INTRAPARTAL PERIOD

From onset of contractions, dilation of cervix up to first 4 hours after delivery

All products of conception are expelled

(baby, placenta and fetal membranes)

Intrapartum Care…care during labor and delivery

Intrapartum…

Fetal expulsion along with products of conception due to:

regular, progressive & frequent

uterine contractions

Parturient – woman in labor Puerpera – woman who gave birth

LABOR…

LABOR ONSETa. Stretching of uterine musclesb. ↓ progesteronec. Release of oxytocind. Maturity of placentae. ↑ prostaglandin

↓Contraction of Uterus

↓Expel products of conception

Preliminary Signs of Labor

a. Lighteningb. Weight lossc. Braxton Hicks Contractiond. Apprehension & Restlessness

RegularRegular , ↑↑ frequencyfrequency, ↑ , ↑ intensity & Shorter IntervalShorter Interval of contractions

Rupture of Rupture of amniotic amniotic membranesmembranes

Effacement and Dilatation

TRUE LABOR Pain = Pain = Back Back

discomfortdiscomfort radiating to abdomen & legs

IntensifiedIntensified by Walking

Bloody showBloody show

Contractions persistpersist during sleep & sedation

4 Stages of Labor1. First Stage – onset of true labor to complete dilation

2. Second stage – complete cervical dilation to delivery

3. Third Stage – placental stage

4. Fourth Stage – first 4 hours after delivery of placenta

Maternal Factors Affecting

Labor Process(5 P’s)

a. Passageway (pelvis)b. Passenger (Fetus & Placenta)c. Power d. Placentae. Psychologic response of mother

› maternal pelvis› Route of fetus when

leaving the uterusIschial spines

= degree of descent (station) of fetal headAbove ischial spine - station

Floating (unengaged)Ischial spine

station 0; engagedBelow ischial spine

+ station

1. Passageway (Pelvis)

Pubis

= front portion

= 2 pubic bones meet at symphysis pubis

Estrogen & Relaxin = Relaxes the symphysis pubis

Slight separation allowing room

for the fetal head

Pelvic Types…1. Gynecoid- Normal female pelvis- Round & wide- Good vaginal

delivery

2. Anthropoid- Narrow, oval- Like ape pelvis- Good Vaginal Delivery

3. Platypelloid- Flat- Poor vaginal

delivery4. Android- Heart-shaped - like male pelvis- Poor vaginal

delivery

› Refers to fetus

› Fetal head consists of :

vault, face & brow

2. Passenger BROW From nose to

anterior fontanel

FACE From chin &

neck to root of nose

2 Frontal Bonesforehead

2 Parietal Bones crown of head

2 temporal Bones

side of head 1 Occipital

Bonesback of head

Vault of fetal head is composed of:

Bones meet at suture lines Allow bones to overlap

(molding/overlapping)

MOLDING - Due to uterine contractions- Head is pressing against

the cervix

Making skull to ↓ in size Easier passage thru birth

canal

Anterior Fontanel - Posterior Fontanel› Bregma

› Large, diamond shape

› Membranous floor

› Formed by 4 bones (2 frontal & 2 parietal)

› ossified by 1 ½ years of age (12-18 mo)

› Lambda

› Small, triangle shape

› Bony floor

› Formed by 3 bones (2 parietal & 1 occipital bones)

› ossified at full term (6-8 wks = 2-3 mo)

3. POWER Force of uterine contractions Refers to:

IntensityDuration

FrequencyInterval

of uterine contractions to result in cervical effacement & dilation 

PRIMARY POWER SECONDARY POWER

Uterine contractions

Maternal bearing down

(readiness for pushing)

Intra-abdominal pressure

a. Uterine Contractions (primary power) - wavelike manner

Phases of Intensity: Increment – intensity ↑ - builds up & longest phase Acme – contraction is at its strongest - peak of contraction Decrement – intensity ↓ - letting down phase

Monitor contractions

Rest a hand onwoman’s abdomen at the fundus of uterus

Sense the gradual tensing andupward rising of fundus thataccompanies a contraction.

Strength of contraction during acme Determined by palpation

Mild – minimally tense. - indented easily with fingertips

Moderate – feels firm; fundus is difficult to indent

Strong – so intense; uterus feels hard as wooden board at peak of contraction - Fundus is firm, can’t be indented with fingers

.

Duration – beginning to end of same contraction

- Seconds - Report if more than 90 sec - During transition phase (2nd stage of

labor)

Frequency - beginning of 1 contraction to beginning of next

contraction. - Minutes; Report if less than 2 minutes

2 parts: 1. Duration of contraction 2. Period of relaxation

Interval – From decrement of first to increment of 2nd contraction

You are ready to push if:

- Cervix is 10 cm dilated & 100% effaced

Dilatation – Widening of cervical canal - Advances from 0 – 10cm- As cervical canal opens = resistance ↓- This eases fetal descent- 10 cm = fully dilated

Effacement… Thinning, shortening of cervical canal Expressed in % 100% effaced cervix = cervical canal is

paper thin or absent 75% = cervix is ¼ of its original length 50% = cervix is ½ of its original length

b. Intra-abdominal pressure This is another secondary power

As the woman pushes, the intra-abdominal pressure increases

Patient Monitoring… Void Frequently

- Full bladder hinders fetal descent

- Cause dysfunctional labor

- If bladder is distended = it is palpable, notify physician

- Catheterization may be necessary

4. Placenta Placental Separation

Calkin’s sign = Uterus becomes globular & firm

Fundus of uterus rises in the abdomen

Umbilical cord lengthening

Gush of blood from the vagina

Placental Expulsion

Natural bearing down of the mother

Gentle pressure on contracting uterus

(Crede’s maneuver)

Brandt andrews maneuver downward sideways gentle controlled cord traction

Crede’s Maneuver

Brandt Andrews Maneuver

Schultze placenta (80%)

Separates at center & fold

(inverted umbrella)

fetal surface exposed Shiny & glistening

Less external bleeding; blood is concealed behind the placenta

Duncan placenta (20%)

Separates at its edges

Umbrella shaped

Maternal surface exposed

Rough, red, raw & irregular from ridges

More external bleeding

Appears bloody

Stages: cont’d

Third stage Placental separation Placental delivery

Fourth stage 1-4 hours

After placenta is delivered= veins in the place of attachment

at decidua is 7cm dilated = mother is prone to hemorrhage

MUST promote contraction after delivery

Average blood loss = 250-300 ml 500 ml or above = postpartal

hemorrhage (maternal mortality)

5. Psyche/ Psychologic Response of Mother

Psychological state

Feelings women bring to labor

Experience & coping mechanisms.

•Amniocentesis - couvade syndrome •Pap smear - placenta•FHR - probable sign•Leopold’s - amniotic fluid•Pregnancy test - fetal distress•Prenatal visit - smoke – effect to NB•Primipara & primigravida - TT•Morning sickness - foods rich in folic acid•Hyperemesis gravidarum - exercise for back pain•Quickening - iron supplement•Uti - foods rich in iron•Weight gain - varicose veins

•Leg cramps - dyspnea•Constipation - Johnson’s rule•Iodine rich foods - bartholomew’s rule•Heartburn/pyrosis - naegele’s rule•Anemia - haase’s rule•Kegel’s exercise - mc donald’s rule•Clothes for pregnant women - incidence of twins•Vaginal secretions/leukorrhea - lightening•Urinary frequency - mesoderm•Alcohol - products of conception•Teratogen - sequence of conception•Type of exercise - implantation

•Cocaine - dilation•AVA - effacement•Fetal attitude - break BOW•Fetal presentation - VBAC•Fetal position - types of placenta•Fetal station - advantage of episiotomy•Pelvic shape - breech presentation•Position for vaginal delivery - types of breech•Cardinal movements of labor - intensity, duration,•Crowning interval, frequency•Laceration - TPAL•Placental separation - 4 stages of labor

Pain Management During Intrapartum Period

Pain during labor accompanies:uterine contractions

cervical dilatation & effacement fetal descent

Response to pain:↑ VS & muscle tension

Hostility, fear or depressionGroaningSweating

Nonpharmacologic measures

Read Method Slow abdominal

breathing in 1st stage of labor:

1 breath/minute (30 sec inhalation & 30 sec exhalation)

Use of panting to prevent pushing until needed

Bradley Method Husband-coached Modification of

Read method

Lamaze Method breathing, effleurage,

relaxation

Blocks recognition of pain

Lamaze breathing techniquescontrolled chest breathing

Slow = inhale thru nose = exhale thru mouth/nose = 6 – 9 times/min

Pant-blow = rapid, shallow breathing thru the mouth only during contractions

Leboyer Method environment Room is darkened Pleasantly warm with soft

music playing

Focusing, Relaxation & Positioning

obstruction Concentrate on

photograph or object during contractions

Imagery

Mental concentration on person, place or thing

Sound = aids in maintaining her concentration on the image

Effleurage Light abdominal massage

woman traces a pattern on the skin – repeating it over and over

For mild to moderate discomfort

Distraction Diversion of attention - early labor Playing games or recalling pleasant

experiencesYoga

Deep-breathing exercises, body stretching postures and meditation

helping the body relax and possibly releasing endorphins

a. Acupuncture – stimulation of trigger points with

needles- release of endorphins to reduce

pain

a. Acupressure – finger pressure or massage at

the same trigger point

a. Opioidsb. Sedativesc. Anesthetics:

EpiduralSpinalLocal

Pharmacologic measures

a. Opioids Commonly used drugs include: Meperidine (Demerol) Butorphanol (Stadol) Nalbuphine (Nubain) Maternal adverse reaction: Respiratory depression Nausea & vomiting Drowsiness Transient hypotension

b. Sedatives Barbiturates - used in early latent

phase of labor secobarbital (seconal) pentobarbital (Nembutal)

Benzodiazepines – midazolam (Versed)

c. Regional Aesthesia Block specific nerve pathways blocking of nerve conduction

Lumbar Epidural Anesthesia Injection into epidural space

Can cause hypotension Can slow down labor process- patient awake & cooperative in delivery- Provides analgesia for the 1st & 2nd stages of

labor & anesthesia for birth

Epidural animation

Spinal Anesthesia injected at cerebrospinal fluid (CSF) at Lumbar 3-

4 Hypotension can occur Spinal headache Increase incidence of urinary retention

Local anesthesiaLocal anesthesia during actual birth of the fetus• injection into perineal nerves• receives relief from discomfort only at receives relief from discomfort only at

delivery not during labordelivery not during labor

Nursing Interventions Know type of anesthesia (Drug Rights)

Allay anxieties; answer questions

Assist in preparation & administration

monitor patient and fetus

adverse reaction = notify physician & have emergency equipment available

Fetal Factors Affecting the Labor

Process:(5 F’s)

Fetal Lie Fetal Attitude Fetal Presentation Fetal Position Fetal Station

1. FETAL PRESENTATION Describes fetal body part to pass

thru cervix and be delivered

The part felt on IE

I. CephalicII. Breech

III. ShoulderIV. Compound

Abnormal Animation(Jot Down Notes)

I. Cephalic Presentation – Head presents first at the cervix

Vertex presentationSinciput/forehead presentation

Brow presentationMentum/Face presentation

Vertex Sinciput/ForeheadSinciput/Forehead

› head is sharply flexed

› posterior fontanel (lambda)

› Chin touches the sternum

› Fetal Attitude: complete/full flexion

chin is not touching the chest

alert or military position

Anterior fontanel (bregma)

Fetal Attitude: Moderate flexion

Brow Brow Mentum/Face

head is moderately extended

brow enters first

Fetal Attitude: Partial extension

› fetal head is hyperextended

› chin presents first

widest diameter

› Fetal Attitude: Complete extension

During labor, the fetal skull press cervix becomes edematous from continued pressure against it.

This edema is called CAPUT SUCCEDANEUM.

II. Breech Presentation – either buttocks/feet are

first to contact the cervix

3 Types: Complete Frank Footling

Complete Breech Presentation…

Thighs are tightly flexed on abdomen

buttocks & flexed feet to present first

Frank Breech Presentation… fetal hips are

flexed but legs are extended, resting on chest

buttocks to present first

Footling Breech Presentation…

1 or both extremities are the presenting part

Most difficult

Cord prolapse is common because of the extended leg

Cesarean birth may be necessary

In breech presentation =

passage of meconium is not a sign of fetal distress

PINARD MANEUVER

MAURICEU MANEUVER

PRAGUE MANEUVER

Breech delivery Video(Jot Down Notes)

III. Shoulder Presentation presenting part is the shoulder, iliac crest,

hand or elbow

abdomen have an abnormal shape –wider horizontally & shorter vertically

transverse lie fetus must be turned before delivery;

successful if fetus is small or preterm

Cesarean birth = to reduce risk of fetal or maternal mortality

IV. Compound Presentation

An extremity prolapses alongside the major presenting parts

2 presenting parts appear at pelvis

2. Fetal Lie Relationship of (spine) of the

fetus to the (spine) of the mother

Can be:I. LongitudinalII. TransverseIII. Oblique

I. Longitudinal Lie Fetal spine parallel

to maternal spine

Fetus is lying top-to-bottom

Can be classified as cephalic or breech

perpendicular to maternal spine

The fetus is lying side-to-side

If labor progresses, the presenting part may be a shoulder, iliac crest, hand or elbow

II. Transverse Lie

TransverseLongitudinal

III. Oblique Lie The fetal spine is 45° angles to

maternal spine

midway between transverse and longitudinal lies

abnormal if fetus maintains this position

Fetal Lie Video(Jot Down Notes)

Degree of flexion

Could be:I. Complete/Full Flexion

II. Moderate FlexionIII. Partial Extension

IV. Complete Extension

3. Fetal Attitude

I. Complete/Full Flexion Most common

Neck is completely flexed

chin touching sternum

vertex presentation

ideal attitude

occupies smallest space in the uterus

II. Moderate Flexion 2nd most common military position

Straight head appear to be “at attention”

Neck is slightly flexed chin doesn’t touch chest

sinciput/forehead presentation

III. Partial Extension IV. Complete Extension

brow presentation

Neck is extended

Head is moved backward

cause a difficult delivery

face presentation

may need cesarean delivery

Head & neck are hyperextended

occiput touching the upper back

Back is usually arched

A – Vertex presentation & Complete flexionB – Forehead presentation & Moderate flexionC – Brow presentation & Partial extensionD – Face presentation & Complete extension

4. Fetal Position Relationship of presenting part

to the mother’s pelvis

Landmarks - QuadrantsO = Occiput, vertex

presentationM = Mentum, face presentationSa = Sacrum, breech presentationA = Scapula/ acromion process, shoulder presentation

R = rightL = leftA = anteriorP = posteriorT = transverse

(center)

Fetal position is described by using 3 letters

1st letter = if presenting part facing mother’s R or L

2nd letter = presenting part of fetus

3rd letter = if presenting part is pointing to A, P or T of mother's

pelvis

Vertex Presentations… ROA ROT ROP LOA LOT LOP

Right occiput anterior Right occiput transverse Right occiput posterior Left occiput anterior Left occiput transverse Left occiput posterior

Face Presentations… RMA RMT RMP LMA LMT LMP

Right mentum anterior

Left mentum anterior

Breech Presentations… RSaA RSaT RSaP LSaA LSaT LSaP

Right sacrum anterior

Left sacrum anterior

LOA & ROA – occiput is towards the front; face is down; favourable delivery position

LOP & ROP – occiput is towards the back; face is up; much back discomfort, labor is slow

5. Fetal Station Relationship of

presenting part to ischial spines of mother’s pelvis

Determined (IE)

Station 0 = level of the ischial spines

engagement occurs

Floating (High) – unengaged

above ischial spines “minus station”

(-1 to -4 cm)

below ischial spines “plus station” (+1 to +4 cm)

If at +4 cm, known as crowning

Relationship between the passage and the fetus

Engagement Station Fetal position

Phase Station Contraction

Phase 1 0 to +2 2 – 3 min apart

Phase 2 +2 to +4 2 – 2.5 min apart with urgency to

bear down

Phase 3 +4 to birth 1 – 2 min apart; fetal head visible

increased urgency to bear down

Fetal Station Video(Jot Down Notes)

Stages of Labor1. First Stage – onset of true labor to complete dilation

2. Second stage – complete cervical dilation to delivery

3. Third Stage – placental stage

4. Fourth Stage – first 4 hours after delivery of placenta

1. First Stage of Labor (Dilatation Stage)

From true labor to complete dilation of cervix

6-18 hours = primipara 2-10 hours = multipara

Divided into 3 phases:I. LatentII. Active

III. Transitional

Phase Dilatation Duration/Interval IntensityLatent Phase

0 – 3 cmMild & short20-40 secQ10 min

6 hrs – primipara4-5 hrs – multipara

Encourage walkingChest breathingEncurage to void q2-3 hours

Active Phase

4 – 7 cmModerate to strong40-60sec q3-5 min

3 hrs – primipara2 hours multipara

Meds should be readyAssess vsAbdominal breathingOral care

Transition Phase

8 – 10 cmVery Strong

60-90 secQ 2-3 min

Cervical dilation TiredInform progress of laborRestless, support her with breathing techniques,

- Take history

vital signs Assess cervical dilation & effacement by IE maintain effective breathing patterns ambulation, if desired & tolerated void every 1-2 hours

Quiet surroundings

comfort measures:

Back rubs Pillow support

Position changes Offer liquids/ice chipsProvide ointment for dry lips

rest between contractions update regarding progress of labor Provide privacy Monitor contractions by palpation/ progress of

labor (frequency, duration & intensity)

Assess color of amniotic fluid; meconium staining = fetal distress

Perineal preparation

Render enema if ordered: to prevent infection, retardation of labor progress

2. Second Stage of 2. Second Stage of LaborLabor› Expulsive stage› complete cervical dilation to delivery of

the newborn› Contractions: strong› Duration: 60 – 90 seconds› Frequency: every 2-3 minutes› Primipara: 40 minutes average 20 contractions› Multipara: 20 minutes average 10 contractions

› Fetus moves along the birth canal by cardinal movements of labor

Increase in bloody show “The baby is coming” “I need to push.”

Pushing will ↑ uterine contractions

Bulging of perineum & crowning of head – hallmark of 2nd stage

bear down only during contractions

Monitor FHR

Monitor contractions: frequency, duration & intensity

Check for rupture of membranes: time, color, odor, amount and consistency of amniotic fluid

Assess signs of hypotensive supine syndrome

- If BP falls, position patient on her Left side

- Increase IV flow rate - Administer O2 through

face mask at 6-10 L/min

When to transfer patient to delivery room? Primigravida: Cervix 10cm with bulging & contractions Multigravida: Cervix 8-9cm

Assist mother in positioning:dorsal recumbent – for bearing downlithotomy – if with position

Check for prolapsed cord an check FHR after rupture of membranes

ProlapsedCord

Prepare for birth & maintain sterile technique

Place legs simultaneously in stirrups

Perineal preparation: front to back

After delivery, cord is clamped and cut within 15~20 seconds.

Delayed cord clamping can result in hyperbilirubinemia = additional blood is transferred to NB.

Cardinal Movements of Labor…

7 movements occur: (ED FIRE ERE)

I. EngagementII. DescentIII. Flexion

IV. Internal RotationV. Extension

VI. External RotationVII. Expulsion

I. Engagement presenting part at

ischial spines

Station 0

downward movement of fetus

Fetal head passes the dilated cervix

II. Descent

III. Flexion head bends

forward

chin is pressed to the chest

rotation of head to pass thru ischial spines

head rotates about 45°

Fetal head is against the front of her pelvis

IV. Internal Rotation

V. Extension delivery of head outside

pelvis

Occiput at vagina Crowning

back of neck is under symphysis pubis

causes the head to extend

extension is controlled by the physician.

An episiotomy may be done

Promoting Gradual Extension:

Ritgen’s maneuver = gradual

extension= exert pressure on

the chin;

Panting & not pushing during crowning

VI. External Rotation VII. Expulsion

After extension, neck is twisted

head needs to externally rotate to realign with the spine

the anterior shoulder descends first

Final birth Delivery of fetal

body

head is raised to deliver shoulder and entire body

When entire body emerges = birth is complete

time of birth recorded and entered in the birth certificate

PD 651 registration with Civil registrar of all births within 30 days

birth certificate = legal document must be complete & accurate, devoid of

any erasures

procedures employed to present trauma/reduce hazard to mother and or infant during the birth process.

First degree: vaginal epithelium or perineal-skin.

Second degree: subepithelial tissues of the vagina/perineum & muscles of the perineum

Third degree: anal sphincter

Fourth degree: rectal mucosa

Episiotomy… A surgical incision of perineum

used to enlarge the vaginal outlet

prevent perineum from tearing

release the pressure on fetal head that accompanies birth

repaired easily & heals faster

Method Done during contraction as the

baby’s head pushes against perineum and stretches it.

Blunt scissors are used

Client is usually on anesthetic, local or inhalation

Type of Episiotomy:a. Midline episiotomy - center of perineum toward anal

sphincter - Easier healing, decreased

blood loss & decreased postpartum discomfort

- Danger of extension into anal sphincter

b. Mediolateral episiotomy - midline and then angled (45°)

to 1 side away from the rectum - Decreased risk of rectal

mucosa tearing Blood loss is greater Healing process is quite painful Incision is harder to repair

OB Forceps Video(Jot Down Notes)

Forceps delivery… Forceps are steel instruments to

assist with delivery and relieve fetal head compression

2 blades connected together; blades are slipped into position one at a time

Commonly used forceps: Kjelland’s, Elliot, Piper, Tucker-

McLean, Simpson’s

For forceps delivery to be performed, the ff must be present:

Ruptured membranesFully dilated cervix

Empty bladderFetal head engaged in maternal pelvis

FHT present before and after forcep application

Absence of cephalopelvic disproportion It shortens 2nd stage of labor

Indications: Fetal distress Poor progress of fetus through

the birth canal Failure of the head to rotate Maternal disease or exhaustion Client is unable to push(with

regional anesthesia)

Types:Low or Outlet – presenting part on perineal

floor

Midforceps – presenting part below or at the level of the ischial spine

High forceps – presenting part above the ischial spine (not engaged). This procedure has been replaced by cesarean birth.

Disadvantage… ↑ perinatal morbidity & mortality ↑ neonatal birth trauma &

depression ↑ incidence of perineal

lacerations, postpartum hemorrhage & bladder injury

Forceps Video(Jot Down Notes)

Vacuum extraction… An alternative to forceps delivery Facilitates descent of fetal head A plastic vacuum cup is applied

to the fetal head, negative pressure is exerted & traction is applied to deliver the head

Advantages… Lower incidence of vaginal,

cervical & laceration Less maternal discomfort because

the cup does not occupy additional space in the birth canal

Little anesthesia needed Neonate born with less respiratory

depression

Disadvantages… Marked caput succedaneum of

neonate’s head lasting as long as 7 days after birth

Preterm neonates is problematic because of extreme softness of their skulls

3. Third Stage of Labor3. Third Stage of Labor› Placental stage

› From delivery of neonate to delivery of placenta

› After delivery, contractions cease for several minutes

Duration: 5 – 30 minutes

Placental Separation Calkin’s sign = Uterus

changes from discoid to globular & from soft to firm

Fundus of uterus rises in the abdomen

Umbilical cord lengthening

Gush of blood from the vagina

Placental Expulsion

Natural bearing down of the mother

Gentle pressure on contracting uterus(Crede’s maneuver)

Brandt andrews maneuver downward sideways gentle controlled cord traction

Schultze placenta (80%)

Separates at center & fold

(inverted umbrella)

fetal surface exposed Shiny & glistening

Less external bleeding; blood is concealed behind the placenta

Duncan placenta (20%)

Separates at its edges

Umbrella shaped

Maternal surface exposed

Rough, red, raw & irregular from ridges

More external bleeding Appears bloody

Stages: cont’d

Third stage Placental separation Placental delivery

Fourth stage 1-4 hours

After placenta is delivered= veins in the place of attachment

at decidua is 7cm dilated = mother is prone to hemorrhage

MUST promote contraction after delivery

Average blood loss = 250-300 ml 500 ml or above = postpartal

hemorrhage (maternal mortality)

Placenta Video(Jot down notes)

wait for signs of placental separation

DO NOT do fundal pressure with pull at the cord if uterus is relaxed

= could cause hemorrhage

Gradual delivery of placentamake sure placenta is intact &

complete

Complete cotyledons (oxygen reserve during 2nd stage of labor to prevent fetal distress)

Complete cord vessels: 2 arteries & 1

vein Complete membranes Monitor maternal vital signs inspect cervix and vagina for

laceration

Feel fundus for contractions or firmness. soft, boggy & non-palpable = uterine atony

massage fundus until firm Ice cap to contract uterus

20 units oxytocin IV or p.o. as ordered to enforce contractions

Introduce NB to patient & her partner

Allow to breast-feed Provide essential newborn care/unang

yakap

1. Immediate & thorough drying2. Skin to skin contact3. Properly timed cord clamping

& cutting4. Early BF

Umbilical cord/funis AVA 53-55cma. Short cord –

abruptio placenta

b. Long cord – cord coil or cord prolapse

c. 2 vessel cord – congenital heart problem; check for AVA

Cord Care Animation(Jot down notes)

Episiotomy Repair Animation

(Jot down notes)

4. Fourth Stage of 4. Fourth Stage of LaborLabor› Recovery & bonding stage› after delivery of placenta› First hour after delivery› Stabilizing NB & helping him adapt

to extrauterine life› maternal-neonate bonding› Uterine contractions prevents

bleeding from placental site

Interventions… Asses mother:

Every 15 min = 1st fourEvery 30 minutes = another hour

Every hour = 2 hours

Ice cap to contract uterus

Apply ice pack to perineum if with episiotomy or laceration, swollen

uterine massage to keep it firm

Assess & document lochia

Perineal pad saturated in 15 minutes or blood pooling under buttock

= excessive blood loss

Bright red lochia = laceration of cervix or vagina

Check perineum for edema, bruising & rectal pain

MIO

Parameter Rubra Serosa AlbaAppearance Mostly

bloodySerosangui-neous

Creamy white

Color Red Brownish White

Amount Moderate Scanty Slight

Time present

1-3 days 4-10 days (7 days – average)

11-14 days (maximum of 21 days

Duration of LaborLabor Stage

First Stage: true labor – full dilatation

1. Latent phase (0 – 3cm) 2. Active phase (4 – 7cm) 3. Transitional (8-10cm)

mild & short (20-40 sec)

6 hrs - primi4-5 hrs -

multi

Encourage walkingChest breathingEncourage to void q2-3 hours

Second stage: (full dilatation – to birth)

Most difficult for fetus

50 minutes= 1 hr

Third Stage: (placental expulsion)

5 – 15 minAve. 5 min

Fourth stage: (recovery/ immediate postpartum)Dangerous for the mother- Due to hemorrhage

1 – 2 hoursMaximum: 4 hours

INDUCTION OF LABOR

Artificial initiation of Labor

Deliberate initiation of labor or uterine contractions before spontaneous onset

192

• Condition before Induction Fetus in Longitudinal lie Cervix is ripe or ready for birth

Presenting part is engaged No CPD

Fetus is mature, mother at or near term

No contraindications for use of oxytocin like CS scar, placenta previa

193

Ways of Induction of Labora. Administer Pitocin – synthetic substitute for uterine contractions

b. Artificial ROM (amniotomy)

Prepare amniotomeCheck FHT after BOW is ruptured

194

Management- on bedrest- VS & FHT every 15 minutes - IV – 10”u” Pitocin add D5W piggybacked to main line

-Stop oxytocin if: - FHT is more than 170 bpm - less than 120 bpm - Meconium passage - Maternal hypotension

IF FETAL DISTRESS DEVELOPS:a. Stop oxytocinb. Turn client to the left sidec. Administer oxygen per maskd. Refer to the physician

Cesarean Birth Removal of NB from uterus thru abdominal &

uterine incision

Indicated for: CPD

Uterine dysfunction Malposition

Previous uterine surgery Placenta previa

DM, cardiac disease Prolapsed umbilical cord

Fetal distress

Types of Incisiona. Low Segment Transverse incision - bikini incision - above pubic hairline

- Blood loss is minimal - less likely to rupture during future labors

due to minimal active contractions at the area

- Vaginal delivery may be possibleVBAC

b. Classic/vertical incision - vertical incision

- used if with previous CS exist

- fetus is in transverse lie

- chance of vaginal birth is low - because incision’s location is in the active contracting portion of uterus

PRE-OPERATIVE Regular preparation

for abdominal / pelvic surgery

POST-OPERATIVE Ensure airway

(suction & oxygen)

VS q15 min until stable

Check dressing & perineal pad for bleeding, lochia

MIO - Bleeding & urine

Clear liquids after flatus

Oxytocic drugs = ensure firm fundus

Analgesic = relief of pain

Antibiotics = prevent sepsis

Assess signs of infection & thrombophlebitis

Regular positioning

Early exercise

Passive then active leg exercises

(Foot & leg exercise, abdominal tightening, pelvic rocking)

Danger Signs Thrombophlebitis:

- Local redness (rubor)

- Warm to touch (calor)

- Swelling (tumor)- Pain (dolor)

Validate by eliciting Homan’s sign (calf pain upon

dorsiflexion)

Effects of Anesthesia Trauma to nerve root or spinal cord

(paresthesia)

Postdural puncture headache (flat on bed)

Hematoma in spinal canal (ischemia)

Diminished uterine contractions (bleeding)

Hypotension

Cesarean Birth Animation

Evaluation During Labor

Leopold’s maneuver

Cervical effacement & dilation

Patient monitoring:Signs of dehydration

ContractionsUrinary elimination

Partograph

Partograph = advocated by WHO

= to assess progress of labor

= Components:

Progress of laborFetal conditionMaternal condition

Alternative Birthing Experience

Birthing Centers Maternity facilities Hospital or institution

close to a hospital Warm, homelike

environment

Families take more responsibility for birth experience

NOT for high-risk deliveries

Care provided by nurse-midwives

Home births Inadequate medical back-

up Woman must ensure the

home is prepared for birth must be in good health

6 Cleans (WHO)- Clean hands- Clean delivery surface- Clean tie for the cord- Clean blade- Clean cloth for mother- Clean cloth for baby

Water birth sitting or reclining in warm

water bath NB is born under water and

brought out of the water for the first breath

Relaxation occurs due to warm water

Risk of fecal contamination May lead to uterine

infection & neonatal aspiration of water