Professional Documents
Culture Documents
INTRAPARTUM
INTRAPARTUM CARE
• refers to the medical and nursing care given to a pregnant woman and her family during labor
and delivery
• Extends from the beginning of contractions that cause cervical dilation to the first 1 to 4 hours
after delivery of the newborn and placenta.
FALSE PELVIS - Superior half formed by the ilia. Offers landmark for
pelvic measurements. Supports the growing fetus into the true pelvis
near the end of gestation
TRUE PELVIS - Inferior half formed by the pubes in front, the ilia and
the ischia on the sides and the sacrum and coccyx behind.
C. Ability of the uterine segment to distend, the cervix to dilate and the
vaginal canal and introitus to distend.
o DILATATION
Enargement of the external cervical os from 0 to 10
cm
As a result of uterine contractions and additionally as
a result of pressure on the presenting part
o EFFACEMENT
Shortening and thinning of cervical canal from 0 to
100%
Primigravida – effacement occurs before dilatation
Mutligravidas – dilatation may precede effacement
b. Passenger
This refers to the fetus and its ability to move through the passageway.
i. Fetal skull
• Size of the fetal head and capability of the head to mold to the
passageway.
o Molding- change in shape of fetal skull produced by force of
contraction pressing the head against the not-yet dilated
cervix
Parents are reassured that molding only lasts a day
or two and is not a permanent condition
No molding when fetus is breech.
• The fetal skull is the most important part of the fetus because:
o It is the largest part of the body
o It is the least compressible of all parts
o It is the most frequent presenting part
Fetal lie or presentation
The part of the fetus that enters the maternal pelvis first; the body part that
will be born first or contact the cervix first
A. Cephalic = head first; ideal presentation for NSVD because the bones
of the skull are capable of molding so effectively to accommodate the
cervix and may actually aid in cervical dilation
a. Vertex – head is sharply flexed, making the parietal bones the
presenting parts
b. Face
c. Brow
d. Chin or mentum
iii. Fetal Lie- relationship between the long axis of the fetal body and the long axis f the woman’s body
(cephalocaudal)
a. Horizontal (transverse)
b. Vertical (longitudinal)- cephalic or breech
MODERATE ATTITUDE- if chin is not touching the chest but is in alert or military position
POOR ATTITUDE- the back is arched, the neck is extended and a fetus is in complete extension
v. Fetal position
The relationship of presenting part and the maternal pelvis which is divided into
4 quadrants:
1. Right anterior
2. right posterior
3. left anterior
4. left posterior
c. Power refers to the frequency, duration and strength of uterine contractions to cause
complete cervical effacement and dilatation.
Interval
o From the end of one contraction to the beginning of the next
contraction
Interval during early labor- 40-45 minutes
Interval in late labor- 60-70 seconds
It is an important aspect of contaction because it is during this
relaxation period when the uterine blood vessels refill themselves
with blood to supply the fetus with adequate oxygen
d. Psyche refers to the client’s psychological state, available support systems, preparation
for childbirth, experiences and coping strategies.
Effects of lightening
• Shooting pains down the legs because of pressure on the sciatic nerve
• Increased lordosis as the fetus enters the pelvis and falls further forward
• Increased amount of vaginal discharges
• Resurgence of sign of pregnancy like urinary frequency, as the gravid uterus
impinges on the bladder
• Relief of abdominal tightness and diaphragmatic pressure
b. Loss of weight
2- 3 lbs is loss 2 days prior to onset of labor, probably due to loss of appetite and
decrease in progesterone level that leads to fluids excretion thus causing loss weight.
c. Burst of energy or Increased tension and fatigue “Nesting behavior” – may occur
right before the onset of labor.
Pregnant woman should be caution not to use this energy to carry out household chores
because it is meant to prepare the body for the labor.
e. Cervical changes include softening “ripening” describe as butter soft and effacement
of the cervix that will cause expulsion of the mucous plug (bloody show).
f. Rupture of amniotic membranes or “the bag of water” may occur before the onset
of labor.
g. Show This is the blood-tinged mucus discharged from the vagina because of pressure of
the descending fetal part on the cervical capillaries, causing their rupture. Capillary
blood mixes with mucus when operculum is release that is why SHOW than a pinkish
vaginal discharge.
Show should be distinguished from bright red vaginal bleeding because the later is a
danger sign during this phase of pregnancy.
ONSET OF LABOR
• Labor normally begins when a fetus is sufficiently mature to cope with extrauterine life, yet not to
large to cause mechanical difficulties with birth.
No increased in duration, frequency and Continue no matter what the woman’s level of
intensity activity
.
4. Stages of Labor
a. First stage ( Stage of Dilatation) begins with the onset of regular contractions which
cause progressive cervical dilation and effacement. It ends when the cervix is
completely effaced and dilated.
1. Latent phase - 1-4 cm
2. Active phase - 4-7 cm
3. Transitional phase - 7-10 cm
• PHASES
I. Latent phase – early time in labor
Regular contraction
Cervical dilation – 1 to 4 cm
Intensity: mild to moderate
Uterine contractions occur Q15-30 minutes and are 15-30
seconds in duration and of mild intensity
Mother is talkative and eager to be in labor
II. Active Phase –
Cervical dilation 4-7 cm
Uterine contractions occur Q3-5 minutes and are 30-60
seconds in duration
Contraction: moderate to strong, frequent, longer more
painful
Mother may experience feeling of helplessness and becomes
restless and anxious as contractions intensifies
Woman fears losing control of herself
•
The newborn exits the birth canal with the help from the following cardinal movements, or mechanisms of
labor (D FIRE ERE)
DESCENT- fetus goes down the birth canal (preceded by engagement)
FLEXION- pressure on the pelvic floor causes the fetal chin to bind towards the chest
INTERNAL ROTATION – from antero-postero to transverse then AP to AP
EXTENTION – as the head comes out, the back of the neck stops beneath the pubic arch. The
head extends and the forehead, nose, mouth and chin appear
EXTERNAL ROTATION (also known as restitution) – anterior shoulder rotates externally to the AP
position so that it is just behind the symphysis pubis
EXPULSION – the delivery of the rest of the body
Episiotomy
Prevent prolonged & severe stretching of the muscles
Natural anesthesia (synchronized with pushing of the woman)
Done to facilitate delivery and avoid laceration of the perineum
Reduce duration of second stage
Enlarge outlet in breech presentations or forcep delivery
TYPES OF EPISIOTOMY
Median
Mediolateral
Application of Ritgen’s Maneuver is the best method for delivery As soon as crowning is taking phase,
cover anus with sterile towel to exert.
c. Third Stage (Placental Expulsion) - Begins with the delivery of the baby
and ends with the delivery of the placenta.
Placental Separation(Mechanisms)
o SCHULTZE MECHANISM: center portion of placenta separates first and
its shiny fetal surface emerges from the vagina. SHINY AND
GLISTENING
o DUNCAN MECHANISM: margin of placenta separates, and the dull, red,
rough maternal surface emerges from the vagina. DIRTY, RAW, RED
AND IRREGULAR WITH THE RIDGES OR COTYLEDONS
Contractions of the uterus controls uterine bleeding and aids with placental
separations and delivery.
Generally, oxytocic drugs (oxytocin 10-20 units) are administered to help the
uterus contract (after placenta out)
METHERGINE
PROMOTES UTERINE CONTACTION AND PREVENTS POSTPARTUM HEMORRHAGE
PRODUCE STRONG AND EFFECTIVE CONTRACTION
ASSESS VITAL SIGNS (BP)
DO NOT ADIMINISTER IF BP IS 140/90 mmHg
LEADS TO HYPERTENSION
DISCONTINUE: MARKED VASOCONSTRICTION (COLDNESS, PALENESS, NUMBNESS
OF THE FEET AND HAND); NOTIFY THE PHYSICIAN
OXYTOCIN
INCREASES UTERINE CONTRACTION
MINIMIZED UTERINE BLEEDING
INCREASES BLOOD PRESSURE (VASOCONSTRICTION)
d. Fourth Stage ( Recovery and Bonding)- From the delivery of the placenta until
the postpartum condition of the woman has become stabilized (usually after 1 hour after delivery).
BP taking should be taken at least every half hour during active labor
Whenever a woman complains of a HEADACHE, remove the blood pressure apparatus from the
arm right away (priority intervention)
5. Managing Discomforts
A. During Labor
1. Physical Assessment. General physical examination, Leopold’s maneuvers and/or internal
examination are done.
2. Bath. Bath is advisable if contractions are still tolerable or are not too close to one
another. Bathing will not only ensure cleanliness but will also provide comfort and
relaxation.
5. Diet. Solid or liquid foods are avoided for the following reasons:
a) Digestion is delayed during labor.
b) A full stomach interferes with proper bearing down.
c) Aspiration may occur during the reflex nausea and vomiting of the transition
phase or when anesthesia is used.
6. Enema Administration. Enema is not a routine procedure for all women in labor but may
be done for the following reasons:
a) A full bowel hinders labor progress; enema increases the space
available for passage of the fetus and improves frequency and
intensity of uterine contractions.
b) Enema decreases the possibility of fetal contamination of the perineum
during the second stage of labor.
c) A full bowel can add to the discomfort of the immediate postpartum
period.
Contraindications of enema:
a) Vaginal bleeding
b) Premature labor
c) Abnormal fetal presentation or position
d) Ruptured membranes
e) Crowning
7. Voiding. The woman in labor should be encouraged to empty her bladder every
2-3 hours because:
a) full bladder retards fetal descent.
b) urinary stasis can lead to urinary tract infection.
c) a full bowel may be traumatized during delivery.
8. Breathing Technique. The woman in the 1st stage of labor should be instructed
not to push or bear down during contractions because it will not only lead to
maternal exhaustion but, more importantly, unnecessary bearing down can lead
to cervical edema bacause of the excessive pounding of the fetal presenting
part of the pelvic floor, thus interfering with labor progress. To minimize bearing
down, the patient should be advised to do abdominal breathing during
contractions.
The inferior vena cava, the blood vessel which carries unoxygenated blood back to the heart, lies just
above the spinal column. When a pregnant woman lies flat on her back, the inferior vena cava is caught
between the gravid uterus and the spinal column, causing a drop in arterial blood pressure, which leads
the woman to complain of dizziness.
10. Contractions. Uterine contractions are monitored every hour during the latent
phase of labor and every 30 minutes during the active phase by spreading the
fingers lightly over the fundus.
11. Vital Signs. Blood Pressure (BP) and Fetal Heart Rate (FHR) are taken every
hour during the latent phase and every 30 minutes during the active phase.
Definitely, BP and FHR should never be taken during a contraction.
During uterine contractions, no blood goes to the placenta. The blood is pooled to
the peripheral blood vessels which results in increased BP. Therefore, the blood
pressure should be taken in between contractions and whenever the mother in labor
complains of a headache.
12. Danger Signals. The nurse must be aware of the following danger signals during
labor and delivery.
a) Signs of fetal distress
1) Tachycardia (FHR more than 180)Bradycardia (FHR less than
100)
2. Meconium-stained amniotic fluid in non-breech presentation
3. Fetal thrashing or hyperactivity due to fetal struggling for
more oxygen
b) Signs of maternal distress
1. BP over 140/90, or a falling BP associated with clinical signs of
shock (pallor, restlessness or apprehension, increased respiratory
and pulse rates)
2. Bright red vaginal bleeding or hemorrhage(blood loss of more
than 500 cc)
It should not also be given when delivery is less than an hour away because it can
cause respiratory depression in the newborn.
It is , therefore, preferably given when cervical dilatation is around 5-8 cm.
15. Transfer of Patients. A sure sign that the baby is about to be born is the bulging
of the perineum. In general, multiparas are transported to the delivery room
when cervical dilatation is about 7-9 cm, while primiparas are transferred to the
delivery room at full dilatation with perineal bulging when crowning is taking
place.
B. During Delivery
1. Positioning on the Delivery Table. When positioning the woman on lithotomy on the
delivery table, the legs should be put up slowly at the same time on the stirrups in order
to prevent trauma to the uterine ligaments and backaches or leg cramps. The same
should be done when putting the legs down from the stirrups after delivery.
2. Bearing Down Technique. At the beginning of a contraction, the woman is asked to take
two short breaths, then to hold her breath and bear down at the peak of contraction.
She should also be told to use blow-blow breathing pattern to prevent pushing between
contractions.
3. Care of the Episiotomy Wound. Episiotomy, a perineal incision done to facilitate the birth
of the baby, is made by the doctor primarily to prevent lacerations. No anesthesia is
necessary during episiotomy b/c the pressure of the fetal presenting part against the
perineum is so intense that the nerve endings for pain are momentarily deadened
(natural anesthesia).
4. Breathing Technique. As soon as the head crowns, the woman is instructed not to push
any longer because it can cause rapid expulsion of the fetus. Instead, she should be
advised to pant (rapid and shallow breathing).
5. Ritgen’s Maneuver.
a) Support the perineum during crowning by applying pressure with the palm
against the rectum. This will not only prevent lacerations of the fourchette but
will also bring the fetal chin down the chest so that the smallest diameter of the
fetal head is the one presented at the birth canal.
b) in order to prevent rapid expulsion of the fetus which could result not only in
lacerations, abruptio placenta, and uterine inversion but also to shock because
of sudden decrease in intraabdominal pressure, the head should be pressed
gently while it slowly eases out.
6. Time of Delivery. Take note of the time the baby is delivered.
7. Handling of the Newborn. Immediately after delivery, the newborn should be held below
the level of the mother’s vulva so that blood from the placenta can enter the infant’s
body on the basis of gravity flow.
The newborn should be held with his head in a dependent position to allow drainage of
secretions.
A newborn is never stimulated to cry unless he has been drained of his secretions
because he can aspirate these secretions into his lungs.
The newborn should be immediately wrapped in a clean diaper to keep him warm
because chilling increases the body’s need for oxygen.
He should then be placed on his mother’s abdomen so that the weight of the baby can
help contract the uterus; a noncontracted uterus can lead to death due to hemorrhage
8. Cutting of the cord. Cutting of the cord is postponed until pulsations have stopped
because it is believed that 50-100 ml of blood is flowing from the placenta to the
newborn at this time. It is then clamped twice, an inch apart, and cut in between.
9. Initial Contact. Maternal-infant bonding is initiated as soon as the mother has eye-to-eye
contact with her baby. The mother is informed of her baby’s sex and helped to hold and
inspect her baby if she wishes.
Nursing Diagnosis
Persistent severe bradycardia- severe bradycardia that persists for longer than 5 minutes
Accelerations
FHR increases than 15 bpm for more than 15 seconds
Appear as smooth patterns on electronic fetal monitoring
Good indicators of fetal well-being
Triggered in the normal mature fetus by fetal body motions, sounds stimulations of the fetal scalp
and other stimuli
Early decelerations
Normal and common
Deceleration pattern matches the contraction with the most deceleration occurring at the peak of
the contraction
FHR rarely goes below 100 bpm
Cause: head compression during uterine contraction
Late decelerations
Decrease in FHR from the baseline rate with a lag time of greater than 20 seconds from the peak
of contraction
First appear at or after the peak of the uterine contractions. The FHR improves only after the
contraction has stopped.
May be mild or severe based on how low the FHR goes and how long it takes for the FHR to
recover
Caused by reduced blood flow to the uterus and placenta during contraction
Associated with uteroplacental insufficiency and is a consequence of hypoxia and metabolic
abnormalities
Variable deceleration
Common type of FHR deceleration in labor
Cause by umbilical cord compression
Significance depends on how low the heart rate drops and how long the episode lasts
Classified severe if they last more than 60 seconds or to a FHR of less than 90 bpm
TYPES OF CHILDBIRTH:
1. Vaginal delivery
• A natural process that usually does not require significant medical intervention
• NSVD- normal spontaneous vaginal delivery
• Forceps delivery- vaginal delivery with the use of obstetric forcep (an instrument
designed to extract the baby’s head)
o Indications:
Uterine inertia or poor uterine contraction and the second stage has
gone pass two hours
Face presentation; OA in flat pelvis, OP position
Relative CPD
Cardiac and pulmonary disorders of the mother, maternal exhaustion
Late deceleration pattern, excessive fetal movement, meconium
stained in cephalic presentation
2. Leboyer method
• Postulated that moving from a warm, fluid-filled intrauterine environment to noisy air
filled, brightly lit birth room creates a major shock for newborn
• He proposed that birthing room should be darkened, kept pleasantly warm, soft music is
played, infant is gently handled, cord is cut late and placed immediately into a warm
water bath
• Advantage: ideal for most birthing institution
• Disadvantage:
o warm bath could reduce spontaneous respiration and high level of acidosis;
o late cutting of the cord causes excess blood viscosity in newborn
4. Caesarean birth
• Latin word “caedore” means to cut
• Birth accomplished through abdominal incision into the uterus, after 28 weeks AOG
• Emergency procedure (under general anesthesia) or elective procedure (under spinal)
• Indications :
o CPD
o Placenta previa
o Abruption placenta
o Malpresentation or malposition
o Preeclampsia/eclapmsia
o Fetal distress
o Cord prolapsed
o Previous CS
o Cervical dystocia
o Cancer of the cervix
o Other factors: poor obstetrical history, vaginoplasty, vesico-vaginal fistula
• Complications
o Uterine rupture in subsequent pregnancy
o Postop infection
o Injury to urinary system
o Injury to uterine vessels
o Embolism
• Types:
o Classic caesarean section
Incision made vertically through the abdominal skin and uterus
Advantage: incision is made high on the uterus to avoid cutting the
placenta and be used with placenta previa
Disadvantage:
• Leaves a wide skin scar
• Scar could rupture during labor and not be able to have a
subsequent vaginal birth
o Low segment incision
Lower segment transverse caesarean section (LSTCS)
Made horizontally across the abdomen over the cervix
Referred to as pfannesteil incision or bikini incision
Advantage:
• Less likely to rupture in subsequent labours
• Less blood loss- easier to suture
• Decrease postpartal infections
• Less possibility of GI complications
Disadvantage:
• Longer procedure
• No assurance for small skin incision and small uterine incision