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University of Santo Tomas

College of Nursing S.Y. 2018-2019


COMPETENCY APPRAISAL

INTRAPARTUM

Submitted by:
Josue, Reinier Hannah F.
Joven, Ernesto Steven Domingo U.
Jugo, Kate Guillan A.
Jurado, Carmella Expectacione P.
Lavadia, Dorothy Rose D.
Legaspi, Andrea Ceejay E.
Lerma, Maria-Jayne B.
Libunao, Camille Grace B.
Licas, Lexin Louie T.
Ligon, Charles Justine P.
Guevarra, Suina Mari
4 NUR-5

Submitted to:
Ma’am Cecilia Buenaflor
on
November 22, 2018
COMPONENTS OF THE BIRTH PROCESS

4 P’s OF LABOR

1. POWER
 Uterine contractions (Involuntary)
 During the first stage of labor (onset to full cervical dilation) uterine contractions are the
primary force that moves the fetus through the pelvis.
 Maternal Pushing Efforts (Voluntary)
 During the second stage of labor (full cervical dilation to birth of the baby), uterine
contractions continue to propel the fetus through the pelvis. In addition, the woman feels
an urge to push and bear down as the fetus distends her vagina and puts pressure on her
rectum. The woman her voluntary pushing efforts to the force of uterine contractions in
the second-stage labor.

CASE:
-Contractions and additional efforts helps for pushing. Contractions need to be strong enough to
dilate the cervix and aid the baby in his decent. They need to be at regular intervals, moving
closer together and increasing in strength throughout labor.
-Uterine contractions may be infrequent, hypotonic, or uncoordinated such that they are unable
to dilate the cervix.
-Maternal exhaustion that can result in ineffective maternal expulsive efforts in the second stage.
-Ineffective maternal pushing effort

2. PASSAGE
 The birth passage consists of the maternal pelvis and soft tissues
 The bony pelvis is usually more important to the outcome of labor than the soft tissues
because the bones and joints do not readily yield to the forces of labor.
 The linea terminalis (pelvic brim) divides the bony pelvis into:
 False pelvis (top) – provides support for the internal organs and the upper part of the
body
 True pelvis (bottom)
-Inlet (upper pelvic opening) – T (13.5 cm); AP (11.5 cm or <)
-Midpelvis (pelvic cavity) – narrowest part; T (10.5 cm); AP (12 cm)
-Outlet (lower pelvic opening) – T (11 cm); AP (9.5-11 cm); PS (11 cm); functions like a
curved cylinder with different dimensions at different levels.
CASE:
-Possible prominent ischial spines or a narrow pubic arch that may impede progressive descent
of the fetus.
-Cephalopelvic disproportion - disparity between the pelvic architecture or size and the fetal
head that precludes vaginal delivery.
-Failure of engagement
3. PASSENGER
 The passenger is the fetus, membranes, placenta, blood and amniotic fluid
 Fetal Head (Transverse Diameter):
 Biparietal – 9.5 cm
 Bitemporal – 8 cm
 Bimastoid – 7 cm
 Occipitofrontal – 12 cm
 Occipitomental – 13.5 cm
 Suboccipitobregmatic – 9.5 cm
 Submentobregmatic – 9.5 cm
 Suboccipitomental – 13.5 cm
 Variations in the Passenger:
 Fetal Lie – longitudinal (96%), transverse (3%), oblique (1%)
 Fetal Attitude – flexion; “C shaped”
 Fetal Presentation:
- Cephalic – vertex, military, brow and face
- Breech – full, footling and frank
- Shoulder
 Fetal Position:
- 1st letter – Right (R) or Left (L)
- 2nd letter – Occiput (O), Mentum (M), Sacrum (S) or Scapula (SC)
- 3rd letter – Anterior (A, Posterior (P) or Transverse
CASE:
-Large for Gestational Age baby
-Fetal malpresentation or malposition.
-The baby needs to be positioned properly to make it through the pelvis.
-The optimal position for birth is Occiput Anterior (OA).

4. PSYCHE
 A woman’s psychological response to labor and birth are influences by:
 Anxiety – Maternal catecholamines are secreted in response to anxiety and fear can
inhibit uterine contractility and placental blood flow
 Culture and Expectations – A woman’s culture affects her values, expectations for and
responses to birth and the practices surrounding it.
 Life experiences – Childbirth is a physical and emotional experience. The woman’s past
experiences with childbirth, pain, personal success and failure will influence her
expectations for this birth
 Support – It includes physical comfort measures, providing information, advocacy, praise
and reassurance, presence and the maintenance of a calm and comfortable environment.
CASE:
-The mother might possible is afraid, tense, stressed out, angry, feels unsafe or unsupported
during birth.
-A good emotional state helps mom to: (1) cope with the pain effectively; (2) tune in to her body;
(3) guide her to her baby’s needs and allows the other 3 P’s to sync up effectively.

Arrest in Cervical Dilation

- It is diagnosed when there has been no change in cervical dilation for at least 2 hours.
- Stage 1 (Dilation) Active phase arrest
o Cervix is dilated to >6cm
o Prolonged/protracted if cervical dilation is <1.2cm/hour (primipara) or
1.5cm/hour (multipara)
o Arrest if no cervical change in > 4 hours with adequate contractions or > 6 hours
with inadequate contractions
Treatment
- Amniotomy: it is a procedure performed to release fluid from the amniotic sac to induce
labor during childbirth.
- Oxytocin: Increases contraction strength and frequency; administer until contractions
deemed adequate by frequency, intensity and duration measures
o If mother does not respond to oxytocin  Cesarean Section
- Morphine: if hypertonic contractions

Contracted Pelvis
- A contracted pelvis may be defined as one in which there is alteration in the size and
shape of the pelvis of sufficient degree so as to alter the normal mechanism of labor in
an average size baby.

Four types of Pelvis


- Gynecoid – most optimal for normal delivery
- Android
- Anthropoid
- Patypelloid

Factors influencing the size and shape of the pelvis


- Nutritional and environmental defects
o Rachitic- a flat pelvis distorted as a result of rickets
o Osteomalacia- softening of the bones, typically through a deficiency of vitamin
D or calcium
o Malnutrition
o Diseases or injuries- fracture, tumor, TB, poliomyelitis, hip joint disease
- Developmental Defects
o Naegele’s pelvis- an obliquely contracted pelvis in which the conjugate diameter
assumes an oblique direction. (infancy)
o Robert’s pelvis- narrowed transversely due to the almost entire absence of the
alae of the sacrum
o Kyphotic pelvis- a deformed pelvis associated with a kyphotic deformity of the
spine.
- Sexual factor: excessive androgen may produce android pelvis
- Congenital or hereditary
Diagnosis
- Medical History- Fracture, tumor, TB, poliomyletis, hip joint disease
- Obstetric History-
o Previous prolonged labor
o Previous still birth
o Baby born with asphysia
o History of neonatal convulsion and mental retardation
o Instrumental delivery
o Maternal injury
o Appearance of the patient
- Small stature
- Pendulous abdomen
- Exaggerated spinal curvature
- Deformities of the limb
- Abdominal examination
- Vaginal examination
- Clinical pelvimetry

Complications of Prelabor Rupture of Membranes


 Early delivery is the most common complication of PROM. 95% of women with PROM at
term will go into labor within 24 hours. According to research by the American Congress of
Obstetricians and Gynecologists, PROM is associated with one third of all preterm births.
Other studies have demonstrated that 57% of patients with midtrimester pPROM (between 16
and 24 weeks) deliver within a week.
 Infection in the woman (chorioamnionitis [intra-amniotic infection]), neonate (sepsis), or
both. Group B streptococci and Escherichia coli are common causes of infection. Other
organisms in the vagina may also cause infection.
 Fetal dystocia. Abnormal fetal size or position resulting in difficult delivery.
 Abruptio placentae. Premature separation of a normally implanted placenta from the uterus,
usually after 20 wk gestation. It can be an obstetric emergency.
 Umbilical cord compression. After a premature rupture of membranes, the umbilical cord is
no longer cushioned by the amniotic fluid, and can become compressed (or flattened). In
some cases, the umbilical cord may also slip out of the birth canal in front of the baby,
becoming compressed between the presenting part of the baby (usually the head) and the
mother’s vaginal canal. This is known as cord prolapse. Cord prolapse and other forms of
compression are dangerous because the flow of oxygen-rich blood to the baby is interrupted,
and the baby may experience dangerous complications.
 Death of the baby
 Respiratory distress syndrome

Purpose of the Amniotic Fluid


- The amniotic fluid is a clear, yellow fluid which is found within the first 12 days following
conception within the amniotic sac. It surrounds the growing baby in the uterus. It is responsible
for:
• Protecting the fetus: The fluid cushions the baby from outside pressures, acting as a shock
absorber.
• Temperature control: The fluid insulates the baby, keeping it warm and maintaining a regular
temperature.
• Infection control: The amniotic fluid contains antibodies.
• Lung and digestive system development: By breathing and swallowing the amniotic fluid, the
baby practices using the muscles of these systems as they grow.
• Muscle and bone development: As the baby floats inside the amniotic sac, it has the freedom to
move about, giving muscles and bones the opportunity to develop properly.
• Lubrication: Amniotic fluid prevents parts of the body such as the fingers and toes from
growing together; webbing can occur if amniotic fluid levels are low.
• Umbilical cord support: Fluid in the uterus prevents the umbilical cord from being compressed.
This cord transports food and oxygen from the placenta to the growing fetus.
So, when the waters break, the amniotic sac tears. The amniotic fluid contained within the sac
then begins to leak out via the cervix and vagina.

Laboratory and Diagnostics


CBC and Urinalysis
- A CBC counts the numbers of different types of cells that make up the blood. The
number of red blood cells can show whether it has a certain type of anemia. The number
of white blood cells shows how many disease-fighting cells are in the blood, and the
number of platelets can reveal whether there is a problem with blood clotting.
- Urine may be tested for red blood cells (to see if there is urinary tract disease), white
blood cells, and glucose (high levels may be a sign of diabetes mellitus). The amount of
protein also is measured. The protein level early in pregnancy can be compared with
levels later in pregnancy. High protein levels in the urine may be a sign of preeclampsia,
a serious complication that usually occurs later in pregnancy or after the baby is born.
CBG
- This screening test measures the level of glucose (sugar) in your blood. A high glucose
level may be a sign of gestational diabetes. This test usually is done between 24 weeks
and 28 weeks of pregnancy. If you have risk factors for diabetes or had gestational
diabetes in a previous pregnancy, screening may be done in the first trimester of
pregnancy.
Blood Typing
- Results from a blood type test can show Rh factor. The Rh factor is a protein that can
be present on the surface of red blood cells. Most people have the Rh factor—they are
Rh positive. Others do not have the Rh factor—they are Rh negative. If the fetus is Rh
positive and you are Rh negative, your body can make antibodies against the Rh factor.
In a future pregnancy, these antibodies can damage the fetus’s red blood cells.
Fetal Heart Monitoring
- Fetal heart rate monitoring measures the heart rate and rhythm of your baby (fetus).
This lets your healthcare provider see how the baby is doing. Healthcare provider may
do fetal heart monitoring during late pregnancy and labor. The average fetal heart rate is
between 110 and 160 beats per minute.
Contraction Monitoring
- Cardiotocography (CTG) is used during pregnancy to monitor the fetal heart and
contractions of the uterus. It is most commonly used in the third trimester. Its purpose is
to monitor fetal well-being and allow early detection of fetal distress.
Internal Exam
- Dilation – or how open the cervix is. This is measured from 1 to 10 centimetres (10 cm
being fully open or fully dilated).
- The consistency of the cervix. Is it soft, stretchy and yielding – often referred to as ripe
or favourable. Or is it firm and tight rimmed often called unripe during late pregnancy.
- The position of the cervix. During pregnancy the cervix leans towards the back (or
posterior) behind the baby’s head. This often makes it difficult for the caregiver to
reach. As the cervix ripens (and during labour) it moves forward towards the front,
making it more accessible for the caregiver and indicating progress is being made.
- The estimation of how far the baby’s head has come down into the pelvis. This is called
the station and is measured from minus 3 (- 3), meaning the baby’s head is high and not
engaged, to plus 3 (+3), where the baby’s head can be seen at birth. Most babies’ heads
are at minus 2 at the beginning of labour and 0 to +1 when the pushing starts.
- The effacement. This is how thin the cervix feels and is measured in percentages from
0% to 100%. 0 % is when the cervix is long and thick, 100 % is when the cervix is
paper thin, when most of it has been pulled up and absorbed into the lower segment of
the uterine wall.
-
NURSING CARE PLAN

SCIENTIFIC
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIO
RATIONALE
N

Objective: Risk for Dystocia refers After This will be helpful in After
maternal to difficult labor administration identifying possible causes, administration
injury related which is usually of nursing needed diagnostic studies, of nursing
VS as follows: to mechanical due to uterine interventions, Review the history of and appropriate interventions,
obstruction to dysfunction, the client will labor, onset, and interventions. the client
fetal descent fetal manifest: duration. manifested:
malpresentation
-HR: 110-
or abnormality
120/min A rigid or unripe cervix will
or pelvic
-cervix dilation not dilate, impending fetal -cervix dilation
-RR: 24/min abnormality.
at least 1.2 descent/labor progress. at least 1.2
cm/hr for Note the condition of Development of amnionitis cm/hr for
-T: 38 degrees
primipara, 1.5 cervix. Monitor for signs is directly related to length primipara, 1.5
celcius
cm/hr for of amnionitis. Note of labor, so that delivery cm/hr for
multipara in elevated temperature or should occur within 24 hr multipara in
active phase, WBC; odor and color of after rupture of membranes. active phase,
(+) ruptured bag with fetal vaginal discharge. with fetal
of water descent at least descent at least
1 cm/hr for 1 cm/hr for
Excess maternal exhaustion
primipara, 2 primipara, 2
contributes to secondary
(+) thinly stained cm/hr for cm/hr for
dysfunction, or may be the
meconium multipara. Evaluate the current level multipara.
result of prolonged
discharge/vagina of fatigue, as well as labor/false labor.
activity and rest prior to
onset of labor.
For *E* CS These indicators of labor
delivery progress may identify a
contributing cause of
Note effacement, fetal prolonged labor.
station, and fetal
presentation.

May be used on occasion to


record progress/
prolongation of labor.
Graph cervical dilation
and fetal descent against
time
A full bladder may inhibit
uterine activity and interfere
with the fetal descent.
Encourage client to void
every 1–2 hr. Assess for
bladder fullness over
symphysis pubis.
Relaxation and increased
uterine perfusion may
correct a hypertonic pattern.
Place client in lateral Ambulation may assist
recumbent position and gravitational forces in
encourage bed rest or stimulating normal labor
sitting position/ pattern and cervical
ambulation as tolerated. dilation.

May indicate developing


uterine tear/acute rupture
necessitating emergency
Investigate reports of surgery. Note: Hemorrhage
severe abdominal pain. is usually occult since it is
Note signs of fetal intraperitoneal with
distress, cessation of hematomas of the broad
contractions, and ligament.
presence of vaginal
bleeding.
Rupture of membranes
relieves uterine over
distension and allows
Prepare client for presenting part to engage
amniotomy, and assist and labor to progress in the
with the procedure, when absence of cephalopelvic
the cervix is 3–4 cm disproportion.
dilated.

Oxytocin may be necessary


to increase or institute
myometrial activity for a
Use nipple stimulation to hypotonic uterine pattern.
produce endogenous
oxytocin or initiate
infusion of exogenous
oxytocin (Pitocin) or
prostaglandins. May help distinguish
between true and false
labor. Morphine helps
Administer narcotic or promote heavy sedation. A
sedative, such as period of rest conserves
morphine, pentobarbital energy.
(Nembutal) for sleep as
indicated.