1. Power 2. Passenger 3. Passage 4. Placenta 5. Psyche

Intrapartum Flashcards by Callie Wanek

series of processes by which the fetus and other products of conception are expelled from the mother’s body

Labor

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regular rhythmic tightening of uterine muscle. Has increment, acme, and decrement

Contraction

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–thinning and shortening of the cervix, measured by percentage

Effacement

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enlargement of the diameter of cervix, measured in centimeters

Dilation

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descent of present part, measured in +/- numbers
- = baby is higher
+ = baby is below ischial spine

station

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The 5 P’s in labor

Power
Passenger
Passage
Placenta
Psyche

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uterine contractions (needs oxytocin)

* maternal pushing

Power

1st P

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how fetus is oriented to mother’s spine •longitudinal–most common, parallel •transverse–at right angles to mother •oblique–somewhere in between

Lie

Passenger - 2nd P

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fontanels allow for…

molding

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how is the fetus flexed.

•Prefer chin on chest, arms and legs flexed toward body

Attitude

Passenger - 2nd P

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fetal part that enters the pelvis first
•cephalic/vertex–head first
•breech – butt/feet first
•transverse–shoulder or side

Presentation

Passenger - 2nd P

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buttocks with feet at shoulders

Can deliver this way

Frank Breech

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buttocks with legs flexed upon abdomen

Complete breech

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foot or feet presenting part

Footling

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Breech causes placenta to be planted in lower uterus or it doesn’t perfuse well so…

Baby is not ready

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how a reference point on presenting part is oriented within pelvis
•cephalic/vertex use occiput
•breech use sacrum

Position

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ROA

Right Occiput Anterior

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LSA

Left Sacrum Anterior

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Mother’s bony pelvis

* Soft tissue–cervix, vagina, perineum

Passage

3rd P

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•Placement 
•Ability to sustain fetus during labor 
•At 40+ weeks it is 
wearing out and breaking down 
Towards end it doesn't produce much progesterone
Should be in upper Posterior

Placenta

4th P

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Mother’s psychological response to labor process
Coping skills
Support system
Expectations for labor
Knowledge base

Psyche

5th P

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Braxton-Hicks contractions–occur throughout pregnancy but do not affect dilation of the cervix
no progressive cervical dilation
amniotic membranes usually intact

False Labor

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After 4 cm you see ….

1 cm per hour

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•Progressive dilation and effacement of cervix
•membranes may or may not be ruptured
•bloody show may be present (“mucous plug” from cervix that falls out when it gets bigger)
•uterine contractions are regular with intervals between shortening
and intensity increasing

Signs of True Labor

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•Physical activity intensifies •Mild sedation does not affect strength or pattern •Pain/discomfort in abdomen and back •Nausea and vomiting may occur in true labor Morphine doesn't work in true labor

What Effects Uterine Contractions in True Labor

•Bloody show--thick mucus mixed with pink or dark brown blood, may occur several days before labor begins •Spontaneous rupture of membranes •SROM •must go to hospital even if no other signs of labor! Infection can occur when it breaks

Signs of approaching Labor

* Risk for infection * open pathway for microorganisms into uterus * prophylactic IV antibiotics during labor if prolonged time of rupture * Risk for prolapsed umbilical cord * emergency C-section * position mother to relieve pressure

SROM

settling of presenting part into pelvis | can breath easier since baby is dropping

Lightening

* Ruptured membranes * Contractions strong and regular q 5-7 min for 1-2 hours for primips, q 10 min for 1 hour for multips * Bleeding greater than bloody show * Decreased fetal movement--no movement felt for > 2-3 hours

when to go to hospital

* Admission charting * Fetal monitoring to check FHR and variability (FIRST THING - makes sure baby is stress free) * Maternal Vital signs * Vaginal exam--dilation, effacement, position. Nitrazine tape (will be blue if ruptured) for SROM•Review prenatal record * Routine UA (look for nitrates, albumin) * Complete blood count * Blood type and antibody screen * IV site established, IV fluids per orders

Do upon admission

* Descent--station * Engagement * Flexion * Internal rotation * Extension * External rotation •Expulsion

Labor process

* “Stage of Dilation” * onset of labor to full dilation * Primiparas 8-10 hours •Multiparas 6-8 hours

First stage of labor

Latent phase

0-3 cm - lasts the longest

Active phase

4-7 cm - more rapid

transition phase

8-10 - short intense pain - must to be complete to push

* “Stage of expulsion” * Complete dilation until birth of babe through vagina * Primiparas 1 1/2 - 3 hours * Multiparas 20-45 minutes * Strong urge to push, may need guidance to push effectively * Fetal head molds to pass through pelvis/vagina * Crowning--head visible at perineum

Second Stage of Birth

•From the birth of the baby to expulsion of the placenta •Approximately 5 -30 minutes •Usually “shiny Schultze” (fetal side) side presents •Manual exam with forceps by examiner to check for retained placenta or tissue •May give Oxytocin IV or IM to contract uterus, fundal massage or breastfeed

Third Stage of Labor

* Period of stabilization and recovery from birth process-- 1-4 hours * Uterus firm, grapefruit sized, at midline * Chilling, involuntary shaking * Perineal discomfort * Important time for breastfeeding and bonding

Fourth stage of labor

* Monitor the fetal oxygen status - do kick counts * Promote adequate fetal oxygen - if mom BP is low the uterus doesn't perfuse well - turn to left side * Take corrective action as needed * Notify MD of fetal oxygenation problems * Document

Nurse responsibilities for fetal monitoring

beginning of one contraction to the beginning of next | measuring the start of hills

frequency

beginning of end of one contraction to other | how long It lasts

duration

how strong contraction is, internal tocotransducer is the most accurate •mild--uterus easily indented (tip of nose) •moderate-uterus firm, indent slightly, (chin) •strong- very firm, can’t indent, (forehead)

Intensity

* period of relaxation between contractions * External – Palpation - soft •Document: Present or Absent * IUPC – 5-25 mmHg * Pressure of uterus should be

Resting Tone

4 things to look for contractions

1. Frequency 2. Duration 3. Intensity 4. Resting tone

* Need to evaluate in conjunction with contractions to determine pattern * Baseline--rate between contractions, 110-160 bpm at full term * Determine mean and round 0-5

Fetal heart patterns

Most effective labor pattern that allows baby to perfuse....

2-3 minutes apart 60-90 seconds duration strong intensity with positive resting tones

``` irregular fluctuations in the baseline •Minimum 0-5 bpm (baby sleeping) •Moderate 6-25 bpm •Marked >25 bpm (mom had burst of energy and went to baby) want this so we know the baby has energy ```

Variability

rate increases 15 bpm for at least 15 seconds in a 10 min strip--Reassuring sign

Accelerations | bible verse 2

rate decreases from baseline •early - need interventions •variable - nursing judgment if ok •late - never good

decelerations

rate decrease during contraction that returns to baseline by the end of contraction. Normal sign *caused by compression of head head is being compressed towards transition and when she's pushing

early decels of decelerations

rate change begins and ends abruptly. V, W, or U shaped. Not always in conjunction with contraction. Indicates cord compression vary in size, shape and frequency *cause is cord compression

Variable decels of decelerations

resemble early but don’t return to baseline until after contraction ends •Indicates not enough O2 to infant by placenta--uteroplacental insufficiency

late decels of decelerations

* Reposition mother to left side * O2 per face mask * Increase IV fluids

Intervention for fetal distress | bible verse 3

* Turn off Pitocin (if applicable) * Notify the provider * Document

intervention for fetal distress | bible verse 4

* Nitrazine paper - cobalt blue * Ferning * Pooling

SROM

artificial rupture of membranes (AROM) using sterile disposable Amnihook. •Assess FHT •Note time and condition of fluid

AROM

* Record color, odor, and amount of fluid * green--meconium. Note if thick or watery (babies 1st stool) * yellow, cloudy, foul odor--infection * large quantity of fluid--at risk for prolapsed cord. * Monitor FHR at least 10 minutes after ROM to detect prolapsed cord or compression

Amniotic fluid

take temp every 2 hours if elevated or ROM | Pulse, BP and respiration every 1 hour

fetal monitoring

* Vaginal exams check: * effacement, dilation, station of fetus * Check when contractions increase in frequency, intensity, woman’s behavior changes * Always use sterile technique

Monitor labor progress

initiation of labor before it begins naturally | last longer

induction

stimulation of contractions after they have begun naturally (ROM, Pitocin)

augmentation

* Prostaglandin gel (Cervidil) or misoprostil (Cytotec) inserted vaginally to soften cervix. * May induce labor by itself or be used with oxytocin

cervical ripening

* “Pit induction”--artificial stimulation of uterine contractions with IV oxytocin (Pitocin) * Oxytocin diluted in IV solution and piggybacked into mainline IV. Always regulated with infusion pump * Slowly increased until desired contraction pattern established * Continuous EFM

types of oxytocin and augmentation

* Drugs are avoided during latent phase of labor--slow or stop labor * Meds can cross placental barrier (if 8 cm, opioids cross placenta) * Goal of pain meds is to reduce pain to tolerable level (doesn't take away all pain) * IV most frequent route

Pain meds - Analgesics

* Most commonly used * Do not give if delivery in 1 hour or less * Butorphanol (Stadol) - 1-2 hours, slows baby heartrate * Fentanyl (Sublimaze) - 1 hour, respiratory depression * Naloxone (Narcan) --antagonist

Narcotics in pregnancy

* Promethazine (Phenergan)--reduces N/V - makes fentanyl work better - cause drowsiness * Diphenhydramine (Benadryl)--reduces itching

Adjunct Medications

numb specific area, but still feel pressure Any meds that end in -caine Local infiltration: injection of perineal area for epistomy before delivery or for repair injection of pudendal nerves 10-20 mins before delivery, nubs lower 2/3 of vagina (saddle part that's numb) •Epidural block -- injection into epidural space • Blocks transmission of pain impulses to brain •No sedation of mother/fetus •May affect ability to push

Regional Anesthetics

``` •Catheter and infusion pump to deliver continuous dose •may be used for c-section •Single dose of epidural opioids administered prior to removal of catheter can last 24 hours ```

Epidural

``` •Spinal Block --injection through lumbar interspace into subarachnoid space •Used for C -sections •Level of anesthesia from nipples to the feet ```

Regional Anesthetics (2)

•Not used for vaginal births •Used for emergency C -sections C-section when epidural or intrathecal contraindicated or refused by woman Use when you have 3 minutes to get baby out

General Anesthetic

* Does not harm mother and fetus * Does not slow labor * No risk of allergy or adverse reaction * May not provide adequate pain relief when used alone * Most methods need to be practiced before labor begins--education

Non-pharmacological pain management

``` •Relaxation - 1 job is to provide smooth environment •Skin stimulation a) effleurage - gate control theory b) sacral pressure c) thermal stimulation •Positioning •Mental stimulation A) focal point B) imagery C) music D) Meditation E) TV ```

Techniques for labor

``` perineal incision to enlarge vaginal opening •midline •mediolateral •lateral ```

episiotomy

tearing of perineal tissue •Classified by how far it extend from the vagina to the anus 1. 1st degree —through the skin 2. 2nd degree – through the muscle 3. 3rd degree--extends into the rectal sphincter 4. 4th degree-extends through rectal sphincter

Laceration

instruments with curved blades that fit around the fetal head •Pull on infant as mother pushes •Use if woman is exhausted, pushing ineffectively •Use if fetus in distress at end of labor •May injure tissue

Forceps

used suction applied to fetal scalp to pull as mother pushes • Does not enter pelvic cavity like forceps • Causes circular edema to infant’s scalp that subsides after birth

Vacuum extraction

``` surgical birth of fetus through incisions in the mother’s abdomen and uterus •32.2% of all deliveries (2014 CDC) ```

C-section

* Abnormal labor * Cephalopelvic disproportion (CPD)-- baby doesn’t fit * PIH * Previous c-section or uterine surgery * Fetal compromise * Placenta previa (its implanted in cervical opening or lower uterine segment) or abruptio placentae (pulling away so not good perfusion)

C-section indications

Types of C-Section

1. planned (breech, repeat) 2. Unplanned 3. Emergency

* Low transverse or Pfannensteil--preferred, less chance of uterine rupture in next pregnancy * Low vertical--allows delivery of larger fetus * Classic-- vertical, rarely used, higher incidence of rupture in subsequent pregnancy

Types of c-section incisions

•Emotional support-- disappointment, guilt, anger, anxiety •Post-op vital signs •Assess fundus and lochia - healing and not bleeding •I & O -- IV and Foley until next a.m. •Dressing changes, assess incision •Pain management -- epidural or PCA • Teach CDB cough and deep breath •Encourage ambulation

Nursing care for c-section

•Meconium in amniotic fluid •Fetal Heart Rate (FHR) decreasing below 110 bpm between contractions •Large amount of bleeding from vagina more than 1 TBSP -- Placental shearing •Maternal HR > 100bpm (sign of infection) •increased temperature •cardiac decompensation, circulatory alterations •Maternal BP 20 mmHg above baseline •Cord presents at or near vaginal outlet •Contractions are > 90 seconds duration, > 2 minutes in frequency •Irregular fetal or maternal heartrate •Elevated maternal temperature •Extreme maternal headache -- increased risk for seizures or stroke •Failure to dilate in 24 hours

Danger signs in labor

•Difficult labor r/t fetus, uterine contractions, birth canal, maternal position during labor, placenta and psychological responses of the mother

Dystocias of Labor

head delivered but shoulders stuck above | symphysis pubis -- fractures

Shoulder dystocia | problems with fetus (passenger)

``` •Fetal anomalies -- hydrocephalus (too much fluid = big head) • Abnormal Presentation •breech •face or brow (emergency c) •Abnormal Positions •LOP or ROP -- face up, back labor •repositioning mother on hands/knees may rotate to OA •Multifetal pregnancy •Overdistention of uterus and ineffective contractions •Abnormal presentation of one or more fetuses Often delivered by C-section ```

passenger

* Contractions too weak | * usually diminish during active phase

Hypotonic labor dysfunction

``` •contractions are frequent, cramplike with poor coordination, very painful •occur during latent phase •Administer mild sedation to promote rest •Tocolytics reduce contractions -- Terbutaline (Brethine) •Hydrate ```

Hypertonic labor dysfunction

Causes increase in heartrate | If mom's heart rate is high you cannot give it

Terbutaline (Brethine)

•Ineffective maternal pushing •Weak abdominal wall •allows uterus to rotate forward and prevent fetus from aligning with birth canal •put mother in upright position, abdominal pressure

Power

* Contractures of the pelvic diameters * congenital anomalies * maternal malnutrition * neoplasms - benign tumors * lower spinal disorders * young maternal age

Problems with birth canal (passage)

* Soft tissue dystocia * Full bladder or rectum * Placenta Previa (grows in lower uterus) * Uterine fibroids * Ovarian tumors * Edematous cervix

Passage

* Abruption/Previa * Infarcts - dead tissue=poor perfusion from smoking/drugs * Postdate - older placenta

Problems with placenta

* Diabetes * Hypertensive disorders * Smoking * Taking cocaine or other drugs * Malnutrition * Maternal age * Multiple births * Blood clotting disorders * Trauma * Prior placenta issue

conditions that cause Add to dictionary insufficiency

* Fetal Kick Count - 10 kicks per hour * Fetal Movement * Fetal Monitoring - look for contractions, baseline, variability * Ultrasound - 20 weeks to check for amniotic fluid if it's too much or little * Post delivery assessment

placenta assessments

``` •Prolonged labor -- > 24 hours •Can result in maternal and/or fetal infections •Exhaustion •Postpartum hemorrhage ```

abnormal labor

``` completed in less than 3 hours •Abrupt onset, quickly intensifies, frequent and intense contractions •Higher risk for injury to mother and fetus ```

Precipitous labor

* Occurs after 20 weeks and before 37 6/7 weeks * Signs: * contractions or cramping * constant backache * pelvic pressure * change in vaginal discharge * general ill feeling

duration of pre-term labor

* Bed-rest * Hydration * Tocolytics--Brethine, MgSO4 - muscle relaxant, only give in hospital so you can monitor because it causes respiratory labor and stops contractions * Treat UTI if present * Steroids given IM to mature fetal lungs * betamethasone - cause production of surfactant- give to mom to give to baby * dexamethasone

preterm labor treatment