INTRAPARTUM

PROCESS OF LABOR AND DELIVERY

Presented by GROUP 3A Andal, Jaybel Ann Bolagao, Reymart B. Cortez, Dyan M. Eridao, Keyne Reenne Herrera, Reggin Caryl V.

INTRAPARTUM CARE
refers

to the medical and nursing care given to a pregnant woman and her family during labor and delivery. from the beginning of contractions that cause cervical dilation to the first 1 to 4 hours after delivery of the newborn and placenta.

Extends

FACTORS AFFECTING
LABOR AND DELIVERY
5 Ps of Labor and Delivery Passageway Passenger Power Placental Factors/Position Psyche

PASSAGEWAY
refers

to the adequacy of the pelvis and birth canal allowing fetal descent; and factors include:

I. TYPES OF FEMALE
PELVIS
typical female pelvis with a rounded inlet. Android normal male pelvis with a heart shaped inlet Anthropoid is an apelike pelvis with an oval inlet Platypelloid is a flat, female-type pelvis with a transverse oval inlet
Gynecoid

II. STRUCTURE OF PELVIS

False

pelvis vs. true pelvis

FALSE PELVIS -Superior half formed by the iliac. Offers landmark for pelvic measurements. Supports the growing fetus into the true pelvis near the end of gestation TRUE PELVIS -Inferior half formed by the pubes in front, the iliac and the Ischia on the sides and the sacrum and coccyx behind.

III. ADEQUATE DELIVERY

DIAMETER
a)

Pelvic Inlet diameter Inlet entrance way to the true pelvis. Its Transverse diameter is wider than its anteroposterior diameter. Also known as pelvic brim.

b)

Pelvic Outlet diameter Outlet inferior portion of the pelvis, bounded on the back by the coccyx, on the sides by the ischial tuberosities and in front by the inferior aspect of the symphysis pubis and the pubic arch. Its anteroposterior diameter is wider than its transverse diameter.

 Engagement-

refers to settling of the presenting part of the fetus into the pelvis to be at the level of the ischial spine, a midpoint of the pelvis, descent to this point means the pelvic inlet is proven adequate for birth. Floating- a presenting part that is not engaged. Dipping- one that is descending but has not reached the ischial spine. Station- or degree of engagement; refers to the relationship of the presenting part of a fetus to the level of the ischial spines.

III. ADEQUATE DELIVERY

DIAMETER
c. Ability of the uterine segment to distend, the cervix to dilate and the vaginal canal and introitus to distend. DILATATION-Enlargement of the external cervical os from 0 to 10cm. As a result of uterine contractions and additionally as a result of pressure on the presenting part.

EFFACEMENT-Shortening and thinning of cervical canal from 0 to100%. Primigravida effacement occurs before dilatation Multigravidas dilatation may precede effacement

PASSENGER
This

refers to the fetus and its ability to move through the passageway
.

PASSENGER (CONT)

Fetal skull
Size of the fetal head and capability of the head to mold to the passageway. Molding- change in shape of fetal skull produced by force of contraction pressing the head against the not-yet dilated cervix Parents are reassured that molding only lasts a day or two and is not a permanent condition No molding when fetus is breech.

 The

fetal skull is the most important part of the fetus because: It is the largest part of the body It is the least compressible of all parts It is the most frequent presenting part

1. 2. 3.

PASSENGER (CONT..)
Fetal

lie or presentationThe part of the fetus that enters the maternal pelvis first; the body part that will be born first or contact the cervix first

Cephalic = head first; ideal presentation for NSVD because the bones of the skull are capable of molding so effectively to accommodate the cervix and may actually aid in cervical dilation

Vertex head is sharply flexed, making the parietal bones the presenting parts 1. Face 2. Brow 3. Chin or mentum

Breech either buttocks or feet first; difficult birth; can be delivered NSVD.
Complete breech thighs are flexed on the abdomen and legs are on thighs. Frank breech thighs are flexed and legs are extended, resting on the anterior surface of the body. Footling Double legs unflexed and extended; feet are presenting parts. Single one leg flexed and extended; one foot is the presenting part. Shoulder presentation- presenting part can be one of the shoulders(acromion process, an iliac crest, a hand an elbow; CS delivery)

FETAL LIE

relationship between the long axis of the fetal body and the long axis f the womans body(cephalocaudal).

a. Horizontal (transverse) b. Vertical (longitudinal)- cephalic or breech

FETAL ATTITUDE
The

relationship of fetal parts to one another; degree of flexion a fetus assumes during labor.

FETAL ATTITUDE(CONT..)
GOOD

ATTITUDE- if in complete flexion; the spinal column is bowed forward, the head is flexed forward so much that the chin touches the sternum, the arms are flexed and folded on the chest, the thighs are flexed onto the abdomen and the calves are pressed against the posterior aspect of the thighs.

FETAL ATTITUDE(CONT..)

MODERATE

ATTITUDE- if chin is not touching the chest but is in alert or military position.

FETAL ATTITUDE(CONT..)

POOR

ATTITUDE- the back is arched, the neck is extended and a fetus is in complete extension

FETAL POSITION
The relationship of presenting part and the maternal pelvis which is divided into4 quadrants: right anterior right posterior left anterior left posterior Four parts of the fetus have been chosen as point of direction 1.Occiput -= in vertex presentation 2.Chin (mentum) in face presentations 3.Sacrum breech presentations 4.Scapula (acromion) in shoulder presentations

Possible fetal positions: LOA (left occipitoanterior)- most common fetal position (birthing is fast) LOP (left occipitoposterior)- difficult delivery; more painful LOT (left occipitotransverse)ROA (right occipitoanterior)second most frequent (birthing is fast) ROP (right occipitoposterior)- difficult delivery, more painful ROT (right occipitotransverse) *Posterior positions may be more painful for the mother, because the rotation of the fetal head puts pressure on the sacral nerves causing sharp back pain.

POWER
to the frequency, duration and strength of uterine contractions to cause complete cervical effacement and dilatation.
refers

3 PHASES OF UTERINE CONTRACTIONS

crescendo/increment- intensity of the contraction increase. This phase is longer than the other two phases combined. acme/apex-the height or peak of the contraction. decrescendo/ decrement- intensity of the contraction decreases

Duration of contractions How Long From the beginning of one contraction to the end of the same contraction Duration during early labor- 20-30 seconds. Duration in late labor- 60-70 seconds. Should never be longer than 60-70 seconds because any muscle that is contracted does not have any blood supply and so will jeopardize the fetus.

Interval
From the end of one contraction to the beginning of the next contraction Interval during early labor- 40-45 minutes Interval in late labor- 60-70 seconds It is an important aspect of contraction because it is durin g this relaxation period when the uterine blood vessels refill themselves with blood to supply the fetus with adequate oxygen

Frequency How Often From the beginning of one contraction to the beginning of the next contraction. Three to four contractions are timed to get a good picture of the frequency.

Intensity How Strong The strength of contraction; may be mild, moderate, strong or severe Measured by the consistency of the fundus at the acme of the contraction When estimating intensity, check fundus at conclusi on of contraction to determine whether it relaxes. More strong: more pain

PSYCHE

to the clients psychological state, available support systems, preparation for childbirth, experiences and coping strategies.
refers

PLACENTAL FACTORS
refer

to the site of placental insertion.

PREMONITORY/PRELIMINARY/ PRODROMAL SIGNS OF LABOR

Lightening is the descent of the fetus and uterus into the pelvic cavity 2-3 weeks before the onset of labor. Effects of lightening Shooting pains down the legs because of pressure on the sciatic nerve Increased lordosis as the fetus enters the pelvis and falls further forward Increased amount of vaginal discharges Resurgence of sign of pregnancy like urinary frequency, as the gravid uterus impinges on the bladder Relief of abdominal tightness and diaphragmatic pressure

PREMONITORY/PRELIMINARY/ PRODROMAL SIGNS OF LABOR

Loss of weight - 2- 3 lbs is loss 2 days prior to onset of labor, probably due to loss of appetite anddecrease in progesterone level that leads to fluids excretion thus causing loss weight.

Progesterone is known to cause fluid retention

PREMONITORY/PRELIMINARY/ PRODROMAL SIGNS OF LABOR

Burst of energy or Increased tension and fatigue Nesting behavior may occur right before the onset of labor. Sudden burst of energy is due to increase in epinephrine in response to the stress brought about by the approaching delivery. Pregnant woman should be caution not to use this energy to carry out household chores because it is meant to prepare the body for the labor.

PREMONITORY/PRELIMINARY/ PRODROMAL SIGNS OF LABOR

Braxton Hicks contraction irregular intermittent contractions that have occurre d throughout the pregnancy, become uncomfortable and produce a drawing pain in the abdomen and groin; painless uterine tightening Also known as practice contraction.

PREMONITORY/PRELIMINARY/ PRODROMAL SIGNS OF LABOR

Cervical changes include softening ripening describe as butter soft and effacement of the cervix that will cause expulsion of the mucous plug (bloody show).

Rupture of amniotic membranes or the bag of water may occur before the onset of labor. Its rupture may be seen as a sudden gush, or a scanty, slow seeping of amniotic fluid from the vagina. It is important to remember that once membranes (BOW) have ruptured; Therefore labor is inevitable. Labor pains will set in within the next 24 hours. Since the integrity of the uterus has been destroyed, infection can easily set in. Thus, ASEPTIC TECHNIQUE should be observed in doing perineal care. Doctors do less of the IE and enemas no longer given. Check for any umbilical cord compression and or cord prolapsed especially in breech presentation)

A WOMAN SEEKING ADMISSION CLAIMS THAT HER BOW HAS RUPTURED.

FIRST NURSING ACTION Put her to bed right away, then take the fetal heart tones. She should be allowed to remain in the standing position or sitting position because if its true that BOW has ruptured, the possibility of cord compression is high. If a woman in labor says that she feels a loop of the cord coming out of her vagina (cord prolapsed), IMMEDIATE ACTION Place her in trendelenberg position to reduce pressure on the cord. REMEMBER: only 5 minutes of cord compression can already lead to CNS damage or even death Apply a warm saline saturated OS on the cord to prevent crying of the cord.

1.

2.

Color should be noted Normal: clear, almost colorless and contains white specks of vernix caseosa. Abnormal: a. green staining amniotic fluid has been contaminated with meconium which signifies fetal distress if the fetus is in a non-breech presentation. b. yellow staining may mean blood incompatibility. c. Pink stain may indicate bleeding

PREMONITORY/PRELIMINARY/ PRODROMAL SIGNS OF LABOR

If labor does not occur within the next 24 hours, the woman will have to be induced to go into labor by administering intravenous drip of oxytocin (Pitocin).

Show This is the blood-tinged mucus discharged from the vagina because of pressure of the descending fetal part on the cervical capillaries, causing their rupture. Capillaryblood mixes with mucus when operculum is release that is why SHOW than a pinkish vaginal discharge. Show should be distinguished from bright red vaginal bleeding because the later is a danger sign during this phase of pregnancy.

ONSET OF LABOR
normally begins when a fetus is sufficiently mature to cope with extra uterine life, yet not to large to cause mechanical difficulties with birth.
Labor

Differentiate TRUE LABOR from a FALSE LABOR.

Contractions Timing

False labor Irregular, no increase in frequency or duration

True labor Regular intervals which gradually become closely spaced

Change with motion

Location Intensity External changes

Stop and start at irregular intervals

Abdomen Weak and remains weak None

Progress is continuous
Back, then travels to the front Intensifies with time Mucus plug may dislodge; membrane rupture; bladder pressure Anytime

Occurrence

Happens when you are tired, especially in the evenings

STAGES OF LABOR

First stage ( Stage of Dilatation)

begins with the onset of regular contractions which cause progressive cervical dilation and effacement. It ends when the cervix incompletely effaced and dilated. 1.Latent phase - 1-4 cm 2.Active phase - 4-7 cm 3.Transitional phase - 7-10 cm Power/Forces at work: involuntary uterine contracts

STAGE OF DILATATION (FIRST STAGE)

LATENT PHASE early time in labor Regular contraction Cervical dilation 1 to 4 cm Intensity: mild to moderate Uterine contractions occur Q15-30 minutes and are 15-30seconds in duration and of mild intensity Mother is talkative and eager to be in labor

STAGE OF DILATATION (FIRST STAGE)

ACTIVE PHASE Cervical dilation 4-7 cm Uterine contractions occur Q35 minutes and are 30-60seconds in duration Contraction: moderate to strong, frequent, longer m ore painful Mother may experience feeling of helplessness and becomes restless and anxious as contractions intensifies Woman fears losing control of herself

STAGE OF DILATATION (FIRST STAGE)

TRANSITIONAL PHASE Cervical dilation 8-10 cm Uterine contractions occur every 2-3 minutes and are 45-90seconds in duration and of strong intensity Mother becomes tired, is restless and irritable and feels out of control Mood change AMNIOTOMY (if not yet ruptured) Gaping (bulging) of vagina or anus or perineum AMNIOTOMY is not done if the station is still negative because this can lead to cord compression

SECOND STAGE ( STAGE OF EXPULSION)

with complete dilatation of the cervix and ends with delivery of the newborn. Duration may differ among primiparas (longer) and multiparas (shorter),but this stage should be completed within 1 hour after complete dilatation.
Begins

SECOND STAGE ( STAGE OF EXPULSION)

1.

2. 3.

4.

5. 6.

Power/Forces at work: INVOLUNTARY UTERINE CONTRACTIONS; CONTRACTIONS OF THEDIAPHR AGMATIC AND ABDOMINAL MUSCLES Contractions are severe at 2-3 minute intervals, with a duration of 50-90seconds Cervical dilation is complete Progress of labor is measured by descent of fetal head thru the birth canal(change in fetal station) Uterine contractions occur every 2-3 minutes, lasting 60-75 seconds, and the intensity is strong. Increase in bloody show Mother feels the urge to bear down

The newborn exits the birth canal with the help from the following cardinal movements, or mechanisms of labor (D FIRE ERE) DESCENT- fetus goes down the birth canal (preceded by engagement) FLEXION- pressure on the pelvic floor causes the fetal chin to bind towards the chest INTERNAL ROTATION from antero-postero to transverse then AP to AP EXTENTION as the head comes out, the back of the neck stops beneath the pubic arch. Thehead extends and the forehead, nose, mouth and chin appear EXTERNAL ROTATION (also known as restitution) anterior shoulder rotates externally to the AP position so that it is just behind the symphysis pubis EXPULSION the delivery of the rest of the body

SECOND STAGE ( STAGE OF EXPULSION)

Episiotomy Prevent prolonged & severe stretching of the muscles Natural anesthesia (synchronized with pushing of the woman) Done to facilitate delivery and avoid laceration of the perineum Reduce duration of second stage Enlarge outlet in breech presentations or forcep delivery TYPES OF EPISIOTOMY Median Mediolateral Application of Ritgens Maneuver is the best method for delivery As soon as crowning is taking phase, cover anus with sterile towel to exert.

THIRD STAGE (PLACENTAL EXPULSION)

Begins

with the delivery of the baby and ends with the delivery of the placenta. Placental separation and expulsion occur Placental birth occur 5-30 minutes after birth of baby.

THIRD STAGE (PLACENTAL EXPULSION)

Placental Separation(Mechanisms) SCHULTZE MECHANISM: center portion of placenta separates first and its shiny fetal surface emerges from the vagina. SHINY AND GLISTENING.

DUNCAN MECHANISM: margin of placenta separates, and the dull, red, rough maternal surface emerges from the vagina. DIRTY, RAW, REDAND IRREGULAR WITH THE RIDGES OR COTYLEDONS.

THIRD STAGE (PLACENTAL EXPULSION)

Signs of Placental Separation uterus becoming globular (calkins sign) Fundus rising in abdomen gushing of blood Lengthening of the cord

THIRD STAGE (PLACENTAL EXPULSION)

Contractions of the uterus controls uterine bleeding and aids with placental separations and delivery. Generally, oxytocic drugs (oxytocin 10-20 units) are administered to help the uterus contract (after placenta out) METHERGINE PROMOTES UTERINE CONTACTION AND PREVENTS POSTPARTUM HEMORRHAGE PRODUCE STRONG AND EFFECTIVE CONTRACTION ASSESS VITAL SIGNS (BP) DO NOT ADIMINISTER IF BP IS 140/90 mmHg LEADS TO HYPERTENSION DISCONTINUE: MARKED VASOCONSTRICTION (COLDNESS, PALENESS, NUMBNESSOF THE FEET AND HAND); NOTIFY THE PHYSICIAN OXYTOCIN INCREASES UTERINE CONTRACTION MINIMIZED UTERINE BLEEDING INCREASES BLOOD PRESSURE (VASOCONSTRICTION)

FOURTH STAGE ( RECOVERY AND BONDING)

From the delivery of the placenta until the postpartum condition of the woman has become stabilized (usually after 1 hour after delivery). the period of time from 1-4 hours after delivery the mother and newborn recover from the physical process of birth The maternal organs undergo initial readjustment to the nonpregnant state The newborn baby systems begins to adjust to extra uterine life and stabilize

THIRD STAGE (PLACENTAL EXPULSION)

Monitoring the Blood Pressure Blood Pressure should not be taken during a contraction as it tends to INCREASE, because no blood supply goes to the placenta during contraction. All the blood is in the periphery, which explains the increased BP during contraction BP taking should be taken at least every half hour during active labor. Whenever a woman complains of a HEADACHE, remove the blood pressure apparatus from the arm right away (priority intervention)

NURSING MANAGEMENT DURING LABOR

1.Physical Assessment. General physical examination, Leopolds maneuvers and/or internal examination are done. 2.Bath. Bath is advisable if contractions are still tolerable or are not too close to one another. Bathing will not only ensure cleanliness but will also provide comfort and relaxation. 3.Perineal Preparation. Perineal flushing is done to prevent contamination of the birth canal and reduce possibilities of postpartum infection.

NURSING MANAGEMENT DURING LABOR

4. Ambulation. Unless contraindicated (by medications, intravenous infusion or ruptured membranes), ambulation is advised during the latent phase of labor in order to help shorten the first stage of labor. 5. Diet .Solid or liquid foods are avoided for the following reasons: a)Digestion is delayed during labor. b)A full stomach interferes with proper bearing down. c)Aspiration may occur during the reflex nausea and vomiting of the transition phase or when anesthesia is used.

NURSING MANAGEMENT DURING LABOR

6.Enema Administration. Enema is not a routine procedure for all women in labor but maybe done for the following reasons: a)A full bowel hinders labor progress; enema increases the space available for passage of the fetus and improves frequency and intensity of uterine contractions b)Enema decreases the possibility of fetal contamination of the perineum during the second stage of labor. c)A full bowel can add to the discomfort of the immediate postpartumperiod. Contraindications of enema: a)Vaginal bleeding b)Premature labor c)Abnormal fetal presentation or position d)Ruptured membranes e)Crowning

NURSING MANAGEMENT DURING LABOR

Voiding. The woman in labor should be encouraged to empty her bladder every2-3 hours because: a)full bladder retards fetal descent. b)urinary stasis can lead to urinary tract infection.
c)a full bowel may be traumatized during delivery.

NURSING MANAGEMENT DURING LABOR

8.Breathing Technique. The woman in the 1st stage of labor should be instructed not to push or bear down during contractions because it will not only lead to maternal exhaustion but, more importantly, unnecessary bearing down can lead to cervical edema because of the excessive pounding of the fetal presenting part of the pelvic floor, thus interfering with labor progress. To minimize bearing, the patient should be advised to do abdominal breathing during contractions.

NURSING MANAGEMENT DURING LABOR

9.Position. Encourage the woman in labor to assume Sims position because: a)It favors anterior rotation of the head. b)It promotes relaxation between contractions. c)It prevents Supine Hypotensive Syndrome.

The inferior vena cava, the blood vessel which carries unoxygenated blood back to the heart, lies just above the spinal column. When a pregnant woman lies flat on her back, the inferior vena cava is caught between the gravid uterus and the spinal column, causing a drop in arterial blood pressure, which leads the woman to complain of dizziness.

NURSING MANAGEMENT DURING LABOR

Contractions. Uterine contractions are monitored every hour during the latent phase of labor and every 30 minutes during the active phase by spreading the fingers lightly over the fundus.

NURSING MANAGEMENT DURING LABOR

Vital Signs Blood Pressure (BP) and Fetal Heart Rate (FHR) are taken every hour during the latent phase and every 30 minutes during the active phase. Definitely, BP and FHR should never be taken during a contraction. During uterine contractions No blood goes to the placenta. The blood is pooled to the peripheral blood vessels which results in increased BP. Therefore, the blood pressure should be taken in between contractions and whenever the mother in labor complains of a headache.

NURSING MANAGEMENT DURING LABOR

Danger Signals. The nurse must be aware of the following danger signals during labor and delivery. a)Signs of fetal distress 1. Tachycardia (FHR more than 180) Bradycardia (FHR less than100) 2.Meconium-stained amniotic fluid in nonbreech presentation 3.Fetal thrashing or hyperactivity due to fetal struggling for more oxygen

NURSING MANAGEMENT DURING LABOR

Signs of maternal distress 1. BP over 140/90, or a falling BP associated with clinical signs of shock (pallor, restlessness or apprehension, increased respiratory and pulse rates) 2. Bright red vaginal bleeding or hemorrhage(blood loss of more than 500 cc) 3. Abnormal abdominal contour (may be due to uterine rupture or Bandls pathological ring, a condition wherein the muscles at the physiological retraction ring become very tense, gripping the fetus causing possible fetal distress)

NURSING MANAGEMENT DURING LABOR

Administration of Analgesics. Narcotics are the most commonly used analgesics, specifically Demerol (meperidine hydrochloride). Demerol acts to suppress the sensory portion of the cerebral cortex. A dose of 25-100 mg is given and it takes effect within 20 min when the patient experiences a sense of well being and euphoria. Demerol, being also an antispasmodic, should not be given very early in labor because it will retard labor progress. It should not also be given when delivery is less than an hour away because it can cause respiratory depression in the newborn. It is , therefore, preferably given when cervical dilatation is around 5-8 cm.

NURSING MANAGEMENT DURING LABOR

Administration of Anesthetics. Regional anesthesia is preferred over any other form because it does not enter the maternal circulation and therefore does not retard labor contractions nor cause respiratory depression in the newborn.

NURSING MANAGEMENT DURING LABOR

Transfer of Patients. A sure sign that the baby is about to be born is the bulging of the perineum. In general, multiparas are transported to the delivery room when cervical dilatation is about 7-9 cm, while primiparas are transferred to the delivery room at full dilatation with perineal bulging when crowning is taking place.

NURSING MANAGEMENT DURING DELIVERY

Positioning on the Delivery Table. When positioning the woman on lithotomy on the delivery table, the legs should be put up slowly at the same time on the stirrups in order to prevent trauma to the uterine ligaments and backaches or leg cramps. The same should be done when putting the legs down from the stirrups after delivery. Bearing Down Technique. At the beginning of a contraction, the woman is asked to take two short breaths, then to hold her breath and bear down at the peak of contraction. She should also be told to use blow-blow breathing pattern to prevent pushing between contractions.

NURSING MANAGEMENT DURING DELIVERY

Care of the Episiotomy Wound. Episiotomy, a perineal incision done to facilitate the birth of the baby, is made by the doctor primarily to prevent lacerations. No anesthesia is necessary during episiotomy b/c the pressure of the fetal presenting part against the perineum is so intense that the nerve endings for pain are momentarily deadened(natural anesthesia). Breathing Technique. As soon as the head crowns, the woman is instructed not to push any longer because it can cause rapid expulsion of the fetus. Instead, she should be advised to pant (rapid and shallow breathing).

NURSING MANAGEMENT DURING DELIVERY

Ritgens Maneuver. a) Support the perineum during crowning by applying pressure with the palm against the rectum. This will not only prevent lacerations of the fourchette but will also bring the fetal chin down the chest so that the smallest diameter of the fetal head is the one presented at the birth canal. b) in order to prevent rapid expulsion of the fetus which could result not only in lacerations, abruptio placenta, and uterine inversion but also to shock because of sudden decrease in intra abdominal pressure, the head should be pressed gently while it slowly eases out. Time of Delivery. Take note of the time the baby is delivered.

NURSING MANAGEMENT DURING DELIVERY

Handling of the Newborn. Immediately after delivery, the newborn should be held below the level of the mothers vulva so that blood from the placenta can enter the infants body on the basis of gravity flow. The newborn should be held with his head in a dependent position to allow drainage of secretions. A newborn is never stimulated to cry unless he has been drained of his secretions because he can aspirate these secretions into his lungs. The newborn should be immediately wrapped in a clean diaper to keep him warm because chilling increases the bodys need for oxygen. He should then be placed on his mothers abdomen so that the weight of the baby can help contract the uterus; a non contracted uterus can lead to death due to hemorrhage

NURSING MANAGEMENT DURING DELIVERY

Cutting of the cord. Cutting of the cord is postponed until pulsations have stopped because it is believed that 50-100 ml of blood is flowing from the placenta to the newborn at this time. It is then clamped twice, an inch apart, and cut in between.9.Initial Contact. Maternal-infant bonding is initiated as soon as the mother has eye-to-eye contact with her baby. The mother is informed of her babys sex and helped to hold and inspect her baby if she wishes.

NURSING DIAGNOSIS

Fear r/t uncertainty about the outcome of the birth process Acute Pain r/t uterine contraction, cervical dilatation and fetal descent Health seeking behaviors: Information about the fetal monitor r/t an expressed desire to understand equipment used Readiness for enhanced family processes r/t opportunity to incorporate newborn into the family

Severe bradycardia- FHR less than 80 bpm Persistent severe bradycardia- severe bradycardia that persists for longer than 5 minutes Accelerations-FHR increases than 15 bpm for more than 15 seconds Appear as smooth patterns on electronic fetal monitoring is good indicators of fetal well-being Triggered in the normal mature fetus by fetal body motions, sounds stimulations of the fetal scalp and other stimuli Early decelerations are normal and common

Deceleration pattern matches the contraction with the most deceleration occurring at the peak of the contraction FHR rarely goes below 100 bpm. Cause: head compression during uterine contraction Late decelerations Decrease in FHR from the baseline rate with a lag time of greater than 20 seconds from the peak of contraction

First appear at or after the peak of the uterine contractions. The FHR improves only after the contraction has stopped. May be mild or severe based on how low the FHR goes and how long it takes for the FHR to recover Caused by reduced blood flow to the uterus and placenta during contraction Associated with uteroplacental insufficiency and is a consequence o f hypoxia and metabolic abnormalities Variable deceleration

Common type of FHR deceleration in labor Cause by umbilical cord compression Significance depends on how low the heart rate drops and how long the episode lasts Classified severe if they last more than 60 seconds or to a FHR of less than 90 bpm

NURSING MANAGEMENT DURING DELIVERY

Interventions for late or variable decelerations lasting more than 60 seconds: 1.Reposition the patient 2.Administer oxygen by face mask 3.Discontinue oxytocin 4.IV fluids to increase maternal volume 5.Notify physician 6.Vaginal exam to check for prolapsed of cord 7.Prepare for emergency caesarean section

TYPES OF CHILDBIRTH
Vaginal delivery

A natural process that usually does not require significant medical intervention NSVD- normal spontaneous vaginal delivery

TYPES OF CHILDBIRTH
Forceps delivery- vaginal delivery with the use of obstetric forcep (an instrumentdesigned to extract the babys head) Indications Uterine inertia or poor uterine contraction and the second stage hasgone pass two hours

Face presentation; OA in flat pelvis, OP position

Relative CPD Cardiac and pulmonary disorders of the mother, maternal exhaustion

Late deceleration pattern, excessive fetal movement, meconiu m stained in cephalic presentation

TYPES OF CHILDBIRTH
Leboyer method Postulated that moving from a warm, fluid-filled intrauterine environment to noisy air filled, brightly lit birth room creates a major shock for newborn He proposed that birthing room should be darkened, kept pleasantly warm, soft music is played, infant is gently handled, cord is cut late and placed immediately into a warm water bath Advantage: ideal for most birthing institution Disadvantage: warm bath could reduce spontaneous respiration and high level of acidosis; late cutting of the cord causes excess blood viscosity in newborn

TYPES OF CHILDBIRTH
Hydrotherapy and Water Birth Baby is born underwater and immediately brought to the surface for a first breath Advantage: reduce discomfort in labor Disadvantage: Contamination of bath water with feces expelled, Aspiration of bath water by fetus: pneumonia, Maternal chilling, Uterine infectionspushing efforts in 2nd stage of labor

TYPES OF CHILDBIRTH
Caesarean birth Latin word caedore means to cut Birth accomplished through abdominal incision into the uterus, after 28 weeks AOG Emergency procedure (under general anesthesia) or elective procedure (under spinal) Indications :CPD, Placenta previa, Abruption placenta, Malpresentation or malposition, Preeclampsia/eclapmsia, Previous CS, Cervical dystocia, Cancer of the cervixFetal distress, Cord prolapsed, Other factors: poor obstetrical history, vaginoplasty, vesico-vaginal fistula

TYPES OF CHILDBIRTH
Complications Uterine rupture in subsequent pregnancy Postop infection Injury to urinary system Injury to uterine vessels Embolism

TYPES OF CHILDBIRTH
Types of CAESAREAN DELIVERY Classic caesarean section- Incision made vertically through the abdominal skin and uterus Advantage: incision is made high on the uterus to avoid cutting the placenta and be used with placenta previa Disadvantage: Leaves a wide skin scar Scar could rupture during labor and not be able to have a subsequent vaginal birth

TYPES OF CHILDBIRTH
Low segment incision Lower segment transverse caesarean section (LSTCS) Made horizontally across the abdomen over the cervix Referred to as pfannesteil incision or bikini incision Advantage: Less likely to rupture in subsequent labours Less blood loss- easier to suture Decrease postpartal infections Less possibility of GI complications Disadvantage: Longer procedure No assurance for small skin incision and small uterine incision.

THE END