INTRAPARTUM

- Period from the onset of contractions to the first 1 to 4 hours after delivery

Intrapartal Notes – inside ER

Admitting the laboring Mother:
Personal Data: name, age, address, etc.
Baseline Data: v/s especially BP, weight
Obstetrical Data: gravida # preg, para- viable pregnancy, 22 – 24 weeks
Physical Exams, Pelvic Exams

LABOR
 Series of processes by which the products of conception are expelled from the maternal body

Theories of the Onset of Labor

1.) Uterine stretch theory (any hallow organ stretched, will always contract & expel its content)
– contraction action
2.) Oxytocin theory – post pit gland releases oxytocin. Hypothalamus produces oxytocin
3.) Prostaglandin theory – stimulation of arachidonic acid – prostaglandin- contraction
4.) Progesterone theory – before labor, decrease progesterone will stimulate contractions &
labor
5.) Theory of aging placenta – life span of placenta 42 wks. At 36 weeks degenerates (leading to
contraction – onset labor).

FACTORS AFFECTING LABOR & DELIVERY PROCESS

1. Passenger
a. Fetal head – is the largest presenting part – common presenting part – ¼ of its length.
Bones – 6 bones S – sphenoid F – frontal - sinciput
E – ethmoid O – occuputal - occiput
T – temporal P – parietal 2 x
Measurement fetal head:
1. transverse diameter – 9.25cm
- biparietal – largest transverse
- bitemporal 8 cm
2. bimastoid 7cm smallest transverse

Sutures – intermembranous spaces that allow molding.

1.) sagittal suture – connects 2 parietal bones ( sagitna)
2.) coronal suture – connect parietal & frontal bone (crown)
3.) lambdoidal suture – connects occipital & parietal bone

Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis

Fontanels:
1.) Anterior fontanel – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18 months
after birth- close
2.) Posterior fontanel or lambda – triangular shape, 1 x 1 cm. closes at 2 – 3 months.
4.) Anteroposterior diameter
  suboccipitobregmatic 9.5 cm, complete flexion, smallest AP
 occipitofrontal 12cm partial flexion
 occipitomental – 13.5 cm hyper extension submentobragmatic-face presentation

2. Passageway

Problems with passageway

Mother: 1.) < 4’9” tall
2.) < 18 years old
3.) Underwent pelvic dislocation

Pelvis
4 main pelvic types
1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy
2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow
3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow
4. Platypelloid – flat AP diameter – narrow, transverse – wider

Pelvis
 2 hip bones – 2 innominate bones

3 Parts of 2 Innominate Bones

Ileum – lateral side of hips
- iliac crest – flaring superior border forming prominence of hips
Ischium – inferior portion
- ischial tuberosity where we sit – landmark to get external measurement of
pelvis
Pubes – ant portion – symphisis pubis junction between the two (2) pubis
1 sacrum – post portion – sacral prominence – landmark to get internal
measurement of pelvis
1 coccyx – 5 small bones compresses during vaginal delivery

Important Measurements

1. Diagonal Conjugate – measure between sacral promontory and inferior margin of the
symphysis pubis.
Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC – 11.5 cm=true conjugate)

2. True conjugate/conjugate vera – measure between the anterior surface of the sacral
promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm

3. Obstetrical conjugate – smallest AP diameter. Pelvis at 10 cm or more.

Tuberoischi Diameter – transverse diameter of the pelvic outlet. Ischial tuberosity –

approximated with use of fist – 8 cm & above.
3. Power
 The force acting to expel the fetus and placenta – myometrium – powers of labor
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity

1. Primary power
 Forces acting to expel the fetus and placenta
 Involuntary uterine contractions
2. Secondary power
 Voluntary bearing down efforts

Aspects of Uterine Contractions:

1. Duration – from the beginning of one contraction to the end of the same contraction.
2. Frequency – from the beginning of one contraction to the beginning of the next contraction.
3. Interval – from the end of one contraction to the beginning of the next contraction.
4. Intensity – strength of a contraction; maybe mild, moderate or strong
 Check fundus at the end of contraction to determine whether it relaxes.
a. Mild – does not feel more than minimally tense
b. Moderate – feels firm
c. Strong – hard as wood

Phases of a uterine contraction:

1. Increment/Crescendo – building up or increasing intensity of contraction
2. Acme/Apex – peak or height of a contraction
3. Decrement/Decrescendo – end/relaxation

3. Psyche
 Pregnant woman’s general behavior and influence upon her
 Maternal responses to uterine contractions
 Cultural influence and perceptions about labor and delivery
 Antepartal and childbirth education
 Ability to communicate feelings to SO and staff
 Support system

Length of Normal Labor

Stages Primipara Multipara

1st stage 12 -13 hours 8 hours
2nd stage 1 hour 20 minutes
3rd stage 4 – 5 minutes 4 – 5 minutes
4th stage 1 – 2 hours 1 – 2 hours
STAGE 16 hours 10 hours
Premonitory Signs of Labor:

1. Lightening – settling of the fetal head into the true pelvis that occurs 14 days before onset of
labor
2. Cervical change – softening, dilation and effacement
3. Backache – low, dull backache and mild cramping
4. Energy burst/Nesting – hyperactivity 1-2 days prior to labor onset
5. Ruptured membrane – (occasional sign) pregnant woman goes into labor within 24 hours after
membrane has rupture.
6. Bloody show – pressure of descending presenting part causes rupture of capillaries in the cervix
—blood mixes with mucus
7. Increased of Braxton- Hicks contractions

Mechanisms of Labor/Fetal Positional Changes (ED FIRE ERE)

1. Engagement – fetal presenting part is fixed in the true pelvis
2. Descent – presenting part progresses through the pelvis
3. Flexion – descending head meets pelvic floor; chin is brought down to chest
4. Internal Rotation – fetal head rotates to facilitate movement through the pelvis
5. Extension – once fetal head reaches the perineum, it extends to be born
6. External Rotation – shoulders engage and move similarly with the head
7. Expulsion – entire infant emerges from the mother

True Labor False Labor

1. Contractions occur at regular intervals 1. Contractions are irregular
2. Pain begins in the back & radiates around 2. Pain confined to abdomen
the abdomen in girdle-like fashion
3. Increase in duration, frequency and 3. Usually no change
intensity
4. Cervical dilatation & effacement are 4. No change
progressing.
- most important difference.
5. Interval between contractions shortens 5. Usually no change
6. Intensity increases with walking 6. Walking has no effect on
contractions

STAGES OF LABOR
1. First Stage
 Stage of cervical effacement and dilation
 Begins with the onset of true labor and ends with complete dilatation of the cervix.
 Considered the longest phase; cervix dilates fully to 10 cm by the end of the 1 st stage.

Management:
 Seeks hospital admission – mild, regular contractions
 Orient the client and the family – provide privacy
 Monitor vital signs and FHR every 15 minutes.
 Bed rest for ruptured membrane
 Empty bladder
  Do not encourage patient to push
 Provide pain relief, breathing techniques, maintain safety

Phases Dilation Interval Duration

Latent 0 – 4 cm 10 – 30 minutes 30 – 40 seconds
Active 5 – 8 cm 2 – 5 minutes 40 – 60 seconds
Transition 8 – 10 1 ½ - 2 minutes 60 – 90 seconds

2. Second Stage
 Stage of expulsion
 From full cervical dilatation to the expulsion of the fetus.
 Contractions very intense, every 1-2 minutes, and lasts 60-90 seconds.

Management:
 Admit patient to Delivery room for 8-9 cm dilation for multigravidas & full dilation for primipara
 Monitor V/S and FHR
 Prepare perineal area
 Position legs on lithotomy at the same time – to prevent injury to the uterine ligament.
 Instruct mother to push with contractions but not during crowning, and to pant (rapid and
shallow breathing to prevent rapid expulsion of the baby)
 Assist in episiotomy – incision made in the perineum to prevent lacerations
 Apply the Modified Ritgen’s maneuver
 Cover the anus with sterile towel and exert upward and forward pressure on the fetal chin while
exerting gentle pressure with two fingers on the head.
 Ease the head out and wipe/suction the nose and mouth of secretions to establish patent airway
 Insert 2 fingers into the vagina to feel for the presence of a cord looped around the neck (nuchal
cord)
 As the head rotates, deliver the anterior should by exerting a gentle downward push and then
slowly give an upward lift to deliver the posterior shoulder. Take note of the time of delivery of
the baby.
 Provide immediate care of the newborn

Episiotomy
 Prevent laceration; widen vaginal canal; shorten 2 nd stage
 Local of pudendal anesthesia

Types:
1. Median - 6 o’clock

Advantages
 Minimal blood loss
 Less painful
 Easy to repair
 Heals fast

Disadvantage: ↑ risk for 3rd or 4th extension

2. Mediolateral – 5 or 7 o’clock
Advantage
 Minimal risk of extension into the rectum

Disadvantage
 Greater blood loss
 Hard to repair
 More painful
 Slow to heal

3. Third Stage
 Stage of Placental Expulsion
 from delivery of infant to delivery of placenta; average duration: 5-30 minutes after the birth of
the newborn

Signs of placental separation

1. Uterus becoming round/globular and firm (Calkin’s sign) – earliest sign of placental separation
2. Fundus rises up in the abdomen
3. Sudden gush of blood from the vagina
4. Protrusion/lengthening of the cord

Types of Placental delivery:

1. Schultz – placenta separates first at its center and last at its edges, and tends to fold itself
like an umbrella presenting the fetal surface which is shiny; 80% of placentas
separate in this manner
2. Duncan – placenta separates first at its edges, and slides along the uterine surface like an
inverted umbrella presenting the maternal surface which is raw, red, beefy,
irregular and “dirty”; only about 20% of placentas separate this way.

Nursing Care:
a. Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous
fundal push – causes uterine inversion.
b. Do the Brandt-Andrew maneuver- slowly wind the cord around the clamp until the placenta
spontaneously comes out
c. Take note of the time of placental separation – usually delivered within 5-20 mins after
delivery of the baby
d. Inspect for completeness of cotyledons.
e. Palpate uterus to determine degree of contraction. If relax, boggy or non-contracted, massage
gently and properly.
f. Inject oxytocin to maintain uterine contractions, thus preventing hemorrhage. NOTE: Should
not be given before placental delivery and take BP before administration.
g. Monitor V/S
h. Inspect the perineum for lacerations
i. Assist the doctor in doing episiorrhaphy
j. Make mother comfortable by perineal care and apply clean sanitary napkin
k. Position the newly-delivered mother flat on bed without pillows to prevent dizziness
l. Provide additional blankets to keep her warm – may complain of chills
m. Allow patient to sleep in order to regain lost energy
4. Fourth Stage
 Stage of recovery
 Time from delivery of placenta to homeostasis
 First 1-4 hours after deliver

Nursing Care:
 Check fundus every 15 mins. for 1 hour then every 30 min for the next 4 hours
 Fundus should be firm, in the midline and is just above the umbilicus
 Monitor V/S every 15 minutes
 Assess lochia– should be moderate in amount
 Assess bladder- a full bladder is evidenced by a fundus to the right of the midline and dark-red
bleeding with some clots
 Check perineum - should be clean, with intact sutures, tender, discolored and edematous

Physiologic effects of labor on a woman

1. CARDIOVASCULAR SYSTEM
 Increased BP
 Increased cardiac output
 Supine hypotension
 Upright or side - lying

2. HEMOPOIETIC SYSTEM
 Leukocytosis d/t stress and heavy exertion
 25,000 to 30,000 cells/mm3

3. RESPIRATORY SYSTEM
 Increased oxygen consumption
 Increased RR
 Possible hyperventilation

4. TEMPERATURE REGULATION
 Slight elevation (1°F) - ↑ muscular activity
 Diaphoresis

5. FLUID BALANCE
 Increase in sensible water loss
 ↑ in fluid loss and ↓ in intake = imbalance

6. URINARY SYSTEM
 Concentrated urine – sp. 1.020 – 1.030
 Proteinuria (trace to +1)
 Reduced bladder tone – ask woman to void q 2 hours

7. MUSCULOSKELETAL SYSTEM
 Relaxin – ovarian released hormone – soften the cartilage around the bones
  Pubis and sacral/coccyx joints – relaxed and movable
 Backache
 Nagging pain at the pubis

8. GASTROINTESTINAL SYSTEM
 Fairly inactive
 Digestive and emptying time is prolonged
 Loose bowel movement as contractions grow strong

9. NEUROLOGIC AND SENSORY

 Pain (↑PR and RR)

Fetal responses to labor

1. NEUROLOGIC SYSTEM
 Increased intracranial pressure
 FHR ↓by 5 bpm during a contraction as soon as contraction strength reaches 40 mmHg
 Early deceleration – head compression

2. CARDIOVASCULAR SYSTEM
 Slight fetal hypoxia

3. INTEGUMENTARY SYSTEM
 Petechiae or ecchymotic areas
 Edema of presenting part – caput succedaneum

4. MUSCULOSKELETAL SYSTEM
 The force of uterine contractions tends to push a fetus into a position of full flexion, the most
advantageous position for birth

5. RESPIRATORY SYSTEM
 Maturation of surfactant production
 Pressure applied to the chest from contractions and passage through the birth canal helps to
clear it of lung fluid

Fetal danger signs

1. Fetal bradycardia or fetal tachycardia - fetal heart rate less than 100 beat per minutes or
tachycardia of more than 180 beat per minutes.
1. Meconium – stained amniotic fluids in non breach
2. Fetal thrashing - hyper activity of the fetus as he struggles for more oxygen.
3. Fetal acidosis - Scalp capillary technique – pH lower than 7. 2

Maternal danger signals

1. Rising or falling blood pressure

 Rising – PIH
  Falling - intrauterine hemorrhage
 120/80 mmHg

Criteria for PIH

 Systolic pressure - ↑ 140 mmHg
 Diastolic pressure - ↑ 90 mmHg
 Increase in systolic pressure of more than 30 mmHg
 Increase in diastolic pressure of more than 15 mmHg

2. Abnormal Pulse
 60 – 100 bpm
 Pregnant – 70 to 80 bpm
 Greater than 100 bpm – hemorrhage

3. Inadequate or prolong contractions

 More frequent, intense and longer
 Uterine inertia – less frequent, intense and shorter in duration

4. Pathologic retraction ring

 Indentation across a woman’s abdomen where upper and lower segments of the uterus join
 Uterine rupture

4. Abnormal lower abdominal contour – a full bladder

Reasons:
a. the bladder may be injured by the pressure of the fetal head
b. pressure of the full bladder may not allow fetal head descend

6. Increasing apprehension
 Oxygen deprivation or internal hemorrhage

XIV. Post Partum

Postpartum
 Puerperium; 6 – week period after childbirth
 5th stage of labor
 After 24hrs :Normal increase WBC up to 30,000 cumm
Involution – return of repro organ to its non pregnant state.
Hyperfibrinogenia
 prone to thrombus formation
 early ambulation

Principles underlying puerperium

 To return to Normal and Facilitate healing

Phases of the Puerperium

1. Taking-in: review pregnancy and labor and birth, time of reflection
  2-3 days
 Woman is passive
 Dependence: let the nurse decision for the woman
 Due to physical discomfort
 Talk about the pregnancy
 Holds child with sense of wonder
 Encourage her to talk

2. Taking-hold: initiate action

 Begins to take a strong interest in caring for her child
 Praise for things she do well

3. Letting-go: redefines her new role

 Gives up the fantasized image of her child

Physiologic Changes in the Postpartum Period

Systemic Changes

1. Cardiovascular System
 The first few minutes after delivery is the most critical period in mothers because the increased
in plasma volume return to its normal state and thus adding to the workload of the heart. This is
critical especially to gravidocardiac mothers.

2. Genital tract
a. Cervix – cervical opening
b. Vaginal and Pelvic Floor
c. Uterus – return to normal 6 – 8 wks. Fundus goes down 1 finger breath/day until 10 th day – no longer
palpable due behind symphisis pubis
- 3 days after post partum: sub involuted uterus – delayed healing uterus with big clots of blood-
a medium for bacterial growth- (puerperal sepsis)- D&C
- after, birth pain:
1. position prone
2. cold compress – to prevent bleeding
3. mefenamic acid

d. Lochia-bld, wbc, deciduas, microorganism. Nsd & Cs with lochia.

1. Ruba – red 1st 3 days present, musty/mousy, moderate amt
2. Serosa – pink to brown 4 – 9th day, limited amt
3. Alba – créme white 10 – 21 days very decreased amt
dysuria
- urine collection
- alternate warm & cold compress
- stimulate bladder
3. Urinary tract
 Bladder – freq in urination after delivery- urinary retention with overflow

4. Colon
 Constipation – due NPO, fear of bearing down

5. Perineal area – painful – episiotomy site – sims pos, cold compress for immediate pain after 24 hrs,
hot sitz bath, not compress
 Sex is resumed - when perineum has healed

Possible complications in postpartum period

1. Hemorrhage – bleeding of > 500cc
CS – 600 – 800 cc normal
NSD 500 cc

I. Early postpartum hemorrhage– bleeding within 1 st 24 hrs. Baggy or relaxed uterus & profuse
bleeding – uterine atony. Complications: hypovolemic shock.
Management:
1.) massage uterus until contracted
2.) cold compress
3.) modified trendelenberg
4.) IV fast drip/ oxytocin IV drip

1st degree laceration – affects vaginal skin & mucus membrane.

2nd degree – 1st degree + muscles of vagina
3rd degree – 2nd degree + external sphincter of rectum
4th degree – 3rd degree + mucus membrane of rectum

Breast feeding – post pit gland will release oxytocin so uterus will contract.
Well contracted uterus + bleeding = laceration
- assess perineum for laceration
- degree of laceration
- mgt episiorapy

DIC – Disseminated Intravascular Coagulopathy. Hypofibrinogen- failure to coagulate.

- bleeding to any part of body
- hysterectomy if with abruption placenta
mgt: BT- cryoprecipitate or fresh frozen plasma

II. Late Postpartum hemorrhage – bleeding after 24 hrs – retained placental fragments
Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C except placenta increta,
percreta,

Acreta – attached placenta to myometrium.

Increta – deeper attachment of placenta to myometrium hysterectomy
Percreta – invasion of placenta to perimetrium
 Hematoma – bluish or purple discoloration of SQ tissue of vagina or perineum.
- too much manipulation
- large baby
- pudendal anesthesia

Management:
1.) cold compress every 30 minutes with rest period of 30 minutes for 24 hrs
2.) shave
3.) incision on site, scraping & suturing

Infection- sources of infection

1.)endogenous – from within body
2.) exogenous – from outside
1.) anaerobic streptococci – most common - from members health team
2.) unhealthy sexual practices
General signs of inflammation:
1. Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling)
2. purulent discharges
3. fever

Gen management:
1.) Supportive care – CBR, hydration, TSB, cold compress, paracetamol, VITC, culture &
sensitivity – for antibiotic
 prolonged use of antibiotic lead to fungal infection
 inflammation of perineum – see general signs of inflammation
2 to 3 stitches dislocated with purulent discharge
Management:
 Removal of sutures & drainage, saline, between & resulting.
 Endometriosis – inflammation of endometrial lining
Sx:
Abdominal tenderness, pos.
Fowlers – to facilitate drainage & localize infection oxytocin & antibiotic

Motivate the use of Family Planning

1.) determine one’s own beliefs 1st
2.) never advice a permanent method of planning
3.) method of choice is an individuals choice.

Natural Method – the only method accepted by the Catholic Church

Billings / Cervical mucus– test spinnbarkeit & ferning (estrogen)
- clear, watery, stretchable, elastic – long spinnbarkeit

Basal Body Temperature 13th day temp goes down before ovulation – no sex
- get before arising in bed

LAM – lactation amenorrheal method – hormone that inhibits ovulation is prolactin.

 breast feeding- menstruation will come out 4 – 6 months
 bottle fed 2 – 3 months
  disadvantage of lam – might get pregnant

Symptothermal – combination of BBT & cervical. Best method

Social Method – 1.) coitus interuptus/ withdrawal - least effective method

2. coitus reservatus – sex without ejaculation –
3. coitus interfemora – “ipit”
4. calendar method

OVULATION –count minus 14 days before next mens (14 days before next mens)

Origoknause formula –
- monitor cycle for 1 year
- -get short test & longest cycle from Jan – Dec
- shortest – 18
- longest – 11

June 26 Dec 33
- 18 -11
8 - 22 unsafe days

21 day pill- start 5th day of mens

28day pill- start 1st day of mens
missed 1 pill – take 2 next day

Physiologic Method

Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland
production of FSH and LH which are essential for the maturation and rupture of a follicle. 99.9%
effective. Waiting time to become pregnant- 3 months. Consult OB-6mos.

Alerts on Oral Contraceptive:

-in case a mother who is taking an oral contraceptive for almost long time plans to have a baby, she
would wait for at least 3 months before attempting to conceive to provide time for the estrogen and
progesterone levels to return to normal.
- if a new oral contraceptive is prescribed the mother should continue taking the previously prescribed
contraceptive and begin taking the new one on the first day of the next menses.
- discontinue oral contraceptive if there is signs of severe headache as this is an indication of
hypertension associated with increase incidence of CVA and subarachnoid hemorrhage.

Signs of hypertension
Immediate Discontinuation
A – abdominal pain
C – chest pain
H - headache
E – eye problems
S – severe leg cramps
 If mom HPN – stop pills STAT!
Adverse effect: breakthrough bleeding
Contraindicated:
1.) chain smoker
2.) extreme obesity
3.) HPN
4.) DM
5.) Thrombophlebitis or problems in clotting factors

- if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that
day. If forgotten for two consecutive days, or more days, use another method for the rest of the
cycle and the start again.

DMPA – depoproveda – has progesterone inhibits LH – inhibits ovulation

Depomedroxy progesterone acetate – IM q 3 months
- never massage injected site, it will shorten duration

Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone.
- 5 yrs – disadvantage if keloid skin
- as soon as removed – can become pregnant

Mechanism and Chemical Barriers

Intrauterine Device (IUD)

Action: prevents implantation – affects motility of sperm & ovum
- right time to insert is after delivery or during menstruation

 primary indication for use of IUD

- parity or # of children, if 1 kid only don’t use IUD

Health teaching:
1.) Check for string daily
2.) Monthly checkup
3.) Regular pap smear
Alerts:
- prevents implantation
- most common complications: excessive menstrual flow and expulsion of the device (common
problem)
- others:
P eriod late (pregnancy suspected)
Abnormal spotting or bleeding
A bdominal pain or pain with intercourse
I nfection (abnormal vaginal discharge)
N ot feeling well, fever, chills
S trings lost, shorter or longer
Uterine inflammation, uterine perforation, ectopic pregnancy
Condom – latex inserted to erected penis or lubricated vagina
Adv; gives highest protection against STD – female condom
Alerts:
Disadvantage:
- it lessen sexual satisfaction
- it gives higher protection in the prevention of STDs

Diaphragm – rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus.
REVERSIBLE

Health teaching:
1.) proper hygiene
2.) check for holes before use
3.) must stay in place 6 – 8 hrs after sex
4.) must be refitted especially if without wt change 15 lbs
5.) spermicide – chem. Barrier ex. Foam (most effective), jellies, creams
S/effect: Toxic shock syndrome

Alerts: Should be kept in place for about 6 – 8 hours

Cervical Cap – most durable than diaphragm no need to apply spermicide

Contraindication: abnormal pap smear

Foams, Jellies, Creams

Surgical Method
(BTL) Bilateral Tubal Ligation – can be reversed 20% chance.
Health teaching: avoid lifting heavy objects

Vasectomy – cut vas deferense.

Health teaching: >30 ejaculations before safe sex
O – Zero sperm count, safe