Intrapartal Nursing Care: Labor and Birth

Linda L. Franco RN MSN NE-BCGreen = must know

Red = Important to knowBlue = history

Factors Important to Birth

• Birth Passage• Baby• Relationship Between the Passage and the

Baby• Physiologic Forces of Labor• Psychosocial Considerations

Birth Passage

• Consists of bony pelvis and soft tissues• Bony Pelvis– False pelvis above linea terminalis– True pelvis below linea terminalis

• Types of pelvis– Gynecoid – female, most common – Android – male, usually not adequate– Anthropoid – narrow from side to side, usually

adequate– Platypelloid – narrow from back to back, usually not

adequate

Pelvic Types

Fetal Head

• Composed of bony parts that can assist or hinder childbirth

• Bones involved in birth not fused– 2 frontal bones– 2 parietal bones– occipital bones

• Sutures – membranous spaces between cranial bones

Fetal Skull

Fontanelles

• Intersections of the cranial sutures• Used in identifying position of fetal head and

assessing newborn after birth– Anterior Fontanelle, diamond shaped, closes by 18

months– Posterior Fontanelle, triangle shaped, closes by 2–

3 months

Landmarks of Fetal Skull

• Mentum – fetal chin• Sinciput – brow• Bregma – anterior fontanelle• Vertex – between anterior and posterior

fontanelles• Occiput – occipital bone

Diameters

• Biparietal – major transverse diameter, average 9.25 cm

• Anterior-Posterior – varies with how much head is flexed, most favorable when head is fully flexed

• Fetal Attitude – position of fetus • Fetal Lie – position of fetus compared to mother– Longitudinal– Transverse

Fetal Presentation

• Cephalic (most common, what we want, occurs 97% of the time)– Vertex – occiput is presenting part (most

common)– Military – head is in neutral position, top of

head is presenting part– Brow – head partially extended, brow is

presenting part (tough on baby’s neck, could have neck or shoulder injuries during delivery)

– Face – head hyperextended, face is presenting part

Fetal Presentations con.

• Breech (occur in 3-4% of all births)– Complete – both knees are flexed, buttocks and

feet present. Kind of sitting indian style– Frank – buttocks presents to pelvis, legs are

usually up in front of the baby’s face– Footling – one or both feet present to pelvis

• Shoulder Presentation– Aka Transverse Lie, occurs in 0.3% of all births,

shoulder, arm, back, abd, or side is presenting. In this case a C-section will be performed

Transverse Lie

• External Version– Where they have the mom lay on her back in the

exam room and the dr tries to make the baby move just by pushing it and turning the baby. Usually doesn’t work

• Cesarean Section– They will usually do this on these babies

• Assess FHR– To make sure the baby isn’t in distress

Engagement

• When largest diameter of presenting part reaches or passes through pelvic inlet– If the baby is engaged it’s starting to drop down…

the top part of the pelvis is adequate, but they may still have to have a c section

– Primigravida – 2 weeks before term– Multigravida – several weeks or at onset of labor

Station

• Relationship of presenting part to an imaginary line drawn at the ischal spines (ischial spines mark the narrowest part thru which a baby must pass)– Zero station at level of ischial spines– Negative numbers above ischial spines• Baby hasn’t passed them yet

– Positive numbers below ischial spines • After they’ve reached the spines and the baby’s head is

descending

Station

Fetal Position

• Relationship of the landmark on the presenting part to the maternal pelvis– Left (L) or Right (R) – Vertex – Occiput (O) (this is the one we want)– Face – Mentum (M)– Breech – Sacrum (S)– Shoulder – Acromion process (A)– Anterior(A), Posterior (P), or Transverse (T)– Could say LOP for left occiput posterior

Forces of Labor

• Primary - uterine contractions– Increment – building up to the contraction, longest phase– Decrement – the decline or letting up of the contraction– Frequency – time between the beginning of one to the

beginning of the next– Intensity – refers to the strength of the contraction at the

peak. Measured by palpating the fundus something or other• mild, moderate, and strong

– Duration – from the beginning of a contraction to the end of that contraction

Psychosocial Considerations

• New role transition• Self expectations• Coping mechanisms• Support systems• Preparation for childbirth• Cultural influences• Fear• Enhancing birth experience

Psychosocial Factors

Physiology of Labor

• Causes– Hormones

• Progesterone – relaxes smooth muscle tissue• Estrogen – promotes uterine contractions, also helps soften

connective tissue which leads to the opening of the cervix• Oxytocin • Prostaglandins• Fetal Cortisol• Corticotropin-Releasing Hormone

– Uterine Distention– Myometrial Activity– Intraabdominal

Premonitory Signs of Labor• Lightening – when the fetus begins to setting into the pelvic inlet, the uterus moves

downward and the fundus no longer presses on the diaphragm, the mom can breathe easier. Also causes leg cramps, increased pelvic pressure and increased urine frequency, and increases venous stasis which causes swelling of their lower extremities. Increased vaginal secretions resulting from congestion of the vaginal mucosa

• Braxton Hicks – irregular intermittent contractions that occur thru ought pregnancy. Can be uncomfortable and exhausting to the mom

• Cervical changes – at beginning of pregnancy it is firm, and over time it stretches and dilates. The softening of the cervix is called ripening

• Bloody show – the mucus plug is expelled and the result of that is small amount of blood loss from the exposed cervical capillaries. That blood tinged secretion is called the bloody show. Usually a sign that labor will begin in 24-48 hours

• Rupture of Membranes – when the membranes do rupture the ambiotic fluid may be expelled in large amounts… when you’re water breaks. Sign of impending labor, once this happens the woman can’t get up and walk around

• Sudden burst of energy – very common, approx 24-48 hours before labor, no one really knows why they have this. May experience “nesting” at this time.

• Other vague signs – weight loss of 1-3 lbs may occur, diarrhea, indigestion, N/V may occur before labor, cause is unknown

True and False Labor

• True– Regular contractions– Cervical changes– Contractions start in

back and radiate around to abdomen

– Pain not relieved with activity

• False– Irregular contractions– No cervical changes– Contractions primarily in

abdomen– Pain may be relieved

with activity

Stages of Labor• Stage One – Effacement and Dilatation– Latent Phase – 0-3 cm; able to cope, talkative, high excitement,

uterine contractions become established. Effacement begins, but little or no fetal descent

– Active Phase – 4-7 cm; sense of helplessness, begins to fear loss of control, pain level is much worse at this level and you can see them kind of getting to the end of their rope. Contractions are usually 2-3 mins apart and last about 60 seconds and very strong in intensity

– Transition Phase – 8-10 cm; significant anxiety, fears being left alone, feels she may be torn apart, contractions are 1.5-2 mins with duration of 60-90 seconds. As it approaches 10 there is increased pressure and a desire to “bear down” and maybe increase in bloody show. Sometimes these moms get the urge to push and we have to tell them not to because it’s too early. If they push and bear down it can cause the cervix to swell which slows the process because we have to wait for that swelling to go away to birth the baby

Stage Two – Maternal Pushing

• Begins with complete cervical dilation and ends with the birth of the baby

• Maternal urge to push• May feel relieved that birth is imminent• Apologetic• Primagravidas – 2-3 hours• Multigravidas – 5-30 mins

Cardinal Movements of Fetal Head• Descent – occurs because of 1 pressure of amniotic fluid, 2 direct

pressure of the uterine fundus, 3 contractions of the abd muscles, 4 straightening of the fetal body

• Flexion- flexion of the baby’s head because of resistance from the soft tissue of the pelvis, the pelvis floor, and the cervix

• Internal Rotation – the fetal head must rotate with the diameter of the pelvic cavity which is widest in the anterior posterior diameter

• Extension – the resistance of the pelvic floor and the mechanical movement of the vulva opening anteriorly and forward with extension of the fetal head as it passes under the symphysis pubis

• Restitution – the shoulders of the fetus enter the pelvis inlet something or other. Because of this rotation the pelvis the neck becomes twisted. Basically the baby’s head becomes twisted around

• External Rotation – as the shoulders rotate the head turns further to one side

• Expulsion – the shoulder moves under the symphysis pubis.

• On pg 391 and she’s reading it word for word

Stage Three – Delivery of PlacentaPlacental Separation

Globular shaped uterusRise in fundus in abdomenSudden gush of bloodFurther protrusion of the umbilical cordSigns usually start after about 5 mins after the birth of the baby. When these

signs start appearing the woman may feel the need to bear down again. Firm pressure may be applied to the fundus and gentle tugging on the cord to get it out

Placental DeliveryMaternal pushing can assist deliveryRetained if > 30 minutesShiny Schultze – inside outDirty Duncan – outer edge to insideIf the placenta or a piece of it is still stuck inside the mom there will be tons of

bleeding

*placenta is only made correctly for about 40 weeks and after that it’s kind of shitty

Stage Four - Recovery

• Recovery 1-4 hours• Hemodynamic changes – In the mom and in the baby, but really looking at mom…

• Blood loss of 250 – 500 ml’s• Decreased blood pressure– Along with increase in pulse pressure and moderate

tachycardia, because of the blood loss mentioned above• Fundus between symphysis and umbilicus• Fatigued, thirsty and hungry• Bladder hypotonic – Check mom for bladder fullness if they aren’t able to

void

Maternal Systemic Response to Labor

• Cardiovascular– Stressed by Uterine Contractions

• Pain, anxiety, apprehension– Increased cardiac output

• 300-500ml blood forced back into maternal circulation with each contraction

• BP increases with uterine contractions– Position lowers cardiac output

• Supine cardiac output• Left lateral BP

Maternal Response con. • Respiratory– Oxygen demand increases– Hyperventilation may occur

• Because of stress and pushing and what not• Fall in pH O2 and respiratory alkalosis may occur

– Pushing increases lactate levels– S/S of hyperventilation

• Tingling/numbness in nose, lips, fingers or toes, might have them breathe into a paper bag

• Renal system– maternal renin, plasma renin, and angiotensiogen –

important in uteroplacental blood flow– Trauma to bladder– Blood and lymph drainage impaired from presenting part

Maternal Response con.• GI system– Gastric motility and absorption – Emptying time is causing risk of aspiration– Glucose levels causing insulin levels– More food in their stomach which sometimes comes

up…

• Immune system– WBC 25 – 30,000 stress response

Pain• Causes of pain– Dilatation of cervix– Hypoxia of uterine muscle

• This is what causes pain. When they are contracting as hard as they can contract they’re not getting oxygen which will cause pain

– Stretching of lower uterine segment– Pressure on adjacent structures– Distention of vagina– Uterine contractions– Delivery of placenta– Episiotomy repair

Factors Affecting Response to Pain

• Preparation for birth – childbirth classes• Respond by what is acceptable to culture– Some cultures it’s ok for woman to go nuts and yell,

some cultures they’re supposed to be stoic and not express pain. Sign of weakness or whatever, but this doesn’t mean that they aren’t feeling pain.

• Fatigue and sleep deprivation– Fatigued woman has less energy and it will be harder to

get them to focus on what we need them to do. • Previous experience• Anxiety

Fetal Response to Labor• Heartrate changes– Early decelerations

• intracranial pressure causes vagal response• During labor

– Late decelerations• uteroplacental blood flow

– Variable decelerations• Cord compression

• Acid-Base Status in Labor– As uterine contractions increase, pH decreases slowly in

response to hypoxia– Blood flow is decreased to the baby during contractions

• Hemodynamic changes– Fetal BP and placental reserves protective mechanism during

anoxic periods