THE INTRA PARTUM PERIOD
MATERNITY NURSING
Study of the Childbearing process that has taken place throughout history. Involves RiskProvides rewards.
They don’t call it labor for nothing!!!
It is the hardest work and most intense physical work a woman will do.
Pains with a purpose- just don’t say “pain”.
PSYCHOPROPHYLACTIC
Lamaze methods are based on classic behavioral conditioning- breathing
Trained to respond to a specific event
Controlled breathing is used to take attention away from the discomfort of the contraction
Goal: Inhibits pain impulses to the brain and keep Mom alert and active participant
BREATHING
Inhale slowly through the nose and exhale through mouth
Cleansing breath in and out as contraction starts and when over- exhalation should take longer
In beginning, take 8-10 breaths
As labor intensifies take 16-20 breaths
Effleurage- significant other sits behind the Mom and massages the stomach
Shallow chest breathing as progress alternating with puffs or huffs
Puffs and pants through an open mouth to control the urge to push prematurely
During delivery prevent sustained breath holding while bearing down- Valsalva- is not
recommend say “push” or “ugh”.- Anything that interferes with Mom’s blood flow, impedes the
baby’s heart flow.
PYSCHOSOCIAL
Dick-Read or Bradley
Focuses on the natural methods of delivery
Focused body relaxation
Positive mental imaging
NURSING MEASURES
Monitor FHR not uterine soufflé (the mother’s own pulse as it perfuses the arteries)
Monitor Vital signs of Mom
How to take a B/P
Between contractions left side lying position
PREMONITORY SIGNS OF LABOR
Lightening
Occurs 2-3 weeks before labor
“Baby drops”
Baby descends into the pelvis in preparation for labor and delivery
Mom breathes better
Urinary frequency is increased
Braxton-Hicks
Mild to moderate irregular uterine tightening/contractions
Do not result in cervical dilation
Bloody Show
Mucous plug that has sealed the uterus breaks free.
Thick, stringy mucus that is streaked or tinged with blood
Very little blood, must distinguish from true bleeding
If bleeding, call doctor stat
Spontaneous Rupture of Membranes
Bag of waters which enclose, protect, and cushion the fetus
May need amniotomy if not spontaneous
Sudden, unexpected gush of fluid from the vagina or in a slow steady trickle of fluid
??? Urine
Nitrazine test: turns blue when exposed to amniotic fluid
Once membranes rupture: 24 hour deadline to deliver
Increased chance of infection
If membranes rupture before the presenting part of fetus is engaged may have prolapsed
cord
Check vaginal area
Any gray bulging structure with pulsation is a prolapsed umbilical cord- 911!
Head down and elevate feet
May have to hold baby’s head during contraction until 911 C-section is done
Based on FHR
Note color, amount, odor, consistency of amniotic fluid- clear with flecks of vernix
Green or brown amniotic fluid is a sign of fetal distress- called meconium stained amniotic
fluid
Baby will have been hypoxic- brain damage or pneumonia
Weight Loss
1-3 pounds noted a few days before labor begins
Hormonal changes affecting fluid and electrolytes
Burst of Energy:
To clean, cook or prepare home or nest- “Nesting Instinct”
Caution not to overexert themselves!
TRUE LABOR- CONTRACTIONS
Follow regular pattern
Come closer together, get stronger, and last longer
Stronger with ambulation
Start in lower back and move to abdomen
Relaxation does not stop the contraction
Cervix softens, dilates, and effaces
TRUE LABOR
Fetus continues descent into pelvis
“5 minutes apart” rule with Primigravidas
FALSE LABOR- CONTRACTIONS
Do not follow predictable pattern
Vary in duration and intensity
Stop with ambulation
Felt in abdomen or lower back
Relaxation may slow or stop
Cervix may soften but does not dilate or efface
No fetal descent
CONTRACTIONS
Increment- when the uterus starts to tighten up
Acme- the peak or strongest effect
Decrement- the contraction starts to relax
Timing contractions: From the beginning of one contraction to the beginning of the next
contraction
Always monitor FHR
FETAL MONITORING
Tocotransducer- Tocodynometer- TOCO
Top of the fundus- Monitors contractions
Doppler transducer over the baby’s back- FHR
Continuous record of baby’s heart rate and contractions
Internal monitors- 2cm dilation- more reliable but invasive
Normal fetal heart rate= 110-160 Baseline
Accelerations- movement 15 beats for 15 seconds= movement or hypoxia
Decelerations- 15 beats for 15 seconds to be true deceleration
Early-contraction- no risk to fetus occurs at the onset of contraction
Late decels- mean fetal hypoxia and acidosis occurs after the contraction has
already started
Variable decels- can lead to fetal hypoxia-911- has no relation to the contraction
Variability: fluctuations in the beat to beat FHR as a result of the autonomic nervous system
activity
Short term variability is more reliable but internal monitor is needed
Long term variability- either external or internal can monitor but just shows large periodic
changes.
Duration: from the beginning of a contraction to the end of the same contraction- feel for
the tightening of the uterus
Relaxation: the interval between contractions- important so Mom can breathe in oxygen
and get enough oxygen to the baby
FACTORS AFFECTING LABOR
Attitude- body position or posture- flexed or extended- head to chest- arms to chestposition that takes up less space
Lie- relationship of long axis of baby to long axis of Mom- longitudinal or horizontal
Presentation- part of fetal body that enters the pelvic cavity first and therefore is the first
part to exit from the mother’s body- head is most common called cephalic
If the fetus is in the flexed position- back portion of the skull or vertex is in contact
with the cervix also called occiput
If slightly extended- brow presentation- B
When fetus is fully extended- the face or mentum is presenting part
Cephalic is desirable with vertex presentation most desirable for dilation and
effacement of cervix
Single footling
Complete and frank breech- s for sacrum
Scapula- Sc or A
Position- refers to the relationship of the presenting part of the fetus with the Mom’s pelvis
Side of maternal pelvis: R or L anatomically
Presenting part: O for occiput- M for mentum- S for sacrum- Sc or A for scapula or
acromion process.
Relative position of landmark to pelvis
A- anterior- aligned with anterior portion of maternal pelvis
P- posterior- aligned with posterior portion of maternal pelvis
T- transverse- aligned with either side or horizontal
Shape of maternal pelvis “passage”
Uterine contractions- the “push power”
Ability to bear down
Psychological readiness “psyche”
Full bladder impedes labor
Epidural Anesthesia slows down labor
TERMS
Station- refers to the relationship between the presenting part of the fetus and an imaginary
line drawn between the ischial spines of the maternal pelvis
-5 to +5
False pelvis/true pelvis- linea terminalis
2 innominate bones: ischium, ileum and symphis pubis
Effacement- 100%- progressive shortening and thinning of the vaginal portion of the cervixlong and thick- 0%
Dilation- 10 cm- progressive expansion or enlargement of the cervical opening- 1in=2.5 cm
CARDINAL MOVEMENTS
Descent
Engagement- head at the level of spines
Flexion
Internal Rotation
Extension
External Rotation
Expulsion
FIRST STAGE OF LABOR- DILATION AND EFFACEMENT
Onset of true labor until complete dilation and effacement of the cervix (6-18 hours)
1. Latent- Onset of labor until 3 cm dilation and 50% effaced (station -5 to 0)
Contractions 5-10 minutes apart
Lasts 8-9 hours
Do not give pain relief during this stage as it will stop contractions
2. Active- 4-7 cm dilation and 75% effaced 0 station
Contractions 3-4 minutes apart and around 45-60 seconds best for
dilation and effacement
Last 4-6 hours
Can give pain relief now
3. Transition- 8 cm to full dilation at 10 cm. 100% effaced Station +1-+2
Contractions occur every 1-2 minutes (should not go beyond 60 seconds)
Shortest phase lasting less than 3 hours
Restless, vomiting, rectal pressure
Mom may want to push but cannot!!
Pushing can cause cervical swelling and lifelong cervical complications
including hemorrhage
May hyperventilate and develop respiratory alkalosis-numbness/tingling
Paper bag or cup hands around mouth and nose to re-breathe CO2
Direct eye contact and simple commands
CONTRACTIONS
Contractions that occur at 2-3 minute intervals and last approximately 60 seconds
are best at dilating the cervix and allows for re-oxygenation of the fetus and uterine
muscles
Report contractions that occur 2 minutes apart and last more than 90 seconds- would most
likely be in the transition stage and can indicate fetal hypoxia and death
2 N D STAGE- DELIVERY
Starts with 10 cm. fully effaced and ends with delivery of the baby
2 hours for a primagravida or a few minutes with a Multigravida varies according to person
and if late medication or with epidural
Bearing down reflex- urge to push
Episiotomy/Lacerations
Check nuccal cord around neck
If delivery is imminent within 2 hours---no pain meds
ASSISTANCE- NEEDS HELP!!
Forceps
Low forceps delivery rather than high or mid forceps deliver
Low forceps- when baby’s head is visible on perineum
Complications: brain trauma, facial paralysis
Vacuum assistance
Caput succedaneum
Complications: edema or cephalhematoma and bleeding
3 R D STAGE- DELIVERY OF THE PLACENTA
Begins with delivery of the neonate and ends with the delivery of the placenta
Duration: 20 minutes
Signs:
lifting, rounding, and firm shape of the uterussudden small gush of blood
Lengthening of the cord that extends from the vagina
PLACENTA
Shiny Schultze: leaves the vagina with smooth shiny fetal side
Dirty Duncan: Leaves with rough raw bloody maternal side (more likely to leave fragments)
Inspected closely: looking for retained placental fragments
4 T H STAGE- RECOVERY
1-4 hours following delivery
Exhilaration
Exhaustion
Watch for hemorrhage- suspect problem when saturates 1 pad in hour/massage fundus
Lochia rubrae- 1-4 days- red, bloody, drainage
Lochia serosa- 4-7 days- pink drainage
Lochia alba- 7th day to 3 weeks white drainage
AT DELIVERY
Uterus firmly contracted to compress the internal blood vessels
Fundus should be midline and at the level of the umbilicus will descend 1 cm./day
Soft, boggy uterus indicates inadequate contractions
After pains/oxytocin from Posterior Pituitary stimulates contractions (LPN can
administer this Pitocin)
LACERATIONS
1st degree- skin and mucous membranes of the posterior connection of the labia minora and
outer vagina
2nd degree- same and plus muscles and fascia up to the anal sphincter
3rd degree- same but extends through the anal sphincter
4th degree- same but extends through the anterior rectal wall- ice vs. heat/sprays/surgery
INDUCTION
Amniotomy
Prostaglandin gel on cervix or vaginal suppository ONLY GIVEN BY RN to soften the
cervix
Pitocin or oxytocin drip-DONE ONLY BY RN
Watch I&O (will get ADH also), contractions, and fetal distress
LABOR INDUCTION OR AUGMENTATION
Oxytocin (Pitocin) stimulates uterine contractions
Nursing observations during induction/augmentation
Fetal heart rate
Character of contractions
If abnormality occurs, nurse stops oxytocin and begins measures to reduce contractions and
increase placental blood flow
CESAREAN SECTION- 25%
Fetal Distress
Failure to make progress
Abnormal Presentation
CPD- cephalopelvic disproportion
Genital Herpes
Abruptio Placentae
Previous C-Section
C-SECTION
NPO except antacid- preop teaching
Catheterization
IV
Midline Incision for emergency
Pfannestiel incision or low transverse or low horizontal incision along the pubic hairlinebikini incision
Massage fundus from the side toward the middle of the incision
ANESTHESIA RECOVERY
General Anesthesia can cause uterine atony- watch for hemorrhage as VS, Pad count, signs
of shock
Regional anesthesia-Epidural anesthesiaWatch for maternal hypotension
Numbness and paralysis
Reaches T6-7
Still during insertion
Position- sit up
Slows down contractions
Time contractions for mom
Safety- Give 2000 mL IV’s before delivery- Biggest complication is maternal
hypotension
PHARMOCOLOGICAL PAIN MANAGEMENT
Analgesics and adjunctive drugs
Regional analgesic and anesthetics
Local Infiltration
Pudendal Block- through the vagina and numbs the cervix
Epidural block
Subarachnoid block (spinal block)/Saddle block- 3-5 minutes/paralysis of lower
extremities/ headache 24-72 hours
Caudal block
General Anesthesia- get out in 7 minutes or the anesthesia will go to the baby
C-SECTION
Mom is always at risk post C-section of uterine rupture during next delivery
VBAC debate
Even more of a risk after a classic incision for emergency C-section.
RH ISOIMMUNIZATION
Blood typing and cross matching
A, B, AB, O
Rh + If blood type differs between Mom and Baby then antibodies will be built up
Recessive gene- Both parents have to contribute (–) in order for baby to remain negative
If (-) mother and (+) baby, the first baby will be fine but then subsequent babies will be
destroyed by the mother
Rhogam must be given with 72 hours after the first birth to prevent antibodies, or if Rhmom will be given Rhogam at 28 weeks to prevent.