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INTRAPARTAL PERIOD

Intrapartum
From

onset of contractions, dilation of cervix up to first 4 hours after delivery products of conception are expelled

All

(baby, placenta and fetal membranes)

Intrapartum Care care during labor and delivery

LABOR
Fetal

expulsion along with products of conception due to: regular, progressive & frequent uterine contractions

Parturient

woman in labor Puerpera woman who gave birth

LABOR ONSET
a. b.

c.
d. e.

Stretching of uterine muscles progesterone Release of oxytocin Maturity of placenta prostaglandin Contraction of Uterus Expel products of conception

Preliminary Signs of Labor


a. b. c. d. Lightening Weight loss Braxton Hicks Contraction Apprehension & Restlessness

TRUE LABOR

Regular , frequency, intensity & Shorter Interval of contractions

Pain = Back discomfort radiating to abdomen & legs Intensified by Walking Bloody show

Rupture of amniotic membranes Effacement and Dilatation

Contractions persist during sleep & sedation

4 Stages of Labor
1. 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 Ps)


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

1. Passageway (Pelvis)
leaving the uterus Ischial spines = degree of descent (station) of fetal head Above ischial spine - station Floating (unengaged) Ischial spine station 0; engaged Below ischial spine + station
maternal pelvis Route of fetus when

Pubis = front portion = 2 pubic bones meet at symphysis pubis Estrogen & Relaxin = Relaxes the symphysis pubis Slight separation allowing room for the fetal head

1.

3. Platypelloid - Normal female pelvis - Flat - Round & wide - Good vaginal delivery - Poor vaginal delivery
2. Anthropoid - Narrow, oval - Like ape pelvis - Good Vaginal Delivery

Gynecoid

Pelvic Types

4. Android - Heart-shaped - like male pelvis - Poor vaginal delivery

2. Passenger
Refers to fetus Fetal head

BROW From nose to anterior fontanel

consists of :

vault, face & brow

FACE From chin & neck to root of nose

Vault of fetal head is composed of:

Frontal Bones forehead

Parietal Bones crown of head

temporal Bones side of head 1 Occipital Bones back of head

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 Lambda Small, triangle shape Bony floor Formed by 3 bones (2 parietal & 1

parietal)

occipital bones)

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

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

3. POWER

Force of uterine Refers to:

contractions

Intensity Duration Frequency Interval

of uterine contractions to result in cervical effacement & dilation

PRIMARY POWER
Uterine

SECONDARY POWER
Maternal

contractions

down (readiness for pushing)


Intra-abdominal

bearing

pressure

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
a.

Monitor contractions Rest a hand on womans abdomen at the fundus of uterus

Sense the gradual tensing and upward rising of fundus that accompanies 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, cant 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 of its original length 50% = cervix is of its original length

b. Intra-abdominal pressure
This As

is another secondary power

the woman pushes, the intraabdominal 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 Calkins 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 (Credes maneuver) Brandt andrews maneuver downward sideways gentle controlled cord traction

Credes Maneuver

Brandt Andrews Maneuver

Schultze placenta (80%)

Duncan placenta (20%)


Separates at center & fold (inverted umbrella)

Separates at its edges Umbrella shaped Maternal surface exposed Rough, red, raw & irregular from ridges

fetal surface exposed Shiny & glistening


Less external bleeding; blood is concealed behind the placenta

More external bleeding Appears bloody

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 Leopolds - 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 - Johnsons rule Iodine rich foods - bartholomews rule Heartburn/pyrosis - naegeles rule Anemia - haases rule Kegels exercise - mc donalds 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 depression Groaning Sweating

Nonpharmacologic measures

Read Method Slow abdominal breathing in 1st stage of labor: 1 breath/minute (30 sec inhalation & 30 sec exhalation)

Bradley Method Husband-coached Modification of Read method Lamaze Method

breathing, effleurage, relaxation

Use of panting to prevent pushing until needed

Blocks recognition of pain

Lamaze

breathing techniques controlled 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


mild to moderate discomfort

For

Distraction Diversion of attention - early labor Playing games or recalling pleasant experiences Yoga Deep-breathing exercises, body stretching postures and meditation

helping the body relax and possibly releasing endorphins

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.

Pharmacologic measures a. Opioids b. Sedatives c. Anesthetics: Epidural Spinal Local

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) midazolam (Versed)

Benzodiazepines

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 anesthesia during actual birth of the fetus

injection into perineal nerves receives relief from discomfort only at delivery not during labor

Nursing Interventions
Know

type of anesthesia (Drug Rights)

Allay
Assist

anxieties; answer questions


in preparation & administration patient and fetus

monitor adverse

reaction = notify physician & have emergency equipment available

Fetal Factors Affecting the Labor Process: (5 Fs)

Fetal Lie Fetal Attitude Fetal Presentation Fetal Position Fetal Station

1. FETAL PRESENTATION
Describes

fetal body part to pass thru cervix and be delivered part felt on IE

The

Cephalic II. Breech III. Shoulder IV. Compound


I.

Abnormal Animation (Jot Down Notes)

I. Cephalic Presentation Head presents first at the cervix Vertex presentation Sinciput/forehead presentation Brow presentation Mentum/Face presentation

Vertex

Sinciput/Forehead
the chest

head is sharply flexed chin is not touching

posterior fontanel (lambda) Chin touches the sternum


Fetal Attitude:

alert or military position Anterior fontanel (bregma) Fetal Attitude: Moderate flexion

complete/full flexion

Brow
head

Mentum/Face
fetal head is

is moderately extended

hyperextended

chin presents first


widest

brow Fetal

enters first

diameter

Attitude: Partial extension

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 & flexed feet to present first

buttocks

Frank Breech Presentation


fetal

hips are flexed but legs are extended, resting on chest to present first

buttocks

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. Longitudinal II. Transverse III. Oblique

I. Longitudinal Lie II. Transverse Lie

Fetal spine parallel to maternal spine Fetus is lying top-tobottom

perpendicular to maternal spine

The fetus is lying sideto-side If labor progresses, the presenting part may be a shoulder, iliac crest, hand or elbow

Can be classified as cephalic or breech

Longitudinal

Transverse

III. Oblique Lie


The

fetal spine is 45 angles to maternal spine between transverse and longitudinal lies if fetus maintains this

midway

abnormal

position

Fetal Lie Video (Jot Down Notes)

3. Fetal Attitude

Degree of flexion

Could be:
I.

Complete/Full Flexion II. Moderate Flexion III. Partial Extension IV. Complete Extension

I. Complete/Full Flexion

Most common

vertex presentation

Neck is completely flexed


chin touching sternum

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 doesnt touch chest


sinciput/forehead presentation

III. Partial Extension

IV. Complete Extension

brow presentation

face presentation

Neck is extended
Head is moved backward cause a difficult delivery

may need cesarean delivery Head & neck are hyperextended

occiput touching the upper back Back is usually arched

A Vertex presentation & Complete flexion B Forehead presentation & Moderate flexion C Brow presentation & Partial extension D Face presentation & Complete extension

4. Fetal Position
Relationship

of presenting part to the mothers pelvis

Landmarks
O = Occiput, vertex presentation M = Mentum, face presentation Sa = Sacrum, breech presentation A = Scapula/ acromion process, shoulder presentation

- Quadrants
R = right L = left A = anterior P = posterior T = transverse (center)

Fetal

position is described by using 3 letters 1st letter = if presenting part facing mothers 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 Right

ROP
LOA

LOT
LOP

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

Face Presentations
RMA RMT Right

mentum anterior

RMP
LMA Left

mentum anterior

LMT
LMP

Breech Presentations
RSaA RSaT Right

sacrum anterior

RSaP
LSaA Left

sacrum anterior

LSaT
LSaP

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 mothers pelvis

Floating (High) unengaged above ischial spines minus station (-1 to -4 cm)

Determined (IE)
Station 0 = level of the ischial spines

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


If at +4 cm, known as crowning

engagement occurs

Phase Phase 1

Station 0 to +2

Contraction 2 3 min apart

Phase 2

+2 to +4

2 2.5 min apart with urgency to bear down 1 2 min apart; fetal head visible increased urgency to bear down

Phase 3

+4 to birth

Fetal Station Video (Jot Down Notes)

Stages of Labor
1. 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. Latent II. Active III. Transitional

Phase

Dilatation

Duration/Interval

Intensity

Latent Phase

0 3 cm Mild & short 20-40 sec Q10 min


4 7 cm Moderate to strong 40-60sec q3-5 min 8 10 cm Very Strong 60-90 sec Q 2-3 min

6 hrs primipara 4-5 hrs multipara

Encourage walking Chest breathing Encurage to void q2-3 hours


Meds should be ready Assess vs Abdominal breathing Oral care Tired Inform progress of labor Restless, support her with breathing techniques,

Active Phase

3 hrs primipara 2 hours multipara

Transition Phase

Cervical dilation

Take history vital signs

Quiet surroundings

Assess cervical dilation comfort measures: & effacement by IE

maintain effective breathing patterns


ambulation, if desired & tolerated void every 1-2 hours

Back rubs Pillow support Position changes Offer liquids/ice chips Provide 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 Labor


Expulsive stage complete cervical dilation to delivery of

the newborn Contractions: Duration: Frequency: Primipara:


Multipara:

strong 60 90 seconds every 2-3 minutes 40 minutes average 20 contractions 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 Bulging

will uterine contractions

of perineum & crowning of head hallmark of 2nd stage

bear down only during contractions Monitor FHR

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

Monitor contractions: frequency, duration & intensity

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 down lithotomy if with position

Check

for prolapsed cord an check FHR after rupture of membranes

Prolapsed Cord

Prepare

for birth & maintain sterile technique legs simultaneously in stirrups preparation: front to back

Place

Perineal 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. Engagement II. Descent III. Flexion IV. Internal Rotation V. Extension VI. External Rotation VII. Expulsion

I. Engagement

II. Descent

presenting part at ischial spines Station 0

downward movement of fetus Fetal head passes the dilated cervix

III. Flexion

IV. Internal Rotation

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

V. Extension

delivery of head outside pelvis

extension is controlled by the physician. An episiotomy may be done

Occiput at vagina Crowning


back of neck is under symphysis pubis causes the head to extend

Promoting Gradual Extension:


Ritgens

maneuver = gradual extension = exert pressure on the chin;


Panting

& not pushing during crowning

VI. External Rotation VII. Expulsion

After extension, neck is Final birth twisted


Delivery

head needs to externally rotate to realign with the spine the anterior shoulder descends first

body

of fetal

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 release

perineum from tearing

the pressure on fetal head that accompanies birth easily & heals faster

repaired

Method
Done

during contraction as the babys head pushes against perineum and stretches it. scissors are used

Blunt

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: Kjellands, Elliot, Piper, TuckerMcLean, Simpsons

For forceps delivery to be performed, the ff must be present: Ruptured membranes Fully dilated cervix Empty bladder Fetal 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 neonates head lasting as long as 7 days after birth Preterm neonates is problematic because of extreme softness of their skulls

3. 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 Calkins sign = Uterus changes from discoid to globular & from soft to firm

Placental Expulsion

Natural bearing down of the mother Gentle pressure on contracting uterus (Credes maneuver) Brandt andrews maneuver downward sideways gentle controlled cord traction

Fundus of uterus rises in the abdomen Umbilical cord lengthening Gush of blood from the vagina

Schultze placenta (80%)

Duncan placenta (20%)


Separates at center & fold (inverted umbrella)

Separates at its edges Umbrella shaped Maternal surface exposed Rough, red, raw & irregular from ridges

fetal surface exposed Shiny & glistening


Less external bleeding; blood is concealed behind the placenta

More external bleeding Appears bloody

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 DO

for signs of placental separation

NOT do fundal pressure with pull at the cord if uterus is relaxed = could cause hemorrhage

Gradual

delivery of placenta make 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

Immediate & thorough drying 2. Skin to skin contact 3. Properly timed cord clamping & cutting 4. Early BF
1.

Umbilical cord/funis AVA 53-55cm a. Short cord abruptio placenta


b.

c.

Long cord cord coil or cord prolapse 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 Labor


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 four Every 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 red lochia = laceration of cervix or vagina

Bright

Check

perineum for edema, bruising & rectal pain

MIO

Parameter

Rubra

Serosa Serosanguineous Brownish

Alba Creamy white White

Appearance Mostly bloody

Color

Red

Amount

Moderate

Scanty

Slight

Time present 1-3 days

4-10 days (7 days average)

11-14 days (maximum of 21 days

Duration of Labor
Labor Stage

First Stage: true labor full dilatation 1. Latent phase (0 3cm) 2. Active phase (4 7cm) 3. Transitional (8-10cm) Second stage: (full dilatation to birth) Most difficult for fetus Third Stage: (placental expulsion) Fourth stage: (recovery/ immediate postpartum) Dangerous for the mother - Due to hemorrhage

mild & short (20-40 sec) 6 hrs - primi 4-5 hrs - multi

Encourage walking Chest breathing Encourage to void q2-3 hours

50 minutes = 1 hr 5 15 min Ave. 5 min 1 2 hours Maximum: 4 hours

INDUCTION OF LABOR
Artificial initiation of Labor

Deliberate initiation of labor or uterine contractions before spontaneous onset


Fetus

Condition before Induction

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
19 2

Ways of Induction of Labor


a. Administer Pitocin synthetic substitute for uterine contractions b. Artificial ROM (amniotomy)

Prepare amniotome Check FHT after BOW is ruptured

19 3

Management
- on bedrest - VS & FHT every 15 minutes - IV 10u Pitocin add D5W piggybacked to main line Stop oxytocin if: FHT is more than 170 bpm less than 120 bpm Meconium passage Maternal hypotension
-

19 4

IF FETAL DISTRESS DEVELOPS: a. Stop oxytocin b. Turn client to the left side c. Administer oxygen per mask d. 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 Incision
a.

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 possible VBAC

b. Classic/vertical incision - vertical incision - used if with previous CS exist - fetus is in transverse lie - chance of vaginal birth is low - because incisions location is in the active contracting portion of uterus

PRE-OPERATIVE Regular preparation for abdominal / pelvic surgery POST-OPERATIVE Ensure airway (suction & oxygen)

MIO - Bleeding & urine


Clear liquids after flatus Oxytocic drugs = ensure firm fundus Analgesic = relief of pain Antibiotics = prevent sepsis

VS q15 min until stable Check dressing & perineal pad for bleeding, lochia

Assess signs of infection & thrombophlebitis

Danger Signs Thrombophlebitis: Local redness (rubor) Warm to touch (calor) Swelling (tumor) Pain (dolor)

Regular positioning
Early exercise

Passive then active leg exercises (Foot & leg exercise, abdominal tightening, pelvic rocking)

Validate by eliciting Homans 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

Leopolds Cervical Patient

maneuver

effacement & dilation

monitoring: Signs of dehydration Contractions Urinary elimination Partograph

Partograph

= advocated by WHO = to assess progress of labor


= Components: Progress of labor Fetal condition Maternal 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