IntraPartum (Process of Labor and Delivery) PDF

INTRAPARTUM (PROCESS OF LABOR AND DELIVERY) MARY GRACE MORADA CU, MAN, RN Clinical Instructor, CNAHS St. Paul University Manila LABOR AND DELIVERY MGGMORADACU2024 LABOR  the series of events by which uterine contractions and...

INTRAPARTUM (PROCESS OF LABOR AND DELIVERY) MARY GRACE MORADA CU, MAN, RN Clinical Instructor, CNAHS St. Paul University Manila LABOR AND DELIVERY MGGMORADACU2024 LABOR  the series of events by which uterine contractions and MGGMORADACU2024 abdominal pressure expel a fetus and placenta from a woman’s body  regular contractions cause progressive dilatation of the cervix and sufficient muscular force to allow the baby to be pushed to the outside  FACTORS AFFECTING LABOR AND DELIVERY 1. Passage – the woman’s pelvis is of adequate size and contour MGGMORADACU2024 2. Passenger – the fetus is of appropriate size and in an advantageous position and presentation 3. Powers – uterine factors are adequate 4. Placenta – separation and delivery 5. Woman’s Psyche –psychological outlook, refers to the psychological state or feelings that a woman brings into labor. A. PASSAGE  the route a fetus must travel from the uterus through the cervix and vagina to the external MGGMORADACU2024 perineum 2 pelvic measurements to determine the adequacy of the pelvic size: 1. Diagonal conjugate (anterior-posterior diameter of The inlet) 2. Transverse diameter of the outlet 1. Diagonal Conjugate  the distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis  the most useful measurement for estimation of MGGMORADACU2024 pelvic size  the one that is most apt to cause a misfit with the fetal head  if the measurement obtained is more than 12.5 cm, the pelvic inlet is rated as adequate for childbirth  the diameter of the fetal head that must pass that point averages 9 cm in diameter MGGMORADACU2024  MGGMORADACU2024 2. Transverse diameter of the outlet  the distance between the ischial tuberosities  a diameter of 11 cm is considered adequate because it will allow the widest diameter of the fetal head, or 9 cm, to pass freely through the outlet  MGGMORADACU2024 Z MGGMORADACU2024 PELVIC MEASUREMENTS  Obstetric conjugate: from inner surface of symphysis pubis, slightly below upper border, to sacral promontory, it is the most important pelvic measurement; can be MGGMORADACU2024 estimated by subtracting 1.5-2 cm from diagonal conjugate  Diagonal conjugate: from lower border of the symphysis pubis to sacral promontory; should be 12.5- 13 cms; may be obtained by vaginal examination  Transverse diameter: the distance between the ischial tuberosities. a diameter of 11 cm is considered adequate because it will allow the widest diameter of the fetal head, or 9 cm, to pass freely through the outlet PELVIC MEASUREMENTS  Oblique Diameter: distance from sacroiliac joint to the iliopectineal eminence (Right oblique diameter =12 cm from the right sacroiliac joint to the left iliopectineal MGGMORADACU2024 eminence and Left oblique diameter = 12 cm from the left sacroiliac joint to the right iliopectineal eminence.  Antero –Posterior Diameters: Anatomical antero-posterior diameter (true conjugate) from upper margin of symphysis pubis to sacral promontory, should be at least 11 cm; maybe obtained by x- ray or ultrasound  PELVIC SHAPES  Android: narrow, heart shaped, male type pelvis MGGMORADACU2024  Anthropoid: narrow, oval shaped, resembles ape pelvis  Gynecoid: classic female pelvis; wide and well rounded in all directions  Platypelloid: wide but flat; may still allow vaginal delivery B. PASSENGER  the fetus MGGMORADACU2024 Neuriel 2016 Neuel 2021  Structure of the Fetal Skull Cranium – the uppermost portion of the skull, MGGMORADACU2024 - comprises 8 bones Bones that are important in childbirth: 1. Frontal – 2 fused bones 2. Two parietal 3. Occipital Other 4 bones of the skull: sphenoid, ethmoid and 2 temporal bones THE FETAL SKULL MGGMORADACU2024 Suture lines  important in birth because they allow the cranial MGGMORADACU2024 bones to move and overlap, molding or diminishing the size of the skull so that it can pass through the birth canal more readily Types of Suture Lines:  Sagittal suture – joins the two parietal bones of the skull  Coronal suture – the line of juncture of the frontal bones and the 2 parietal bones MGGMORADACU2024  Lambdoid suture – the line of juncture of the occipital bone and the 2 parietal bones SUTURE LINES OF THE FETAL SKULL MGGMORADACU2024 Fontanelles  membrane covered spaces MGGMORADACU2024  found at the junction of the main suture line  spaces compress during birth to aid in molding of the fetal head  MGGMORADACU2024 FONTANELLE Parts: 1. Anterior fontanelle – “bregma” MGGMORADACU2024  diamond shaped  lies at the junction of the coronal and sagittal suture lines ANTERIOR FONTANELLE MGGMORADACU2024 2. Posterior fontanelle  triangular in shape MGGMORADACU2024  lies at the junction of the lambdoid and sagital sutures  smaller than the anterior fontanelles POSTERIOR FONTANELLE MGGMORADACU2024 Vertex – space between 2 fontanelles Sinciput – area over the frontal bone MGGMORADACU2024 Occiput – area over the occipital bone Diameters of the Fetal Skull  to fit through the birth canal, a fetus must present the smaller MGGMORADACU2024 diameter (transverse diameter) to the smaller diameter of the maternal pelvis  in full flexion, a fetal head flexes so the chin rests on the thorax, and the smallest antero-posterior diameter, the suboccipitobregmatic, is presented to the birth canal  good head flexion is important because a fetal head presenting a diameter of 9.5 cm will fit through a pelvis than if the diameter is 12.0 or 13.5 cm SUBOCCIPITOBREGMATIC PART OF THE FETAL SKULL MGGMORADACU2024 Molding – the change in shape of the fetal skull produced by the force of uterine contractions MGGMORADACU2024 pressing the vertex of the head against the not-yet- dilated cervix  pressure causes the bones of the fetal skull to overlap and cause the head to become narrower and longer to facilitate passage through the rigid pelvis MOLDING IN THE FETAL SKULL MGGMORADACU2024 CAPUT SUCCEDANEUM IN THE FETAL SKULL MGGMORADACU2024  Fetal Presentation and Position 1. Attitude – the degree of flexion a fetus assumes MGGMORADACU2024 during labor  the relation of the fetal parts to each other  good attitude – fetus is in complete flexion  “normal fetal position” – advantageous for birth because it helps a fetus present the smallest antero-posterior diameter of the skull to the pelvis  ATTITUDE OF THE FETUS Normal Fetal Position MGGMORADACU2024  moderate flexion – chin of fetus is not touching the chest but is in an alert or “military position” MGGMORADACU2024  partial extension – fetus presents the “brow” of the head to the birth canal  if fetus is in poor flexion presenting the occipitomental diameter of the head to the birth canal, “face” presentation appears  TYPES OF FLEXION: A. FULL FLEXION B. MODERATE FLEXION C. PARTIAL EXTENTION (BROW) D. PARTIAL EXTENTION (FACE) MGGMORADACU2024 2. Engagement  the settling of the presenting part of a fetus far MGGMORADACU2024 enough into the pelvis to be at the level of the ischial spines, a midpoint of the pelvis  descent to this point means that the widest part of the fetus (biparietal diameter in a cephalic presentation) has passed through the pelvis  A presenting part that is not engaged - “floating”  A presenting part that is not descending but has not yet MGGMORADACU2024 reached the ischial spines – “dipping” FETAL ENGAGEMENT MGGMORADACU2024 3. Station  the relationship of the presenting part of a fetus to the level of the ischial spines a. 0 station (synonymous with engagement) = MGGMORADACU2024 when the presenting part is at the level of the ischial spines b. -1 to -4 cm = when the presenting part is above the spines; distance is measured and described as minus stations c. + 1 to + 4 cm = the presenting part is below the ischial spines; the distance is stated as MGGMORADACU2024 plus stations d. at +3 or +4 station = the presenting part is at the perineum and can be seen if the vulva is separated (e.g. crowning) MGGMORADACU2024 STATIONS OF THE FETAL SKULL IN THE PELVIC INLET MGGMORADACU2024 4. Fetal Lie  the relationship between the long axis of the fetal MGGMORADACU2024 body (cephalocaudal) and the long axis of a woman’s body (cephalocaudal) whether the fetus is lying in a horizontal (transverse) or a vertical (longitudinal) position  classified as cephalic – head will be the first part to contact the cervix; in breech, buttocks will be the first position to contact the cervix  MGGMORADACU2024 FETAL LIE  FUNCTIONAL RELATIONSHIPS OF PRESENTING PART Types of Fetal Presentation  denotes the body part that will first contact the MGGMORADACU2024 cervix or be born first  determined by a combination of fetal lie and the degree of fetal flexion (attitude) 1. Cephalic Presentation  most frequent type of presentation, occurring at MGGMORADACU2024 95% of the time  fetal head is the bony part that will first contact the cervix  Vertex - the ideal presenting part because: a. skull bones can be molded to accommodate the cervix b. aid in cervical dilatation and prevents complications Types of Cephalic Presentation 1. Vertex MGGMORADACU2024 Lie: longitudinal Attitude: good (full flexion) Description: - head is sharply flexed - vertex the presenting part - most common presentation CEPHALIC PRESENTATION (VERTEX) MGGMORADACU2024 2. Brow Lie: longitudinal MGGMORADACU2024 Attitude: moderate (military) Description: - head is only moderately flexed, the brow or sinciput becomes the presenting part CEPHALIC PRESENTATION (BROW) MGGMORADACU2024 3. Face Lie: longitudinal MGGMORADACU2024 Attitude: poor Description: - fetus extends the head to make the face the presenting part - edema and distortion of the face may occur - birth may be impossible due to wide presenting diameter CEPHALIC PRESENTATION (FACE) MGGMORADACU2024 4. Mentum Lie: longitudinal MGGMORADACU2024 Attitude: very poor Description: - fetus completely hyper-extended the head to present the chin - fetus cannot enter the pelvis due to widest diameter presenting CEPHALIC PRESENTATION (MENTUM) MGGMORADACU2024 2. Breech Presentation  either the buttocks or the feet are the first body MGGMORADACU2024 parts that will contact the cervix  occurs approx. 3% of births and are affected by fetal attitude  can be difficult births; presenting point influences the degree of difficulty Types of Breech Presentation 1. Complete MGGMORADACU2024 Lie: longitudinal Attitude: moderate Description: - fetus has thighs tightly flexed on the abdomen - buttocks and the tightly flexed feet present the cervix BREECH PRESENTATION (COMPLETE) MGGMORADACU2024 2. Frank Lie: longitudinal MGGMORADACU2024 Attitude: moderate Description: - hips are flexed but the knees are extended to rest on the chest - buttocks alone present to the cervix BREECH PRESENTATION (FRANK) MGGMORADACU2024 3. Footling Lie: longitudinal MGGMORADACU2024 Attitude: poor Description: neither thighs nor lower legs are flexed  if one foot presents – single-footling breech  if both present – double footling breech BREECH PRESENTATION (FOOTLING) MGGMORADACU2024 3. Shoulder Presentation  transverse lie – fetus lies horizontally in the pelvis so MGGMORADACU2024 that the longest fetal axis is perpendicular to that of the mother  presenting part is usually one of the shoulders (acromion process), an iliac crest, a hand or an elbow  fewer than 1% of fetuses  usual contour of the abdomen at term is distorted  must be born by cesarean birth SHOULDER PRESENTATION MGGMORADACU2024 Causes: a. relaxed abdominal walls from grand multiparity MGGMORADACU2024 which allows the unsupported uterus to fall forward b. pelvic contraction – horizontal space is greater than the vertical space c. placenta previa – placenta is located low in the uterus, obscuring some of the vertical space limiting a fetus’ ability to turn Types of Fetal Position 1. Position MGGMORADACU2024  the relationship of the presenting part to a specifc quadrant of a woman’s pelvis 4 Quadrants of Maternal Pelvis According to the Mother’s Right and Left a. Right anterior C. Right posterior b. Left anterior B. Left posterior  4 Parts of a Fetus as Landmarks to Describe the Relationship of the Presenting Part to one of the Pelvic Quadrants MGGMORADACU2024 1. Vertex presentation - occiput 2. Face presentation - chin (mentum) 3. Breech presentation - sacrum 4. Shoulder presentation - scapula/acromion process  position is indicated by an abbreviation of 3 letters  influences the process and efficiency of labor  Possible Fetal Positions 1. Vertex Presentation (occiput) LOA, left occipitoanterior LOP, left occipitoposterior MGGMORADACU2024 LOT, left occipitotransverse ROA, right occipitoanterior ROP, right occipitoposterior ROT, right occipitotransverse 2. Breech Presentation (sacrum) LSaA, left sacroanterior LSaP, left sacroposterior LSaT, left sacrotransverse MGGMORADACU2024 RSaA, right sacroanterior RSaP, right sacroposterior RSaT, right sacrotransverse 3. Face Presentation (mentum) LMA, left mentoanterior LMP, left mentoposterior LMT, left mentotransverse MGGMORADACU2024 RMA, right mentoanterior RMP, right mentoposterior RMT, right mentotransverse 4. Shoulder Presentation (acromion process) LAA, left scapuloanterior LAP, left scapuloposterior RAA, right scapuloanterior RAP, right scapuloposterior MGGMORADACU2024 MGGMORADACU2024  INTRAPARTUM (PROCESS OF LABOR AND DELIVERY) MARY GRACE MORADA CU, MAN, RN Clinical Instructor, CNAHS St. Paul University Manila  Mechanisms (Cardinal Movements) of Labor  involves a number of different position changes to keep the smallest diameter of the fetal head (in cephalic presentations) always presenting to MGGMORADACU2024 the smallest diameter of the birth canal  Passage of a fetus through the birth canal involves several different position changes to keep the smallest diameter of the fetal head (in cephalic presentations) always presenting to the smallest diameter of the pelvis. These position changes are termed the cardinal movements of labor: descent, flexion, internal rotation, extension, external rotation, and expulsion MECHANISMS OF LABOR (CARDINAL MOVEMENTS)  Passage of a fetus through the birth canal involves several MGGMORADACU2024 different position changes to keep the smallest diameter of the fetal head (in cephalic presentations) always presenting to the smallest diameter of the pelvis. These position changes are termed the cardinal movements of labor:  Engagement  Descent,  Fexion,  Internal Rotation,  Extension,  External Rotation, and  Expulsion Engagement – or the entering of the biparietal diameter (measuring ear tip to ear tip across the top MGGMORADACU2024 of the baby's head) into the pelvic inlet. Descent – the downward movement of the bi-parietal diameter of the fetal head to the pelvic inlet MGGMORADACU2024  occurs when the fetal head extrudes beyond the dilated cervix and touches the posterior vaginal floor  may be aided by muscle contraction as the woman pushes Flexion – fetal head reaches the pelvic floor, the head bends forward onto the chest, making the MGGMORADACU2024 smallest anteroposterior diameter (the suboccipitobregmatic diameter) the one presented to the birth canal  aided by abdominal muscle contraction during pushing Internal Rotation – the head flexes as it touches the pelvic floor and the occiput rotates until it is MGGMORADACU2024 superior or just below the symphysis pubis, bringing the head into the best relationship to the outlet of the pelvis Extension – as the occiput is born, the back of the neck stops beneath the pubic arch and acts as a MGGMORADACU2024 pivot for the rest of the head; the head extends, and the foremost parts of the head, face and chin are born External Rotation – the head rotates back to the diagonal or transverse position of the early MGGMORADACU2024 part of labor; this brings the shoulders into an anteroposterior position which is best for entering the outlet Expulsion – once the shoulders are born, the rest of the body is born easily and smoothly MGGMORADACU2024 because of its smaller size  the end of the pelvic division of labor MGGMORADACU2024 MECHANISMS (CARDINAL MOVEMENTS) OF LABOR MGGMORADACU2024 Importance of Determining Fetal Presentation and Position MGGMORADACU2024  presentation of a body part other than the vertex could put a fetus at risk  a proportional difference between the fetus and the pelvis implies a cesarean birth  4 Methods Used to Determine Fetal Position, Presentation and Lie MGGMORADACU2024 1. Leopold’s maneuvers 2. vaginal examination 3. auscultation of FHT 4. sonography  MGGMORADACU2024 C. POWERS Powers of Labor  supplied by the fundus of the urethra MGGMORADACU2024  implemented by uterine contractions – process that causes cervical dilatation and then expulsion of the fetus from the uterus  after full dilatation of the cervix, the preliminary power is supplemented by the use of abdominal muscles  Uterine Contractions MGGMORADACU2024 Mark of effective uterine contractions: 1. rhythmicity 2. progressive lengthening 3. intensity Origin of labor contractions:  begin at a “pacemaker” point located in the MGGMORADACU2024 myometrium. Each contraction begins at that point and then sweeps down over the uterus as a wave. After a short rest period, another contraction is initiated and the downward sweep begins again  3 Phases of Uterine Contractions: 1. Increment – when the intensity of the MGGMORADACU2024 contraction increases 2. Acme – when the contraction is at its strongest 3. Decrement – when the intensity decreases  as labor progresses, relaxation intervals decrease from 10 min. early in labor to only 2-3 min.  duration of contractions also changes, increasing from 20 to 30 sec. to a range of 60 to 90 sec. MGGMORADACU2024  Contour Changes of the Uterus 2 Distinct Functioning Areas: MGGMORADACU2024 1. Upper portion – becomes thicker and active, preparing it to be able to exert the strength necessary to expel the fetus when the expulsion phase of labor is reached 2. Lower segment – becomes thin-walled, supple, and passive, so that the fetus can be pushed out of the uterus easily  boundary between the 2 portions is marked by a ridge on the inner uterine surface – physiologic MGGMORADACU2024 retraction ring  overall contour of the uterus changes from a round, ovoid structure to an elongated one which serves to straighten the body of the fetus for better alignment with the cervix and pelvis  Interval and Duration of Uterine Contractions 1. Frequency of contractions – the time from the MGGMORADACU2024 beginning of one contraction to the beginning of the next contraction  consists of 2 parts: a. duration of the contraction b. period of relaxation Cervical Changes 1. Effacement – shortening and thinning of the MGGMORADACU2024 cervical canal – approx. 1-2 cm. long; with effacement, the canal disappears because of longitudinal traction from the contracting uterine fundus primiparas– effacement is accomplished before dilatation begins multiparas- dilatation may proceed before effacement is complete 2. Dilatation  the enlargement or widening of the cervical canal MGGMORADACU2024 from an opening a few millimeter wide to one large enough to permit passage of a fetus  occurs for 2 reasons: 1. uterine contractions gradually increase the diameter of the cervical canal lumen by pulling the cervix up over the presenting part of the fetus 2. the fluid-filled membranes press against the cervix MGGMORADACU2024  as dilatation begins, there is an increase in the amount of vaginal secretions (show)  THEORIES OF LABOR ONSET Factors influencing labor: 1. uterine muscle stretching, which results in release MGGMORADACU2024 of prostaglandins 2. pressure on the cervix, which stimulates the release of oxytocin from the posterior pituitary 3. oxytocin stimulation, which works together with prostaglandins to initiate contractions 4. change in the ratio of estrogen to progesterone  increasing estrogen in relation to progesterone stimulates uterine contractions 5. placental age, which triggers contractions at a set point MGGMORADACU2024 6. rising fetal cortisol levels, which reduce a progesterone formation and increase prostaglandin formation 7. fetal membrane production of prostaglandins, which stimulates contractions  COMMON SIGNS OF LABOR Preliminary Signs of Labor 1. Lightening – descent of the fetal presenting MGGMORADACU2024 part into the pelvis a. primipara – occurs approx. 10-14 days before labor begins b. multipara – occurs on the day of labor or even after labor begins 2. Increase in level of activity  increase in epinephrine release to prepare a MGGMORADACU2024 woman’s body for the work of labor ahead 3. Slight Loss of Weight  progesterone level falls, body fluid is more easily excreted from the body. This increase in urine production can lead to a weight loss between 1 and 3 pounds. 4. Braxton Hicks contractions  false contractions MGGMORADACU2024 5. Ripening of the cervix  cervix feels softer than normal, similar to an earlobe (Goodell’s sign)  at term, cervix becomes still softer (butter-soft), and it tips forward  seen only on pelvic exam  labor is imminent  Signs of True Labor: 1. Uterine contractions MGGMORADACU2024  surest sign that labor has begun  involuntary and come without warning 2. Show  exposed cervical capillaries seep blood due to the pressure exerted by the fetus; blood mixed with mucus become pink tinged or bloody 3. Rupture of membranes  a sudden gush of clean fluid from vagina MGGMORADACU2024 DIFFERENTIATION BETWEEN TRUE AND FALSE LABOR CONTRACTIONS False Contractions True Contractions  begin and remain * begin irregularly but become MGGMORADACU2024 irregular regular and predictable  felt first abdominally * felt first in lower back and and remain confined sweep around to the to the abdomen and abdomen in a wave groin  often disappear with * continue no matter what the ambulation and sleep woman’s level of activity  do not increase in * increase in duration, duration frequency and intensity  do not achieve cervical * achieve cervical dilatation dilatation  4 STAGES OF LABOR First stage: Stage of dilatation  begins with the initiation of true labor MGGMORADACU2024 contractions and ends when the cervix is fully dilatated Second stage: Stage of full dilatation to infant’s birth  from the time of full dilatation until the infant is born Third Stage: Placental Stage  from the time the infant is born until MGGMORADACU2024 after the delivery of the placenta Fourth stage: first 1-4 hours after birth  emphasizes the importance of close observation or monitoring of the woman needed at this time  importance: helpful in planning nursing interventions A. FIRST STAGE – STAGE OF DILATATION MGGMORADACU2024 A. First Stage – Stage of Dilatation 3 Phases: 1. Latent Phase or Preparatory Phase MGGMORADACU2024 2. Active Phase 3. Transition Phase A. First Stage – Stage of Dilatation 3 Phases: 1. Latent Phase or Preparatory Phase MGGMORADACU2024  begins at the onset of uterine contractions and ends when rapid cervical dilatation begins  contractions are mild and short, lasting from 20 to 40 sec.  takes longer than usual for a woman who enters labor with a “nonripe” cervix  cervical effacement occurs, and the cervix dilates from 0 to 3 cm MGGMORADACU2024 nullipara – lasts approx. 6 hours multipara – lasts approx 4.5 hours  cause minimal discomfort for a woman who is psychologically prepared for labor and who does not tense at each tightening sensation in her abdomen 2. Active Phase  cervical dilatation occurs more rapidly, increases MGGMORADACU2024 from 4 – 7 cm  contractions grow stronger, lasting 40 – 60 sec., and occur approx. every 3 – 5 min. nullipara – lasts approx. 3 hours multipara – lasts approx. 2 hours  show and spontaneous rupture of membranes may occur  difficult time - contractions grow so strong, last longer and begin to cause true discomfort MGGMORADACU2024  exciting time - a woman realizes something dramatic is happening  frightening time – labor is progressing and woman’s life is about to change forever 3. Transition Phase  contractions reach peak of intensity occurring MGGMORADACU2024 every 2 – 3 min. with a duration of 60-90 sec. and causing max. dilatation of 8-10 cm.  by the end of this phase, both full dilatation (10 cm.) and complete cervical effacement have occurred  woman may experience intense discomfort, so strong accompanied by nausea and vomiting  woman may experience a feeling of loss of control, anxiety, panic or irritability MGGMORADACU2024  peak can be identified by a slight slowing in the rate of cervical dilatation when 9 cm. is reached  as woman reaches the end of this stage at 10 cm. of dilatation, a new sensation occurs e.g. an irresistible urge to push B. SECOND STAGE – STAGE OF FULL DILATATION TO INFANT’S BIRTH MGGMORADACU2024 B. Second Stage – Stage of full dilatation to infant’s birth MGGMORADACU2024  the period from full dilatation and cervical effacement to birth of the infant  takes about 1 hour  contractions changes from the “crescendo-decrescendo” pattern to an uncontrollable urge to push or bear down with each contraction as if to move her bowels  woman may experience momentary nausea and vomiting because pressure is no longer exerted on her stomach as the fetus descends in the pelvis  woman pushes with such force that she perspires and blood vessels in her neck may become MGGMORADACU2024 distended  as fetal head touches the internal side of the perineum, the perineum begins to bulge and appear tense  anus may become everted, stool may be expelled  as fetal head pushes against the perineum, the vaginal introitus opens and the fetal scalp appears at the opening of the vagina  at first, opening is slitlike, then becomes oval and then circular  circle enlarges from the size of a dime, then a quarter, then a MGGMORADACU2024 half dollar - ”crowning”  the need to push becomes so intense that woman cannot stop herself- all of her energy are directed toward giving birth  as woman pushes, the fetus is pushed out of the birth canal using her abdominal muscles RITGEN’S MANEUVER MGGMORADACU2024 C. THIRD STAGE – PLACENTAL STAGE MGGMORADACU2024 C. Third Stage – Placental Stage  begins with the birth of the infant and ends with MGGMORADACU2024 the delivery of the placenta 2 Phases: 1. Placental separation 2. Placental expulsion  after the birth of an infant, uterus can be palpated as firm, round mass just inferior to the level of the umbilicus  after a few min. of rest, uterine contractions begin again and the organ assumes a discoid shape – MGGMORADACU2024 retains the new shape until the placenta has separated, approx. 5 min. after the birth of the infant  4. PLACENTA 2 Phases: MGGMORADACU2024 1. Placental Separation  active bleeding on the maternal surface of the placenta begins with separation; this bleeding helps to separate the placenta further by pushing it away from its attachment site  as separation is completed, the placenta sinks to the lower uterine segment or the upper vagina Signs of Placental Separation: a. lengthening of the cord MGGMORADACU2024 b. sudden gush of vaginal blood c. change in the shape of the uterus d. firm contraction of the uterus e. appearance of the placenta at the vaginal opening CREDE’S AND BRANDT ANDREW’S MANEUVER MGGMORADACU2024  2 Types of Placental Delivery: a. Shultze MGGMORADACU2024  placenta separates first at its center then to its edges and folds on itself like an umbrella and presents at the vaginal opening with the fetal surface evident  appear shiny and glistening from the fetal membranes SHULTZE TYPE OF PLACENTA MGGMORADACU2024 b. Duncan  placenta separates first at its edges, slides along MGGMORADACU2024 the uterine surface and presents at the vagina with the maternal surface evident  looks raw, red and irregular, with the ridges or cotyledons that separate blood collection spaces showing DUNCAN TYPE OF PLACENTA MGGMORADACU2024  MGGMORADACU2024 DUNCAN – DIRTY LOOKING SHULTZE – SHINY LOOKING 2. Placental Expulsion  after separation, placenta is delivered either by MGGMORADACU2024 the natural bearing-down effort of the mother or by gentle pressure on the contracted uterine fundus by the physician or nurse-midwife pressure must never be applied to post-partal uterus: causes to evert and hemorrhage  if the placenta does not deliver spontaneously, it can be removed manually  withthe delivery of the placenta, the third stage of labor is over MGGMORADACU2024  INTRAPARTUM (PROCESS OF LABOR AND DELIVERY) MARY GRACE MORADA CU, MAN, RN Clinical Instructor, CNAHS St. Paul University Manila  COMMON DISCOMFORTS OF THE WOMAN DURING LABOR AND DELIVERY Physiologic Effects of Labor on a Woman MGGMORADACU2024 1. Cardiovascular System a. Cardiac Output – increase in systolic and diastolic BP due to pressure on the uterine arteries b. Blood Pressure – systolic BP rises to an average of 15mm.Hg. 2. Hemopoietic System  sharp increase in the number of circulating MGGMORADACU2024 WBC – 25,000 to 30,000 cell 3. Respiratory System  hyperventilation  total O2 consumption increase by about 100% during the 2nd stage of labor 4. Temperature Regulation  slight increase in temperature due to increase MGGMORADACU2024 muscular activity associated with labor  diaphoresis occurs 5. Fluid Balance  water loss increase during labor due to diaphoresis 6. Urinary System  kidneys concentrate urine to preserve fluid MGGMORADACU2024 and electrolytes due to decrease fluid intake  reduced bladder tone due to pressure of fetal head as it descends in the birth canal 7. Musculoskeletal System  increase back pain and nagging pain at the pubis as the woman walks or turns in labor due to soften cartilage between bones 8. Gastrointestinal System  digestive and emptying time of the stomach MGGMORADACU2024 becomes prolonged due to pressure on the stomach and intestines from the contracting uterus  loose bowel movement (LBM) as contractions grow strong 9. Neurologic and Sensory Responses  increase PR and RR due to pain 5. THE WOMAN’S PSYCHE  the psychological state of feelings that a woman brings MGGMORADACU2024 into labor  women who manage best in labor: those who have a strong sense of self-esteem and with a meaningful support system  women without adequate support: frightened and stressful; can develop a post traumatic stress syndrome Psychological Effects of Labor on a Woman 1. Fatigue MGGMORADACU2024  tired from the burden of carrying so much extra weight with her 2. Fear  begin to worry that her infant may die or be born with an abnormality  might not meet own behavioral expectation 3. Cultural Influences  responds to cultural cues: pain, choice of MGGMORADACU2024 nourishment, preferred birthing position, support person and customs related to post partal period  Fetal Responses to Labor 1. Neurologic System  FHR decrease by as much as 5 bpm during MGGMORADACU2024 contraction 2. Cardiovascular System  amount of nutrients, including O2 is decreased causing fetal hypoxia  Increased intracranial pressure (ICP) caused by uterine pressure on the fetal head 3. Integumentary System  edema on the presenting part (caput MGGMORADACU2024 succedaneum)  petechiae/ecchymotic areas due to the pressure involved in the birth process 4. Musculoskeletal System  push a fetus into a position of full flexion due to the force of uterine contraction 5. Respiratory System  maturation of surfactant production in the fetal MGGMORADACU2024 lung DANGER SIGNS DURING LABOR AND DELIVERY A. Fetal Danger Signs High or low FHR MGGMORADACU2024 1.  FHR of more than 160 bpm- fetal tachycardia or less than 100 bpm – fetal bradycardia: a sign of possible fetal distress 2. Meconium Staining  green color in the amniotic fluid: fetus has passed meconium into the amniotic fluid 3. Hyperactivity  may be a sign that hypoxia is occurring MGGMORADACU2024  frantic motion is a common reaction to the need for O2 4. Fetal Acidosis  blood ph lower than 2 is a sign that fetal well- being is compromised B. Maternal Danger Signs 1. Rising or falling BP  systolic pressure greater than 140 mmHg and a diastolic pressure greater than 90 mmHg or MGGMORADACU2024 increase in systolic more than 30 mmHg or 15 mmHg diastolic: Pregnancy Induced Hypertension (PIH) 2. Abnormal pulse  PR greater than 100 bpm indicate hemorrhage 3. Inadequate or prolonged contractions  may indicate uterine exhaustion: CS may be necessary 4. Pathologic Retraction Ring (Bandl's ring)  Ring of the uterus is a constriction located at the junction of the thinned lower uterine segment and the thick MGGMORADACU2024 retracted upper uterine segment that is associated with obstructed labor.  maybe a sign of extreme uterine stress and possible uterine rupture 5. Increasing Apprehension  can be a sign of O2 deprivation or internal hemorrhage 5. Abnormal Lower Abdominal Contour  if a woman has a full bladder during labor, a round bulge on her lower abdomen may appear: danger signal for 2 reasons: MGGMORADACU2024 a. bladder may be injured by the pressure of the fetal head b. may not allow the fetal head to descend  MATERNAL AND FETAL ASSESSMENT DURING LABOR Immediate Assessment of a Woman in Labor  encourage every woman to bring a support person MGGMORADACU2024 with her into labor A. Initial Interview and Physical Examination  obtain information about the ff. areas: 1. expected date of birth 2. frequency, duration, and intensity of contractions 3. amount and character of show 4. whether rupture of membranes has occurred 5. VS – temp., PR, RR and BP (assess between MGGMORADACU2024 contractions) 6. time the woman last ate 7. any known drug allergies 8. post pregnancy and previous pregnancy history 9. her birth plan or individualized measures she has planned  B. Detailed Assessment During the First Stage of Labor MGGMORADACU2024 1. History a. Current pregnant history > documentation of gravida and para status; a description of this pregnancy (pattern or place of pre-natal care, adequacy of nutrition, whether any complications has occurred: e.g. spotting, falls, HPN, infection, alcohol or drug ingestion b. Past Pregnancy History > includes dates, types of birth, any MGGMORADACU2024 complications, and outcomes, including sex and birth weights of children c. Past Health History > includes any previous surgeries, heart disease or diabetes, anemia, TB, kidney disease and STI D. Family Medical History > ask if any family member is cognitively MGGMORADACU2024 challenged or has a condition such as heart disease, diabetes, kidney disease, cancer, allergies, seizures or congenital disorder 2. Physical Examination  Pelvic exam – to confirm the presentation and MGGMORADACU2024 position of the fetus and the stage of cervical dilatation a. Abdominal Assessment > estimate fetal size by fundal height > assess presentation and position by Leopold’s manuever > palpate and percuss the bladder area for full bladder > assess for abdominal scars 3. Leopold’s manuever 4. Assessing rupture of membranes MGGMORADACU2024 > the woman may feel a sudden gush of amniotic fluid from her vagina 5. Vaginal Examination > determines the extent of cervical effacement and dilatation and to confirm the fetal presentation, position, and degree of descent 6. Assessment of pelvic adequacy > done during pregnancy, so that by week 32- MGGMORADACU2024 36, the midwife or physician is alerted that a cephalopelvic disproportion could occur 7. Sonography > determines the diameters of the fetal skull and to determine presentation, presenting part, position, flexion, and degree of descent of a fetus 8. Vital signs a. Temperature – taken every 4 hours during MGGMORADACU2024 labor > report a temp. greater than 37.2 degrees centigrade > after rupture of membranes, temp. should be taken every 2 hours b. Pulse and Respiration > measured and recorded every 4 hours during labor (ranges bet. 70-80 bpm) > RR during labor: 18-20 bpm  c. BP - measured and recorded every 4 hours during labor > tends to rise by 5 to 15 mmHg during a contraction MGGMORADACU2024 9. Laboratory Analysis a. Blood > drawn for hemoglobin and hematocrit, a serologic test for syphyllis, hepatitis antibodies, and blood typing to determine the woman’s level of health b. Urine > obtain a clean-catch urine specimen and test it immediately for protein and glucose 10. Assessment of uterine contractions MGGMORADACU2024 a. Length of contractions > time the duration of a contraction from the moment the uterus first tenses until it has relaxed again b. Intensity of contractions > rate a contraction as mild if the uterus MGGMORADACU2024 doesnot feel more than minimally tense; moderate if the uterus feels firm; and strong if the uterus feels as hard as a wooden board at the peak of contractions c. Frequency and contractions > is timed from the beginning of one contraction to the beginning of the next contractions MGGMORADACU2024  Initial Fetal Assessment 1. Auscultation of Fetal Heart Sounds (FHS)  in cephalic presentaion, FHS are heard loudest low in the abdomen: MGGMORADACU2024 ROA position – RLQ LOA position – LLQ LOP or ROP – woman’s side  determine the FHR every 30 min. during beginning of labor, every 15 min. during active labor, and every 5 min. during the 2nd stage of labor 2. Electronic Monitoring  the monitor is left in place for continuous monitoring on women who are categorized as high risk for any reason or who have oxytocin MGGMORADACU2024 stimulation  Cardiotocography (FHT and Contractions) CARE OF A WOMAN DURING THE FIRST STAGE OF LABOR 6 concepts to make labor and birth as natural as possible: 1. labor should begin on its own, not be artificially induced MGGMORADACU2024 2. woman should be able to move about freely throughout labor, not be confined to bed 3. women should receive continuous support during labor 4. no interventions such as IVF should be used routinely 5. women should be allowed to assume a non-supine (upright, side-lying) position for birth 6. mother and baby should be housed together after the birth with unlimited opportunity for breast feeding Amniotomy  the artificial rupturing of membranes -(a long thin instrument –amniohook) is passed vaginally  allows the fetal head to contract the cervix more directly and may increase the MGGMORADACU2024 efficiency of contractions  a woman’s cervix must be dilatated at least 3 cm. and placed in a dorsal recumbent position  the membranes are torn and amniotic fluid is allowed to escape  puts a fetus at risk for cord prolapse – a possibility that a loop of cord will escape with the fluid  always measure the FHR immediately after the rupture of membranes  MGGMORADACU2024 AMNIOTOMY  CARE OF A WOMAN DURING THE SECOND STAGE OF LABOR  assess FHR at the beginning of the second stage of labor to be certain that the baby’s passage in the MGGMORADACU2024 birth canal is not occluding the cord and interfering with fetal circulation 1. PREPARING THE PLACE OF BIRTH  Birthing Room: labor-delivery-recovery- postpartal rooms  MGGMORADACU2024 BIRTHING ROOM 2. POSITIONING FOR BIRTH  lithotomy position Alternative birth positions: a. lateral/Sim’s MGGMORADACU2024 b. dorsal recumbent c. semi-sitting d. squatting LITHOTOMY POSITION MGGMORADACU2024 3. PROMOTING EFFECTIVE SECOND-STAGE PUSHING  pushing is usually best done from a semi-Fowler’s squatting, or “all-fours” position rather than MGGMORADACU2024 lying flat, to allow gravity to aid the effort 4. PERINEAL CLEANING MGGMORADACU2024 5. EPISIOTOMY – surgical incision of the perineum to prevent tearing of the perineum and to release pressure on the fetal head with birth MGGMORADACU2024 Advantages:  substitutes a clean cut for a ragged tear MGGMORADACU2024  minimizes pressure on the fetal head  may shorten the last portion of the second stage of labor 6. BIRTH  as soon as head of fetus is at vaginal opening, place a sterile towel over the rectum and MGGMORADACU2024 press forward on the fetal chin while the other hand is pressed downward on the occiput (Ritgen’s Maneuver) – controls the rate at which the head is born  pressure should never be applied to the fundus of the uterus – uterine rupture may occur RITGEN’S MANEUVER MGGMORADACU2024  woman is asked to continue pushing until the occiput of the fetal head is at the pubic arch, then MGGMORADACU2024 fetal head is born between contractions: - helps to prevent the head from being expelled too rapidly - helps to avoid perineal tears and a rapid change in pressure in the infant’s head  an infant is considered born when the whole body is born – this is the time that should be noted and recorded as the time of birth 7. CUTTING AND CLAMPING OF THE CORD MGGMORADACU2024 Neuriel 2016 Neuel 2021 8. INTRODUCING THE INFANT WHO: FIRST EMBRACE- DOH PH: “UNANG YAKAP” MGGMORADACU2024 Neuriel 2016 Neuel 2021  CARE OF THE WOMAN DURING THE THIRD AND FOURTH STAGE OF LABOR  a time of excitement: infant has been born  a time of feeling anticlimactic: infant has finally MGGMORADACU2024 arrived after being expected for so long Fourth stage – first few hours after birth  signals the beginning of dramatic change: marks the beginning of a family D. FOURTH STAGE – FIRST 1- 4 HOURS AFTER BIRTH MGGMORADACU2024 1. Oxytocin  usually ordered to be administered IM or IV to the mother  increases uterine contractions and MGGMORADACU2024 minimizes uterine bleeding  cause HPN by vasoconstriction: be sure to obtain a baseline blood pressure measurement before administration  IV administration may be continued for up to 8 hrs. after birth to ensure uterine contractions PHARMACOLOGIC AGENT  Oxytocin (pitocin)- used for labor induction, used for WHO/EINC Active Management for the Third Stage of labor (AMTSL)  Misprostol (cytotec)- is a prostaglandin used for MGGMORADACU2024 cervical ripening an labor induction (Phased out)  Ergonovine (ergotrate)- is an oxytocin used for postpartum or postabortion hemorrhage, not labor induction  Carboprost (hemabate)- is a prostaglandin used for pospartum hemmorrhage, not labor induction  Dinoprostone (prepidil)- is used for cervical ripening, not labor induction. 2.Placental Delivery  placenta is inspected to be certain that it is intact and normal in appearance and weight of the infant MGGMORADACU2024  Counting of cotelydons- 15-30  Counting of cotelydons- 15-30 Cotyledons:  round structure consisting of chorionic villi MGGMORADACU2024  receive fetal blood from chorionic vessels, branch into capillaries.  surrounded by maternal blood, which can exchange oxygen and nutrients with the fetal blood in the capillaries Retention of a cotyledon in the uterus may lead to late puerperal hemorrhage. MGGMORADACU2024 3.Perineal Repair: Episiorrhaphy  after delivery of the placenta, any necessary perineal stitch is performed MGGMORADACU2024  INTRAPARTUM (PROCESS OF LABOR AND DELIVERY) MARY GRACE MORADA CU, MAN, RN Clinical Instructor, CNAHS St. Paul University Manila IMMEDIATE POSTPARTUM ASSESSMENT AND NURSING CARE  obtain VS every 15 min. for the first hr. and then according to the agency policy MGGMORADACU2024  palpate the woman’s fundus for size, consistency and position  observe the amount and characteristics of lochia  perform perineal care and apply a perineal pad  PROVIDING COMFORT DURING LABOR AND BIRTH Etiology of Pain During Labor and Birth MGGMORADACU2024  during contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain. As labor progresses and contractions become longer and harder, the ischemia to cells increases, the anoxia increases, and the pain intensifies Physiology of Pain pain sensation begins in nociceptors, the end points of afferent nerves. MGGMORADACU2024 When they are stimulated by mechanical, chemical or thermal stimuli, chemical mediators such as prostaglandins, histamine, bradykinin, and serotonin are synthesized and sensitize the nociceptors. The pain impulse is transmitted along small, unmyelinated C fibers, and large, myelinated A-delta fibers to the spinal cord. The C fibers conduct slowly and carry dull, low-level pain, while the A-delta fibers carry sharp, well-localized pain such as labor contractions Perception of Pain  the amount of pain a woman experiences during contractions differs according to her expectations of and preparation for labor, the length of her labor, MGGMORADACU2024 the position of her fetus, and the availability of support people around her Factors Influencing Pain Perception 1. fetal position e.g. if the fetus is in an occiput posterior position, the woman experiences intense or nagging MGGMORADACU2024 back pain even between contractions 2. psychological factors a. fear b. anxiety c. worry d. expectation of pain e. body image f.self-efficacy  COMFORT AND PAIN RELIEF MEASURES COMPLEMENTARY AND ALTERNATIVE THERAPIES FOR PAIN RELIEF 1. Relaxation MGGMORADACU2024  music or aromatherapy in the birthing room is a good way to aid relaxation 2. Focusing and Imagery  concentrating intently on an object, e.g. photo MGGMORADACU2024 of a loved one (focusing), or a mental image, e.g. waves rolling onto a beach (imagery) 3. Prayer  For many women, any time they are facing a stressful MGGMORADACU2024 situation, prayer is the first measure that they use to relieve stress.  Women may bring helpful worship objects such as a Bible or cross into a hospital with them to use during prayer. These are sacred objects so be careful when changing sheets during labor that you do not accidentally throw away such important objects. MGGMORADACU2024 MGGMORADACU2024 4. Breathing techniques  help relax the woman’s abdomen MGGMORADACU2024 5. Herbal preparation  used to reduce pain with dysmenorrhea or MGGMORADACU2024 labor e.g. Rasberry leaves, fennel and life root 5. Aromatherapy and essential oil aromatherapy – the use of aromatic oils to complement emotional and physical well-being e.g. Jasmine and lavander oils – responsible for easier labor HERBAL PREPARATION, AROMATHERAPY AND ESSENTIAL OILS MGGMORADACU2024 7. Heat or cold application  women who are having back pain - apply heat to the lower back by a MGGMORADACU2024 heating pad or a moist compress  women who become warm from exertion of labor – apply cool washcloth to the forehead  dryness of mouth – suck ice chips 8. Bathing or hydrotherapy MGGMORADACU2024  apply heat to help reduce the pain of labor by standing under a warm shower or soaking in a tub of warm water  not recommended for women with ruptured membranes due to the risk of infection  MGGMORADACU2024 9. Therapeutic touch and Massage  the use of touch to comfort and relieve pain therapeutic touch – the laying on of hands to redirect the energy fields that lead to pain (Krieger, 1990) 10. Yoga  reduce the pain of MGGMORADACU2024 labor through its ability to relax the body and possibly through the release of endorphins that may occur 11. Reflexology  application of MGGMORADACU2024 pressure to specific areas of the hands, feet and ears to alleviate common ailments such as headaches, back pain, sinus colds, and stress 12. Crystal or Gemstone Therapy  women may bring in the birthing room some MGGMORADACU2024 gemstones or crystals thought to have healing powers 13. Hypnosis  provides a very satisfactory drug-free method of pain relief 13. Biofeedback  a biofeedback apparatus is used to measure muscle tone or the woman’s ability to relax GEMSTONE THERAPY, HYPNOSIS, BIOFEEDBACK MGGMORADACU2024 15. Transcutaneous Electrical Nerve MGGMORADACU2024 Stimulation (TENS)  relieves pain by counter- irritation on nociceptors  two pairs of electrodes are attached to a woman’s back to coincide with the T10-L1 nerve pathways  as labor progresses, high intensity stimulation is needed to control the pain 16. Acupressure and Acupuncture acupressure – application MGGMORADACU2024 or massage between the first and second metacarpal bones on the back of the hand acupuncture – needles are inserted into the skin at designated susceptible body points located along meridians throughout the body to supply the organs of the body with energy 17. Intracutaneous Nerve Stimulation (INS)  a technique of counter-irritation involving the MGGMORADACU2024 intradermal injection of sterile water or saline along the borders of the sacrum to relieve low back pain during labor  PHARMACOLOGIC PAIN RELIEF DURING LABOR includes: analgesia – reduces/decreases awareness of MGGMORADACU2024 pain anesthesia – causes partial or complete loss of sensation Goals:  medication used during labor must relax the woman and relieve her discomfort, yet have minimal systemic effects on her uterine contractions, her pushing effort, or her fetus ANALGESIA AND ANESTHESIA SITES DRUING LABOR MGGMORADACU2024 Preparation for Medication Administration 1. Narcotic Analgesics MGGMORADACU2024 Narcotics – often given during labor because of their potent analgesic effect  cause fetal CNS depression so do not give to a woman who is in preterm labor  given IM or IV e.g. Meperidine hydrochloride (Demerol), morphine sulfate, nalbuphine (Nubain), fentanyl (Sublimaze), and butorphanol tartrate (Stadol) 2. Intrathecal Narcotics  refers to injection into the spinal cord  a catheter is introduced MGGMORADACU2024 into the spinal canal (subarachnoid space) and a narcotic, e.g., morphine or fentanyl citrate is injected into the canal by way of the catheter 3. Additional Drugs  tranquilizers may be administered during labor MGGMORADACU2024 to reduce anxiety or potentiate the action of a narcotic e.g. hydroxine hydrochloride (Vistaril), phenothiazine 4. Regional Anesthesia  the injection of a local anesthetic to block specific nerve pathways e.g. Chloroprocaine (Nesacaine), bupivacaine (Marcaine) Epidural Anesthesia (Peridural Block)  anesthetic agents placed in the epidural space at the L4-5, L3- MGGMORADACU2024 4, or L2-3 interspace block the spinal nerve roots in the space and the sympathetic nerve fibers which provide pain relief for both labor and birth EPIDURAL ANESTHESIA DURING LABOR MGGMORADACU2024  NURSING CARE OF A WOMAN DURING LABOR 1. reduce anxiety with explanation of the labor process MGGMORADACU2024 2. help the woman identify coping strategies 3. provide comfort measure 4. encourage comfortable positioning 5. assist the woman with prepared childbirth method 6. provide pharmacologic pain relief MGGMORADACU2024  INTRAPARTUM (PROCESS OF LABOR AND DELIVERY) MARY GRACE MORADA CU, MAN, RN Clinical Instructor, CNAHS St. Paul University Manila