Professional Documents
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INTRARTUM/INTRAPARTAL PERIOD
1. The intrapartum period extends from the beginning of contractions that cause cervical
dilation to the first 1 to 4 hours after delivery of the newborn and placenta.
2. A series of physiological and mechanical processes by which all the products of conception
are expelled from the birth canal.
3. Intrapartum care refers to the medical and nursing care given to a pregnant woman and her
family during labor and delivery.
4. Woman in labor is called the PARTURIENT.
GOALS OF INTRAPARTUM CARE
1. To promote physical and emotional well-being in the mother and fetus.
2. To incorporate family-centered care concepts into the labor and delivery experience.
FACTORS AFFECTING THE INTRAPARTUM EXPERIENCE
1. Previous experience with pregnancy
2. Cultural and personal expectations
3. Pre-pregnant health and biophysical preparedness for childbearing
4. Motivation for childbearing
5. Socioeconomic readiness
6. Age of mother
7. Partnered versus unpartnered status
8. Extend of parental care
9. Extend of childbirth education
PHENOMENA AND PROCESS OF LABOR AND DELIVERY
I.
ONSET OF LABOR
Initiation of Labor
1. Labor is the process by which the fetus and products of conception are expelled as the result
of regular, progressive, frequent, strong uterine contractions.
2. The exact mechanism that initiates labor is unknown.
3. Theories include:
A. Uterine stretch theory Uterus becomes stretched and pressure increases, causing
physiologic changes that initiate labor.
B. Oxytocin stimulation The pressure of the fetal head on the cervix in late pregnancywill
stimulate the PPG to secrete oxytoxin.
C. Progesterone deprivation - As pregnancy advances, progesterone (uterine mucle relaxant)
is less effective in controlling rhythmic uterine contractions that normally occur. In
addition, there may also be an actual decrease in the amount of circulating progesterone.
D. Prostaglandin, Estrogenic and Fetal Hormone Theory
a. There is increased production of prostaglandins by fetal membranes
and uterine decidua as pregnancy advances.
b. In later pregnancy, the fetus produces increased levels of cortisol that
inhibit progesterone production from the placenta.
c. Initiation of labor is said to result from the release of arachidonic acid
produced by steriod acstion sonlipid precursors. Arachidonic acid is
said to increase prostaglandin synthesis which causes uterine
contraction.
E. Aging Placenta as the palcenta matures blood supply will be diminished causing uterine
contraction.
II.
Criteria
Contractions
Discomfort
2.
3.
4.
5.
6.
7.
True labor
False labor
Regular, progressive
Irregular, non-progressive
Lumbo-sacral radiating to the
Abdominal
front, increasing intensity
Withnot
progressive
cervical
dilation
No cervical dilation and effacement
Cervix
Engagement should
be confused
with ligthening.
and when
effacement
the most
Engagement occurs
presenting
partimportant
passes through the pelvic brim.
For Primis occurs earlier or 2difference
weeks before labor
Generally
intensified
Generally unaffected
Walking
Multis occurs a day before
labor or
on a day of labor.
Enema
Signs of lightening:
Generally intensified
Generally unaffected
Show
Present
and increasing
Absent
a. Relief
of dyspnea
Medication
Notofeasily
disrupted
by
Generally relieved by mild sedation
b. Relief
abdominal
tightness
c. increase in
urinary frequency, varicosities, pedal edema due to
medications
pressure on the bladder and pelvic girdle
d. shooting pains down the legs because of pressure on the sciatic nerve
e. increase amount of vaginal discharge
Braxton hicks contractions occur 3 to 4 weeks before labor are irregular, intermittent
contractions that have occurred throughout the pregnancy; become uncomfortable, produce
a drawing pain in the abdomen and groin and does not dilate the cervix. Relieve by walking
and enema.
Cervical changes include softening ripening and effacement of the cervix that will cause
explosion of the mucus plug (bloody show) and increased vaginal discharge.
Rupture of amniotic membranes may occur before the onset of labor if the woman suspects
that her membranes have ruptured, she should contact her health care provider and go to
the labor suite immediately so that she may be examined for prolapsed cord a lifethreatening condition for the fetus.
Burst of energy or increased tension and fatigue may occur before the onset of labor
because of hormone epinephrin
Weight loss of about 1 to 3 pounds may occur 2 to 3 days before the offset of labor.
Urinary frequency returns.
III.
PHYSIOLOGIC ALTERATION IN LABOR
1. Dilatation : progressive opening/widening of the cervical os
a. Expressed in cm
b. Described as opening, widening, enlarging or increase in diameter
c. Specifically refering to external cervical os
d. 10 cm is fully dilated cervix the end of the first stasgse sof labor
2. Effacement: thinning and obliteration of the cervical canal
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a. Expressed in %
b. Described a thinning, shortening or narrowing
c. 100% effacement means the cervix is fully effaced cervical canl is paper-thin or
absent
75% effacement means the cervix has become of its original length
50% effacement means the cervix has become of its original length
25% effacement means the cervix has become of its original length
3. Physiologic retraction ring: Is formed at the boundary of the upper and lower uterine
segments.
In difficult labor when the fetus is larger than the birth canal, the round ligaments of the
uterus become tense during dilatation and expulsion causing abdominal indentation
called BANDLS pathological retraction ring, a danger sign signifying impending
rupture of the uterus if not managed.
IV.
1. POWER
A. The primary Power: Uterine Contraction
This refers to the frequency duration and strength of uterine contraction to cause
complete cervical effacement and dilation.
Successful labor also depends on uterine contractions occurring at regular intervals
and having adequate intensity.
Uterine contractions are involuntary, rhythmic, and intermittent.
Uterine contractions cause vasoconstriction of the umbilical cord vessels;
considered normal.
Uterine contractions increase in intensity, frequency, and duration as labor
progresses due to stretching of the cervix.
During uterine contractions, the active upper portion of the uterus becomes
thicker and shorter, whereas the lower uterine segment stretches and becomes
thinner and longer (referred to as fundal dominance).
The differentiation point between the upper and lower uterine segment is known
as the physiologic retraction ring.
D
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Android heart shape male pelvis- anterior part pointed, posterior part shallow,
deep transverse arrest of descent of the fetus and failure of rotation of the fetus are
common
Anthropoid oval, ape like pelvis, oval shape, AP diameter wider transverse
narrow, may allow for easy delivery of an occiput-posterior presentation of the
fetus;
Platypelloid flat AP diameter narrow, transverse wider, arrest of fetal descent
at the pelvic inlet is common
b. Structure of pelvis (true versus false pelvis)
False pelvis lies above an imaginary line called the linea terminalis or pelvic bri.
Function of the false pelvis is to support the enlarged uterus.
True pelvis lies below the pelvic brim or linea terminalis; it is the bony canal
through which the fetus must pass. It is divided into three planes: the inlet, the
midpelvis, and the outlet.
Inlet:
- Upper boundary of the true pelvis bounded by upper margin of symphysis
pubis in front, linea terminalis on sides, and sacral promontory (first sacral
vertebra) in back.
- Largest diameter of inlet is transverse
- Smallest diameter of inlet is anteroposterior. Anteroposterior diameter is
most important diameter of inlet: measured clinically by diagonal
conjugate, distance from lower margin of symphysis to the sacral
promontory (usually 5 inches [14 cm])
- Obstetric (true) conjugate, distance between inner surface of symphysis and
sacral promontory measured by subtracting to inch (1.5 to 2 cm)
(thickness of symphysis) from the diagonal conjugate. Adequate diameter
is usually 11.5 cm. This is the shortest anteroposterior diameter through
which the fetus must pass.
Midpelvis:
- Bounded by inlet above and outlet below true bony cavity. Contains the
narrowest portion of the pelvis.
- Diameters cannot be measured clinically.
- Clinical evaluation of adequacy is made by noting the ischial spines.
Prominent spines that protrude into the cavity indicate a contracted
midpelvic space. The interspinous diameter is 4 inches (10 cm).
Outlet:
- Lowest boundary of the true pelvis.
- Bounded by lower margin of symphysis in front, ischial tuberosities on
sides, tip of sacrum posteriorly.
- Most important diameter clinically is distance between the tuberosities (> 4
inches
Important Measurements at the 3 plane of pelvis for
anteroposterior diameters
1. Diagonal Conjugate measure between sacral promontory and inferior
margin of the symphysis pubis.Measurement: 11.5 cm - 12.5 cm basis in
getting true conjugate. (DC 11.5 cm=true conjugate).estimated on
vaginal examination. Widet anteropoterior diameter at outlet.
2. True conjugate/conjugate vera measure between the anterior surface of
the sacral promontory and superior margin of the symphysis pubis.
Measurement: 11.0 cm
3. Obstetrical conjugate smallest AP diameter. Pelvis at 10 cm or more.
4. Tuberoischi Diameter transverse diameter of the pelvic outlet. Ischial
tuberosity approximated with use of fist 8 cm & above.
Pelvic Dimensions
Adequate pelvic inlet (anteroposterior diameter; normal shape).
Adequate midpelvis (ischial spines do not protrude into bony canal).
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3. PASSENGER.
This refers to the fetus and its ability to move through the passage way
Important fetal dimensions influenced by fetal size, posture/attitude, lie, and
presentation. Fetal position is also an important factor in successful labor.
i. Fetal head
It is the most important part of the fetus because it is:
a. Largest part of the body
b. Most frequent presenting part
c. Least compessible of all parts
In approximately 95% of all births, the fetal head presents first. The sutures and
fontanelles provide important landmarks for determining fetal position during a
vaginal examination
Bones of the fetal skull:
a. Occipital bone posteriorly
b. Two parietal bones on the sides.
c. Two temporal bones anteriorly.
d. Two frontal bones anteriorly.
Sutures of the fetal skull; membranous spaces between the bones of the fetal skull:
allows the bones to move and overlap, changing the shape of the fetal head in order
to fit the birth canal, a process called molding
a. Frontal suture is between the two frontal bones.
b. Sagittal between the two parietal bones.
c. Coronal between the frontal and parietal bones.
d. Lambdoidal between the back of the parietal bones and the margin of the
occipital bone.
Fontanelles are irregular spaces formed where two or more sutures meet.
a. Anterior fontanelle largest fontanelle; junction of the sagittal, frontal, and
coronal sutures. Closes by age 12 18 months; diamond shaped.
b. Posterior fontanelle located where the sagittal suture meets the
lambdoidal (smaller than anterior). Closes at age 6 to 8 weeks/ 2 3
months; triangle shaped.
ii. Fetal Size
Size of the fetal head and capability of the head to mold the passageway.
With excessive size, fetal skull bones may not be able to override enough to be
accommodated in the bony pelvic cavity.
iii. Fetal presentation
The part of the fetus enters to maternal pelvis first.
Whichever portion of the fetus is deepest in the birth canal and is felt on vaginal
examination is referred to as the presenting part; this determines fetal presentation.
Presentation can be:
A. Vertical
1. Cephalic presentation. Classified according to the relationship between the
head and body of the fetus ordinarily, the head is flexed sharply so that the
chin is in contact with the thorax. 95 % of term deliveries.
a. Vertex or occiput- occipital fontanel is the presenting part,
completely flexed upon the fetal chest
b. Face presentation- fetal neck sharply extended occiput and back
come in contact, hyperexted with the chin presenting.
c. Sinciput- partially flexed with the anterior fontanel or bregma
presenting, moderately flexed.
d. Brow- partially extended,
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STAGES OF LABOR
Normal Length of Labor
Stages of Labor
First
Second
Third
Total
Primipara
12 hours
80 minutes
10 minutes
14 hours
Multipara
7 hours, 20 minutes
30 minutes
10 minutes
8 hours
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o
o
o
o
o
o
o
o
o
o
o
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o Sudden gush of amniotic fluid(if membranes are intact) as fetus is pushed into
the birth canal
o Amniotomy is done (if BOW is not ruptured) to prevent fetus from aspirating
the fluid as it makes its different fetal position changes. Done only if station is
still minus to prevent cord compression.
o Show becomes prominent
o Nausea and vomiting decrease gastric motility and aborption
o In primis, baby I delivered within 20 contractions (40 minutes); in multis, after
10 contractions (20 minutes)
Nursing Actions: Primarily comfort measures
o Sacral pressure; relieves discomfort from contractions
o Proper bearing down technique; push with contractions
o Controlled chest breathing during contractions
o Emotional support
2.
2.
3.
4.
5.
6.
7.
Nursing Care:
o Continue to offer psychological support
Praise
Reassurance
Encouragement
Inform mother of the progress
Support system
Touch
o Placed mother in lithotomy position put legs same time up.
o During crowning instruct mother to pant--- if hyperventilation occurs --- let
patient breathe into a paper bag or cupped hands over the mouth to recover lost
CO2.
o Assist in the Episiotomy (surgical incision in perineum) may be done to facilitate
delivery and avoid laceration of the perineum, reduced duration of second stage
and enlarge outlet.
Types of episiotomy:
a. median from middle portion of lower vaginal border directed
towards the anus;less bleeding, less pain easy to repair, fast to heal,
possible to reach rectum ( urethroanal fistula)
b. Mediolateral begun in the midline but directled laterally away from
the anus, often done because it prevents 4th degree laceration. More
bleeding & pain, hard to repair, slow to heal
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Clamp the umbilical cord approximately 1 inch (2.5 cm) from the abdominal
wall with a cord clamp.
o Count the number of vessels in the cord; fewer than three vessels have
been associated with renal and cardiac anomalies or normal outcome.
2
> 100
Good, crying
Active motion
Vigorous cry
Completely pink
Cover the neonate's head with a cotton stocking cap to prevent heat loss.
Place the neonate under a radiant heat warmer, or place the neonate on the
mother's abdomen with skin-to-skin contact.
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o Feel the fundus for contraction or firmness. If boggy, soft, non-palpable, noncontracted means uterine atony --- massage fundus gently and properly until firm.
Ice cap maybe applied will further contract the uterus.
o Inject oxytoxin (Methergin=0.2mg/ml or Syntocinon= 10U/ml, IM) after placental
delivery, to maitain uterine contractions
o Assess VS, Monitor BP for HPN (or give oxytocin IV)
o Check perineum for lacerations
a. First degree involves the vaginal mucous membranes and perineal skin
b. Second degree involves not only the vaginal mucous membranes and perineal
skin but also the muscles
c. Third degree involves not only the vaginal mucous membranes and perineal
skin and muscles including the external sphincter of the rectum
d. Fourth degree - involves not only the vaginal mucous membranes and perineal
skin and muscles and the external sphincter of the rectum but also the mucous
membranes of the rectum
o Assist MD for episiorapy (repair of episiotomy); vaginal pack should be removed
after 24-48 hours.
o Position mother flat on bed to prevent dizziness
o May complain of Chills-due dehydration or decreased BP, fatigue or cold
temperature in DR. Provide blanket; give clear liquid-tea, ginger ale, clear gelatin.
Allow to sleep to regain energy.
C. FOURTH STAGE (Recovery and Bonding Stage)
This stage lasts form 1 to 4 hours after birth.
The mother and newborn recover from the physical process of birth.
The maternal organs undergo initial readjustment to the nonpregnant state.
The newborn body systems begin in the midline of the abdomen with the fundus midway
between the umbilicus and symphysis pubis.
Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.
Check placement of fundus at level of umbilicus.
If fundus above umbilicus, deviation of fundus
Empty bladder to prevent uterine atony
Check lochia a vaginal discharge that consists of fatty epithelial cells, shreds of
membrane, decidua, and blood
Parameter
Rubra
Color
Red
Amount
Moderate
Time Present
1 3 days
Serosa
Brownish
Alba
Scanty
White
Slight
4 10 days lower
limit 7 days)
10 -14 days(upper
limit 21 days)
Check for bladder distention displaces uterus to the side a factor for uterine atony.
Bonding interaction between mother and newborn rooming in types
1.) Straight rooming in baby: 24hrs with mom.
2.) Partial rooming in: baby in morning , at night nursery
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