47385717 intrapartal care

8/3/2019 47385717 Intrapartal Care

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care of a pregnant woman from the onset

of labor to the completion of the fourth

stage of labor with the expulsion of the

placenta.


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The Process of Labor Four Ps

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1. Labor: coordinated sequence of

involuntary uterine contractions

2. Delivery: actual even of birth


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Powers

Passageway

Passenger

Psyche


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1. The forces acting to expel the fetus

2. Effacement: shortening and thinning of

the cervix during the first stage of labor

3. Dilation: enlargement of cervical os andcervical canal during first stage.

4. Pushing efforts of mother during second

stage.


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the mothers rigid bony pelvis and the softtissues of the cervix, pelvic floor and vagina.


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False Pelvis

The false pelvis is

the shallow

portion above thepelvic brim

The false pelcis

supports the

abdominal viscera

True Pelvis

The true pelvis lies

below the pelvic

brim

The true pelvis

consists of the

pelvic inlet, mid-

pelvis and pelvic

outlet


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Normal female pelvis

Transversely rounded or blunt

Most favorable for successful labor andbirth


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Oval shaped

Adequate outlet with a normal ormoderately narrow pubic arch


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Wedge-shaped or angulated

Seen in males

Not favorable for labor

Narrow pelvic planes can cause slow

descent and midpelvis arrest

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Flat with an oval inlet

Wide transverse diameter but shortantero-posterior diameter, making outletinadequate.


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: the Fetus


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This is the relationship between the

presenting part of the baby -- the head,shoulder, buttocks, or feet -- and two

parts of the mother's pelvis called the

ischial spines. Normally the ischial spines

are the narrowest part of the pelvis.

They are a natural measuring point for

the delivery progress.

If the presenting part lies above the

ischial spines, the station is reported as anegative number from -1 to -5 (each

number is a centimeter). If the

presenting part lies below the ischial

spines, the station is reported as a

positive number from +1 to +5. The baby

is said to be "engaged" in the pelvis when

it is even with the ischial spines at 0


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This is the relationship between the head

to tailbone axis of the fetus and the head

to tailbone axis of the mother. If the two

are parallel, then the fetus is said to be

in a longitudinal lie. If the two are at 90-

degree angles to each other, the fetus is

said to be in a transverse lie. Nearly all

(99.5%) fetuses are in a longitudinal lie.


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The fetal attitude describes the

relationship of the fetus' body parts to

one another. The normal fetal attitude is

commonly referred to as the fetal

position. The head is tucked down to the

chest, with arms and legs drawn in

towards the center of the chest.

Abnormal fetal attitudes may include a

head that is extended back or other body

parts extended or positioned behind the

back. Abnormal fetal attitudes can

increase the diameter of the presenting

part as it passes through the pelvis,

increasing the difficulty of birth.


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Cephalic (head-first) presentation:Cephalic presentation is considered normaland occurs in about 97% of deliveries. Thereare different types of cephalic presentation,which depend on the fetal attitude.Rarely, the fetus' head is extended back, andthe chin, face, or forehead will present firstdepending on the degree of extension. This is amore difficult delivery, because this is not thesmallest part of the fetus' head. It may resultin a need for cesarean delivery.

A cesarean delivery may be recommended forany of the fetal positions other than cephalic.Breech presentation:Breech presentation is considered abnormaland occurs about 3% of the time. A completebreech presentation occurs when the buttockspresent first, and both the hips and knees areflexed. A frank breech occurs when the hipsare flexed so the legs are straight and

completely drawn up toward the chest. Otherbreech positions occur when either the feet orknees come out first.Shoulder presentation:The shoulder, arm, or trunk may present first ifthe fetus is in a transverse lie. This type ofpresentation occurs less than 1% of the time.Transverse lie is more common with prematuredelivery or multiple pregnancies.


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The mother may experience anxiety or fear.It is the mental preparation of the mother

for labor and deliver.


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True Labor Contraction increase in

duration and intensity. Discomfort that begins

in the back andradiates to the front ofthe abdomen.

Walking intensifiescontraction.

Cervical dilatation andeffacement areprogressive.

Resting or relaxing inwarm water does notdecrease the intensityof contractions.

False Labor Irregular contractions

that do not increasein duration andintensity.

Discomfort that is feltprimarilu in theabdomen

Contractions that arenot affected orlessened by walking,rest or warm water.

No change(contraction)

Contractions thatproduce no effect oncervix


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Leopolds Maneuver is preferably

performed after 24 weeks gestation when

fetal outline can be already palpated.


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Instruct woman to empty her bladder first.

Place woman in dorsal recumbent position,

supine with knees flexed to relax abdominal

muscles. Place a small pillow under the headfor comfort.

Drape properly to maintain privacy.

Explain procedure to the patient.

Warms hands by rubbing together. (Coldhands can stimulate uterine contractions).

Use the palm for palpation not the fingers.


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Purpose Procedure Findings

First Maneuver:

Fundal Grip

To determine fetal part lying in the

fundus.

To determine presentation.

Using both hands, feel for the fetal

part lying in the fundus.

Head is more firm, hard and round

that moves independently of the

body.

Breech is less well defined that movesonly in conjunction with the body.

Second Maneuver:

Umbilical Grip

To identify location of fetal back.

To determine position.

One hand is used to steady the uterus

on one side of the abdomen while the

other hand moves slightly on a

circular motion from top to the lower

segment of the uterus to feel for the

fetal back and small fetal parts.

Use gentle but deep pressure.

Fetal back is smooth, hard, and

resistant surface

Knees and elbows of fetus feel with a

number of angular nodulation

Third Maneuver:

Pawliks Grip

To determine engagement of

presenting part.

Using thumb and finger, grasp the

lower portion of the abdomen above

symphisis pubis, press in slightly and

make gentle movements from side to

side.

The presenting part is not engaged if

it is not movable.

It is not yet engaged if it is still

movable.

Fourth Maneuver:

Pelvic Grip

To determine the degree of flexion of

fetal head.

To determine attitude or habitus.

Facing foot part of the woman,

palpate fetal head pressing

downward about 2 inches above the

inguinal ligament.

Use both hands.

Good attitude if brow correspond

to the side (2nd maneuver) that

contained the elbows and knees.

Poor atitude if examining fingers

will meet an obstruction on the same

side as fetal back (hyperextended

head)

Also palpates infants anteroposterior

position. If brow is very easily

palpated, fetus is at posterior position

(occiput pointing towards womans

back)


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Provides a focus during contractions,

interfering with pain sensory transmission.

Begin with simple breathing patterns and

progress to more complex ones as needed. Promote relaxation and oxygenation.


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First stage (stage of dilatation)

2 to full dilation


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y Latent Phase

Cervical dilatation is 0 to4cm

Uterine contractionsoccur every 15 to 3omminutes and are 20 to 40second in duration and ofmild intensity

Mothe is talkative andeager to be in labor

Interventions

Encourage mother andpartner to participate incare

Assist with comfortmeasures changes ofposition (left sidelying), ambulation.

Keep mother andpartner informed ofprogress

Offer fluids and icechips

Encourage voiding every1 to 2 hours.


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Active Phase

Cervical dilatation is 4to 7cm

Uterine contractionsoccur every 2 to 5 mins.And are 30 to 50 secondsin duration andmoderate intensity.

Mother may experiencefeelings of helplessness

Mother becomes restlessand anxious ascontractions becomestronger

Interventions:

Encouragemaintenance of

effective breathingpatterns.

Provide a quietenvironment

Keep mother and

partner informed ofprogress.

Promote comfort withbackrubs, sacralpressure, pillowsupport and position

changes. Instruct partner in

effleurage/back rub


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Transition Phase

Cervical dilation is 7 to10cm

The uterine contractionsoccur every 2 to 3 minutesand are 45 to 90 seconds induration and of strongintensity.

Mother becomes tired, is

restless and irritable andfeels out of control

Interventions:

Envoucare rest betweencontractions

Wake mother at beginningof contraction so she can

begin breathing pattern Keep mother and partner

informed of progress

Provide privacy

Offer fluids and ice chipsand ointment dry lips

Encourage voiding every 1to 2 hours.


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Monitor maternal V/S

Monitor FHR via:

Doppler

Fetoscope

Electronic fetal monitor

Assess FHR before, during, and after contraction, noting that the normal FHR

is 120 to 160 bpm Monitor uterine contractions by palapation or monitor, determining frequency,

duration, and intensity.

Assess status of cervical dilataion and effacement.

Assess fetal station, presentation, and position by Leopolds Maneuvers.

Assist with pelvic examination and prepare for Nitrazine test and a fern test

Nitrazine test - used to test vaginal pH during late pregnancy to determine the

breakage of the amniotic sac.W

hile vaginal pH is normally acidic, a pH above7.0 can indicate that the amniotic sac has ruptured

Fern Test - test for estrogenic activity in which cervical mucus smears form afernlike pattern at times when estrogen secretion is elevated, as at the timeof ovulation.

Assess the color of the amniotic fluid if the membranes have ruptured becausemeconium-stained fluid can indicate fetal distress.


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> complete dilation to expulsion


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1. Assessment cervical dilation is complete

progress of labor is measured bydescent of fetal head through thebirth canal (changes in fetal station)

uterine contractions occur every 2 to3 minutes, lasting 60 to 70 75seconds, and the intensity is strong.

Increase in bloody show occurs

Mother feels urge to bear down,assist mother in pushing efforts.

Interventions:

Perform assessments every5minutes

Monitor maternal v/s

Monitor FHR Assess FHR before, during and after

contractions

Monitor uterine contractions bypalpation or monitor, determiningfrequency, duration, and intensity.

Provide mother withencouragement and praise and

provide rest between contractions Keep mother and partner informed

Maintain privacy

Provide ice chips and ointment fordry lips

Assist mother into a position thatpromotes comfort and assistspushing efforts, such as lithotomy,

semi-sitting,kneeling, side-lying, orsquatiting.

Monitor for sighs of approaching,birth, such as perineal bulging orvisualization of the fetal head.

Prepare for birth.


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- delivery of newborn to delivery of

placenta


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contractions occur untilthe placenta is born

placental separationand expulsion occur.

Birth of placental occursto 5 to 15 minutes afterbirth of the baby

Schultz mechanism:

margin of placentaseparates, and the dull,red, rough maternalsurface emerges fromthe vaginal first.

Duncan mechanism:

margin of placentaseparates, ans the dullred, rough maternalsurface emerges fromthe vagina first

Interventions: Assess maternal v/s

Assess uterine status

Provide parents with anexplanation regardingbirth of the placenta

Following birth of theplacenta, uterine fundusremains firm and is

located two fingerbreathsbelow the umbilicus

Examine placenta forcotyledons andmembranes to verify thatis intact.

Asses mother for shivering

and provide warmth Promote a parental-

neonatal attachement.


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Calkins sign - the change of shape of the

uterus from discoid to ovoid, indicating

placental separation from the uterine wall.

Lengthening of the cord Sudden gush of blood


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> placenta to hemostasis


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Assessment blood pressure returns to pre-labor

level

pulse is slightly lower than duringlabor

fundus remains contracted, in themindline,1 to 2 fingerbreadths belowthe umbilicus

Lochia (. Discharges from the vaginaof mucus, blood, and tissue debris,following childbirth.) is moderate orscant is red; vagina discharge withmucus

Lochia rubra bloody red in color,1-3 days after birth

Lochia serosa brownish 4-6 after

birth Lochia alba whitish in colo, 7-10

days after birth

Interventions:

Perform maternal assessmentsevery 15 minutes for 1 hour, every3o mins for 1 hour, and hourly for 2hours

Provide warm blankets

Apply ice packs to perineum

Massage the uterus if needed andteach the mother to massage theuterus

Provide breast-feeding support asneeded


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47385717 intrapartal care

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