st 3. Decrement contraction to the increment ( descresendo)- of the next contraction. “letting up”, end phase of contractions.q  D. Intensity- refers to the strength of uterine contraction during 2. acme.(can be determined by C. palpation). E.  Strong- uterine fundus is very firm, and cannot be 1. indented with fingers.  Moderate – fundus is 3. 4. difficult to indent.  Mild – fundus is tense but can be indented with fingertips. A ( from 1 t0 3)duration f. Intrauterine catheter- directly measures the strength of B contractions. (from1to4)frequency  Secondary powers: a. Maternal bearing down/ pushing readiness for pushing:  cervical dilatation: 10cm; fully dilated  Fetal station: +1  Correct pushing:  Discourage prolonged maternal breath holding of more than 6 seconds, during pushing.  Have 4 or more pushes /contraction. b. Intraabdominal pressure: as the woman pushes, the intraabdominal pressure increases.  Position of the parturient 1. 1st stage of labor a. LL- most comfortable and best for fetal well being as this prevents supine hypotensive syndrome or vena caval syndrome. Avoid supine position.  b. optimal position 2. 2nd stage of labor:  may ambulate- if a. Lithotomy position- water is intact  May still ambulate, most commonly provided the station is used which favors at least 0 , or + the nurse stations to prevent cord ensure equal prolapse – water has height of the ruptured.  If with IVF, a movable stirrups. pole should be used to  Pad the stirrups. allow ambulation.  Simultaneous  In the choice of position placement of the in labor, consider the following; maternal, legs on the stirrups. physical and  Avoid any pressure psychologic needs, on the popliteal fetal well being region.  Psychologic response 2. women’s psychologic of the mother. responses to uterine 1. Factors that make contractions. labor meaningful: a. fear b. anxious (Clark and Alfonso, 1978) 3.Other factors a. Cultural influences a. childbirth preparation process- integrating maternal considered as a attitudes valuable tranquilizer b. Expectations and during child birth process goals for the labor b. support system process - husband – can c. Feedback from other provide emotional people participating support ( lessen in birthing process. anxiety -> lessen emotional tension- >less pain perception.  - attending nurse-should provide a supporting and caring environment , respect the client’s/ family’s needs and attitudes- >provide therapeutic communications CAUSES OF LABOR PAIN 1st stage of labor 2nd stage @primary source of @hypoxia of pain- dilatation of contracting uterine muscles the cervix @distension of the @Hypoxia of the vagina and uterine muscles perineum during contraction -pudendal nerve @stretching of the plexus lower uterine pudendal block segment technique @pressure at the @pressure on adjacent adjacent structures structures NATURAL CHILDBIRTH  Dick – read method: 1st of natural childbirth - Utilizes relaxation techniques and primarily abdominal breathing to interrupt the circular pattern of “ fear”- >”tension”->”pain”. - Woman concentrates on forcing the abdominal muscles to rise - Use of slow abdominal breathing in the 1st stage of labor: 1 breath/minute(30 seconds inhalation and 30 sec. exhalation) - Use of panting to prevent pushing until needed. LAMAZE METHOD OF PSYCHOPROPHYLAXIS  Mind prevention using body conditioning exercises, education, relaxation,and chest breathing. - based on “Pavlov’s Theory on Conditioned Reflexes”- the brain cells can respond to only 1 set of signals at a time and they accept only the strongest signal. - 2 components: education and training - - uses focal points to concentrate on during contractions. Fundamental techniques(lamaze method)  Conditioning –  Discipline  Concentration Bradley Method- partner or husband coached natural childbirth -uses relaxation and slow controlled breathing - Basically same techniques as the ones used in read method. CARDINAL MECHANISMS OF LABOR  Engagement  Descent  Flexion  Internal rotation  Extension  Restitution  External rotation  Expulsion EDFIREREE  DURATION OF LABOR Labor stage Primigravida Multigravida First stage: phases 1. Latent ( 0-3cm cervix) 8-10 hours ( ave.9 5 hours 2. Active ( 4-8 cm cervix) hrs.) 4 hours 3. Transitional (8-10 cm 6 hours 1 hour cervix) 2 hours 2nd stage Mean: 50 minutes 20 minutes Most difficult for the fetus ( 1 hour) (1/2 hour) 3rd stage 5-15 minutes 5-10 minutes The ave. duration of the 3rd stage is 5 min. 4th stage – most dangerous for both privi and for the mother ( when the multi: a1-2 hours ave. fundus fails to contracts and period of recovery, remain atonics in spite of stabilization or management, the woman can homeostasis, or the have hemorrhage leading to most up to 4 hours. maternal mortality. STAGES OF LABOR First Stage During first stage labor your cervix is effacing (getting thinner) and dilating (opening up). First stage labor is considered complete when your cervix is fully dilated and your body switches from opening contractions to expelling contractions.  There are three phases to first stage labor. Each has its own physical and emotional signs. Women also have very different needs in each of these phases.  Early Stage of Labor ( latent phase) – the majority of your labor will likely be in this stage. Ranging from 8-15 hours, contractions are usually between 30 and 55 seconds long and 5-20 minutes apart. @nursing intervention: Proper positioning( side lying) @backrub(backache with abdominal cramps) @ support system Active Labor – this stage generally lasts 3-5 hours. Contractions are 45- 60 seconds long and 3-5 minutes apart, cervix is 4-8 cm; complete effacement Nursing intervention: @encourage slow and shallow breathing @offer paper bag to breathe into( hyperventilate->hyperventilation is main problem in this stage) @instruct woman to cupped hands and breathe into it. Note: hyperventilation may lead to respiratory alkalosis.  Transition – this is the shortest stage and most intense stage. It marks the complete dilation of your cervix: 8-10 cm. Typically only 10-60 minutes long, contractions are 60-90 seconds in length for every 2-3 min. Generally women only have between 5-10 transition contractions. The mother may have strong desire to push but she should not!>to eliminate the tendency to push with contractions, lamaze technique suggest pant blow pattern of chest breathing.  Maternal problem: backache, pressure on the bladder and rectum and leg trembling  Nursing intervention: @provide comfort with dry lines and cool clothes @ clean up vomitus @provide backrub @pant blow breathing pattern @stay with patient and help her focus on her task: inform progress and be understanding of her irritability. (PREIST:praise, reassure, encourage, inform mother of progress, support system and touch)  Second Stage - best known as pushing stage, starts after you have complexly dilated. The top of your uterus will now start contracting down towards your cervix to expel your baby.  Ranging from 20 minutes to 2 hours long, pushing contractions are around 60 seconds long with 5-10 minute breaks between pushing contractions.  Crowning is the hallmark of this stage.  Maternal behavior: progresses from irritability to participation, eagerness and excitement. >pushes with uterine contractions due to the need to bear down.  Perineum bulges  Increase bloody show with leg cramps  BOW ruptures ( best time) then to check the FHT immediatley. Nursing intervention:  Psychological support  Monitor FHT  Position the mother – lithotomy: padded stirrups, no pressure on popliteal region, and equal height of legs, simultaneously raised the legs into stirrups.  Third stage – placental stage  Period from the delivery of the baby to the delivery of the placenta.  Signs of placental separation: > uterus becomes mobile/ rising or globular formation > sudden gushing of blood > lengthening of the cord(most definite sign)  Type of placental delivery 1. Schultze mechanism – most common(80% of cases) > shiny, clean bluish side is first delivered > less external bleeding because blood is usually concealed behind the placenta. >separation starts at the center then to the edges causing inverted umbrella shape. 2. duncan’s mechanism : less common( 20% of cases) >rough, dirty reddish maternal side out first. > more external bleeding so I appears more bloody. A. FIRST HOUR AFTER DELIVERY (4th stage of labor) 1. Evaluate woman’s v/s every 15minutes 2. Evaluate fundal height 3. Inspect perineum for signs of bleeding including hematoma formation 4. Evaluate the amount of vaginal bleeding.  VAGINAL DISCHARGE- consisting of blood, fragments of deciduas, white blood cells, mucus, and some bacteria is termed LOCHIA.  Characteristics of Lochia:  Rubra- red in color, 1 to 3 postpartal day, composition of blood, fragments of deciduas, mucus.  Serosa- pink in color, 4 to 10 postpartal day, composition of blood, mucus, invading leukocytes.  Alba- white in color, 10 to 14 ( may last 6 weeks) postpartal day, largely mucus, leukocytes count high.