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CARE AND MANAGEMENT OF THE INTRAPATAL WOMANI. Intrapartum CareA. Frgm the beginning of contractions to the first 1-$ hours after delivery.B. Referes to the medical and nursing care given to the pregnanp women during

labor and `elivery.

C. Admitting the labor mother:1. personal data2. baseline data3. obstetrical dada4. physic!l exam5. pelvic exam

I. Essential Knowledge of the Antrapartum ProcersA. Theories of thd onset of Labor:

1. Uterine Stretch Theory) any hollow organ once stretched to its maximumpotential will contr`ct and expel its content.

2. Prostaglandin Th%ori- due to stimulation of Arachidonic acid

prostaglandin as produce that cause uterus to contract and initaate labor.3. Progesterone Depriv!tion- sudden dr/p in progesterone near deliverYstimulates labor.

4. Theory of Aging Placenta- as the placental degeNerates, the bodyperceives it as a foreign body and expeds it by contraation.

5. Oxytocin Stimulation heory- the production of it by the poster)orpituitarq gland causes aontraction.

B. Tha 4Ps /f Labora. Passenger (fetus) Fetal head: Largest 0art of newb/rn body

(1/4 of length).b. Bones: Sphenoid, ethmoid, temporal, frontal or sinciput, occipital

or occiput, and parietal.c. Suture l)nes1. sagittal- connects 0 parietal bones

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2. coronal- connects parie4al and frontal3. lambdoid!l- parietal and occipital.*MOLDING- overlapping of sutures to permit passage of headto 0elviS.

d. Fontanels: 2 Are palpable

1. Bregma (ante2ior)- diamond, closes at 12-18 months2. Lambda (p/sterikr)- triangle, clos%s at 2-3 mmnths.2. Passageway (Vagina and Pelvis)

a. 42main pelvic types1. Gynecoid- round, wide, deeper most suitable for

pregnancy.2. Anthropoid- oval, ape-like pelvis. The APD: wide and TD:

narrow.3. 3. Android- heart shape male pelvis. Anterior: pointed

while posterior: shallow.4. Platypelloid- flat. APD: narrow and TD: wide.

b. Only the gynecoid and anthropoid types can deliver via normalspontaneous vaginal delivery (NSVD).c. Pelvic bones

1. Ileum- lateral/side of hips2. Ischium- inferior portion3. Pubis- anterior4. Sacrum- posterior5. Coccyx- 5 small bones that compress during vaginal

delivery.

3. Power- force to expel the fetus and placenta.a. Involuntary contractionsb. Voluntary bearing down effortsc. Wave like characterd. Timing: frequency, duration, intensity.

4. Psyche and Person- psychological stress.a. Cultural interpretation.b. Preparationc. Past experienced. Support system.

II. Normal Labor and DeliveryA. Pre-eminent Signs of Labor

1. Lightening- settling of presenting part into pelvic brim. Occurs 2 weeksprior to delivery in primi.

i. S.S: shooting pain in legs and urinary frequency.ii. Engagement : settling of presenting part into pelvic inlet.

2. Braxton Hicks Contractions- painless or irregular contraction.3. Increased activity of the mother

i. aka: Nesting instinct cause by epinephrine.

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ii. Nursing intervention: bed rest4. Ripening of the cervix- butter softness5. Decrease in weight- 1.5-3.0 lbs prior to labor6. Bloody show- pinkish vaginal discharge (leucorrhea, operculum,& blood)7. Rupture of membranes

i. Nsg Intervention: check FHTii. Check temp q 2hrs (Mother prone to infection after rupture)B. Difference between False and True Labor

False labor: Irregular contraction, no increase in intensity, pain is relieve bywalking, pain in abdomen, & no cervical changes.True Labor: Regular contractions, intensity increases, pain intensified by walking,pain in lower back radiating to stomach, and effacement and dilatation isoccurring.

C. Duration of Labor:1. Primipara- 14 hrs but not more than 20 hrs2. Multipara- 8 hrs but not more than 14 hrs.

D. Stages of Labor1. First Stage- onset of contractions to full dilatation & effacement of thecervix.

a. Divided into 3 phases: Latent, Active, & Transitionalb. Effacement- softening & thinning of cervical canal.c. Dilatation- widening of the external os to 10cm as a result of contraction,pressure of presenting part & the bag of water.d. Station- relationship of presenting part to the ischial spine.

*-3 to -5: fetus is 3-5 cim above the ischial spine and still floating.Nursing Care: Therapeutic rest.

*-1: 1cm above the ischial spine*0: fetus is at the level and is engaged.*+1 to +2: fetus is 1-2 cm below the ischial spine.*+3 to +5: crowning occurs, & signals the 2nd stage of labor.

e. Presentation- relationship of the log axis of fetus to the long axis of themother.

a. Longitudinal or Vertical Lie- 99% of all presentation.*Cephalic- 95%

**Vertex- fetus completely flexed.**Brow- Partial flexion or military attitude.**Chin- hyperextension**Face- poor flexion.

*Breech- 4%**Complete- thighs rest on abdomen while legs rest on thighs.**Incomplete

a. Frank- thighs rest on abdomen while leg extend to head.b. Footlingc. Kneeling-

b. Transverse- shoulder presentation (1%)

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f. Position- Relationship of fetal presenting part to mothers quadrant.*LOA- most common, favorable* For breech, place stethoscope above umbilicus when monitoring FHT.*LOP & ROP- malposition, most painful. Put mother in squatting position

to lessen low back pain.

g. Monitoring the contractions & FHTs:> Best time to get MBP & FHT is midway of contractions.*Contraction- blood vessel constrict that increases MBP and

decreases FHT.*Placental reserve of O2 last only 60sec, so duration of

contractions should not exceed 60 sec.* Contractions of more than 60 sec may lead to fetal distress.

Signs of Featal Distress:a. FHT of 160 bpm.b. Meconium-stained amniotic fluid.c. Fetal Thrashing- hyperactivity of fetus due to lack

of O2.g. Health Teachings:1. take BP is mother complains of headache.2.Encourage to bathe.3. Prohibit food intake as GIT stops to function during labor.4. Administer enema as needed.5. Maintain on left Lateral Position to prevent Supine Hypotension

i. Maternal Analgesia and Anesthesia1. Narcotic & analgesic drugs (per doctors order)

a. Meperidine HCL (Demerol)- fast-acting, given during activephase of labor when cervix is 5-6cm dlated.

2. Fentanyl (Sublimaze)- same with Demerol but faster and short acting3. Butorphanol (Stadol)- potentiates the effect of other narcotics.4. Nalbuphine (Nubain)- 5-10mg SC or IV q2-3h.5. Epidural Anesthesia- regional, placed into epidural space of L2 and L4.

-cause loss of sensation, birth is slow and easy to control.6. Spinal Anesthesia- local, placed into CSF and useful in CS birth.

2. Second Stage- complete dilatation and effacement to birth of baby (FetalStage)

i. Multipara: 7-8 cm dilatedii. Primipara: 10cm

iii. Lithotomy & Dorsal recumbent position.iv. Bulging of perineum- surest sign the baby is about to be delivered.v. Breathing exercises.

vi. Push with an open glottis to prevent hypotension.vii. Prevent hyperventilation which leads to respiratory alkalosis.

viii. S/S:1. Shallow rapid RR2. Light headedness

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3. Circumoral numbness4. Carpopedal spasm5. Tingling sensation.

ix. Nsg Intervention: mother breath into a paper bag to rebreath lostCO2.

2 Major Division of Pelvis:a. True Pelvis- below pelvic inletb. False Pelvis- above pelvic inlet, supports uterus during

pregnancy.

Engagement- head enters the pelvic inlet in the transverse biparietaldiameter.

g. Mechanisms of Labor (D-F-IR-E-ER-E)1. descent2. flexion3. Internal Rotation

4. Extension5. External Rotation6. Expulsion

h. EpisiotomiesTypes:1. Median- from middle portion of the lower vaginal border directed

towards to anus.2. Mediolateral- begun in the midline but directed laterally away from the

anus.Types of Anesthesia:1. Natural- no anesthetic is injected, done during episiotomy.2. Pudendal- local, administered during 2nd stage of labor.

3. Third Stage-birth of the baby up to expulsion of placenta. (Placental

Stage)

a. Care of the Baby1. Clear airway of mucus.2. APGAR scoring3. Keep thermoregulated4. Assess for visible abnormalities5. Administer eye antibiotic.

b. Assist with the delivery of placentac. Palpate the uterus to determine degree of contraction.d. Check v/s especially the BP.e. Administer medications as ordered- methergine and oxytocin.f. Inspect the perineum for lacerations.g. Assist physician in doing episioraphy

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4. Fourth Stage- the first 1-2 hours after placental delivery (Recovery Stage)a. Monitor v/sb. Fundus at the same height with umbilicus.c. Palplate fundus every 15 minutes for firmness.d. Monitor mother as body gradually regains homeostasis.

i. Lochia- post-partum vaginal dischargeii. Observe perineum for: (REEDA)1. Redness2. Edema3. Ecchymosis4. Discharges5. Approximation

e. Make mother comfortablef. Promote maternal-infant bondingg. Adhere to Rooming-in concept

III. Complicated Labor and DeliveryA. Premature Rupture of Membranes- rupture of amniotic sac prior o onset of labor.B. Cord Prolapse- a complication when the umbilical cord falls or is washed through

the cervix into the vagina.C. Dystocia- abnormal or difficult labor and delivery due to mechanical factors as a

result of any of the ff during labor:a. Abnormalities of expulsive forces (power).b. Abnormalities of presentation, position, or development of the fetus

(passenger).c. Abnormalities of the maternal bony pelvis or birth canal (passageway).

D. Uterine Inertia- sluggishness or contractions.E. Prolonged Labor- labor more than 20 hours for primigravidaas and more than 14

hours for multigravidas.Attributing factors:

a. Possible cephalopelvic disproportion (CPD).b. Malpresentations of the fetal head.c. Posterior presentation of the baby.d. Brow presentatione. Face presentationf. Uterine atonyg. Uncoordinated uterine actionh. Maternal exhaustioni. Maternal hypoglycemiaj. Cervical dystociak. Cervical adhesionsl. Psychological factorsm. Tight nuchal or short cordn. Compressed cordo. Compound or nuchal arm.

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F. Precipitate labor- labor and delivery that is completed in less than 3 hours afterthe onset of true labor pains. Probably due to multiparity or following oxytocinadministration or amniotomy.

G. Inversion of Uterus- fundus is forced through the cervix so that the uterus isturned inside out.

H. Amniotic Fluid Embolism/Anaphylactic Syndrome of Pregnancy- occurs whenamniotic fluid is forced into an open maternal uterine blood sinus.I. Uterine Rupture- occurs when the uterus undergoes more strain than it is capable

of straining.J. Trial Labor- if a woman has just adequate pelvic measurements but fetal position

and presentation are good, labor may be continued for as long as there isprogressive fetal descent of the presenting part and cervical dilatation.

K. Preterm Labor- labor after 20 weeks and before 37 weeks.