1. Intrapartal Nursing Care: Labor and Birth Linda L
Intrapartal Nursing Care: Labor and Birth Linda L. Franco RN MSN NE-BC Green = must know Red = Important to know Blue = history

2. Factors Important to Birth
Birth Passage
Baby
Relationship Between the Passage and the Baby
Physiologic Forces of Labor
Psychosocial Considerations

3. Birth Passage Consists of bony pelvis and soft tissues Bony Pelvis
False pelvis above linea terminalis
True pelvis below linea terminalis
Types of pelvis
Gynecoid – female, most common
Android – male, usually not adequate
Anthropoid – narrow from side to side, usually adequate
Platypelloid – narrow from back to back, usually not adequate

4. Pelvic Types

5. Fetal Head Composed of bony parts that can assist or hinder childbirth
Bones involved in birth not fused
2 frontal bones
2 parietal bones
occipital bones
Sutures – membranous spaces between cranial bones

6. Fetal Skull

7. Fontanelles Intersections of the cranial sutures
Used in identifying position of fetal head and assessing newborn after birth
Anterior Fontanelle, diamond shaped, closes by 18 months
Posterior Fontanelle, triangle shaped, closes by 2–3 months

8. Landmarks of Fetal Skull
Mentum – fetal chin
Sinciput – brow
Bregma – anterior fontanelle
Vertex – between anterior and posterior fontanelles
Occiput – occipital bone

9. Diameters Biparietal – major transverse diameter, average 9.25 cm
Anterior-Posterior – varies with how much head is flexed, most favorable when head is fully flexed
Fetal Attitude – position of fetus
Fetal Lie – position of fetus compared to mother
Longitudinal
Transverse

10. Fetal Presentation
Cephalic (most common, what we want, occurs 97% of the time)
Vertex – occiput is presenting part (most common)
Military – head is in neutral position, top of head is presenting part
Brow – head partially extended, brow is presenting part (tough on baby’s neck, could have neck or shoulder injuries during delivery)
Face – head hyperextended, face is presenting part

11. Fetal Presentations con.
Breech (occur in 3-4% of all births)
Complete – both knees are flexed, buttocks and feet present. Kind of sitting indian style
Frank – buttocks presents to pelvis, legs are usually up in front of the baby’s face
Footling – one or both feet present to pelvis
Shoulder Presentation
Aka Transverse Lie, occurs in 0.3% of all births, shoulder, arm, back, abd, or side is presenting. In this case a C-section will be performed

12. Transverse Lie External Version Cesarean Section Assess FHR
Where they have the mom lay on her back in the exam room and the dr tries to make the baby move just by pushing it and turning the baby. Usually doesn’t work
Cesarean Section
They will usually do this on these babies
Assess FHR
To make sure the baby isn’t in distress

13. Engagement
When largest diameter of presenting part reaches or passes through pelvic inlet
If the baby is engaged it’s starting to drop down… the top part of the pelvis is adequate, but they may still have to have a c section
Primigravida – 2 weeks before term
Multigravida – several weeks or at onset of labor

14. Station
Relationship of presenting part to an imaginary line drawn at the ischal spines (ischial spines mark the narrowest part thru which a baby must pass)
Zero station at level of ischial spines
Negative numbers above ischial spines
Baby hasn’t passed them yet
Positive numbers below ischial spines
After they’ve reached the spines and the baby’s head is descending

15. Station

16. Fetal Position
Relationship of the landmark on the presenting part to the maternal pelvis
Left (L) or Right (R)
Vertex – Occiput (O) (this is the one we want)
Face – Mentum (M)
Breech – Sacrum (S)
Shoulder – Acromion process (A)
Anterior(A), Posterior (P), or Transverse (T)
Could say LOP for left occiput posterior

17. Forces of Labor Primary - uterine contractions
Increment – building up to the contraction, longest phase
Decrement – the decline or letting up of the contraction
Frequency – time between the beginning of one to the beginning of the next
Intensity – refers to the strength of the contraction at the peak. Measured by palpating the fundus something or other
mild, moderate, and strong
Duration – from the beginning of a contraction to the end of that contraction

18. Psychosocial Considerations
New role transition
Self expectations
Coping mechanisms
Support systems
Preparation for childbirth
Cultural influences
Fear
Enhancing birth experience

19. Psychosocial Factors

20. Physiology of Labor Causes Hormones Uterine Distention
Progesterone – relaxes smooth muscle tissue
Estrogen – promotes uterine contractions, also helps soften connective tissue which leads to the opening of the cervix
Oxytocin
Prostaglandins
Fetal Cortisol
Corticotropin-Releasing Hormone
Uterine Distention
Myometrial Activity
Intraabdominal

21. Premonitory Signs of Labor
Lightening – when the fetus begins to setting into the pelvic inlet, the uterus moves downward and the fundus no longer presses on the diaphragm, the mom can breathe easier. Also causes leg cramps, increased pelvic pressure and increased urine frequency, and increases venous stasis which causes swelling of their lower extremities. Increased vaginal secretions resulting from congestion of the vaginal mucosa
Braxton Hicks – irregular intermittent contractions that occur thru ought pregnancy. Can be uncomfortable and exhausting to the mom
Cervical changes – at beginning of pregnancy it is firm, and over time it stretches and dilates. The softening of the cervix is called ripening
Bloody show – the mucus plug is expelled and the result of that is small amount of blood loss from the exposed cervical capillaries. That blood tinged secretion is called the bloody show. Usually a sign that labor will begin in hours
Rupture of Membranes – when the membranes do rupture the ambiotic fluid may be expelled in large amounts… when you’re water breaks. Sign of impending labor, once this happens the woman can’t get up and walk around
Sudden burst of energy – very common, approx hours before labor, no one really knows why they have this. May experience “nesting” at this time.
Other vague signs – weight loss of 1-3 lbs may occur, diarrhea, indigestion, N/V may occur before labor, cause is unknown

22. True and False Labor True False Regular contractions Cervical changes
Contractions start in back and radiate around to abdomen
Pain not relieved with activity
False
Irregular contractions
No cervical changes
Contractions primarily in abdomen
Pain may be relieved with activity

23. Stages of Labor Stage One – Effacement and Dilatation
Latent Phase – 0-3 cm; able to cope, talkative, high excitement, uterine contractions become established. Effacement begins, but little or no fetal descent
Active Phase – 4-7 cm; sense of helplessness, begins to fear loss of control, pain level is much worse at this level and you can see them kind of getting to the end of their rope. Contractions are usually 2-3 mins apart and last about 60 seconds and very strong in intensity
Transition Phase – 8-10 cm; significant anxiety, fears being left alone, feels she may be torn apart, contractions are mins with duration of seconds. As it approaches 10 there is increased pressure and a desire to “bear down” and maybe increase in bloody show. Sometimes these moms get the urge to push and we have to tell them not to because it’s too early. If they push and bear down it can cause the cervix to swell which slows the process because we have to wait for that swelling to go away to birth the baby

24. Stage Two – Maternal Pushing
Begins with complete cervical dilation and ends with the birth of the baby
Maternal urge to push
May feel relieved that birth is imminent
Apologetic
Primagravidas – 2-3 hours
Multigravidas – 5-30 mins

25. Cardinal Movements of Fetal Head
Descent – occurs because of 1 pressure of amniotic fluid, 2 direct pressure of the uterine fundus, 3 contractions of the abd muscles, 4 straightening of the fetal body
Flexion- flexion of the baby’s head because of resistance from the soft tissue of the pelvis, the pelvis floor, and the cervix
Internal Rotation – the fetal head must rotate with the diameter of the pelvic cavity which is widest in the anterior posterior diameter
Extension – the resistance of the pelvic floor and the mechanical movement of the vulva opening anteriorly and forward with extension of the fetal head as it passes under the symphysis pubis
Restitution – the shoulders of the fetus enter the pelvis inlet something or other. Because of this rotation the pelvis the neck becomes twisted. Basically the baby’s head becomes twisted around
External Rotation – as the shoulders rotate the head turns further to one side
Expulsion – the shoulder moves under the symphysis pubis.
On pg 391 and she’s reading it word for word

26. Stage Three – Delivery of Placenta
Placental Separation
Globular shaped uterus
Rise in fundus in abdomen
Sudden gush of blood
Further protrusion of the umbilical cord
Signs usually start after about 5 mins after the birth of the baby. When these signs start appearing the woman may feel the need to bear down again. Firm pressure may be applied to the fundus and gentle tugging on the cord to get it out
Placental Delivery
Maternal pushing can assist delivery
Retained if > 30 minutes
Shiny Schultze – inside out
Dirty Duncan – outer edge to inside
If the placenta or a piece of it is still stuck inside the mom there will be tons of bleeding
*placenta is only made correctly for about 40 weeks and after that it’s kind of shitty

27. Stage Four - Recovery Recovery 1-4 hours Hemodynamic changes
In the mom and in the baby, but really looking at mom…
Blood loss of 250 – 500 ml’s
Decreased blood pressure
Along with increase in pulse pressure and moderate tachycardia, because of the blood loss mentioned above
Fundus between symphysis and umbilicus
Fatigued, thirsty and hungry
Bladder hypotonic
Check mom for bladder fullness if they aren’t able to void

28. Maternal Systemic Response to Labor
Cardiovascular
Stressed by Uterine Contractions
Pain, anxiety, apprehension
Increased cardiac output
ml blood forced back into maternal circulation with each contraction
BP increases with uterine contractions
Position lowers cardiac output
Supine  cardiac output
Left lateral  BP

29. Maternal Response con. Respiratory Renal system
Oxygen demand increases
Hyperventilation may occur
Because of stress and pushing and what not
Fall in pH O2 and respiratory alkalosis may occur
Pushing increases lactate levels
S/S of hyperventilation
Tingling/numbness in nose, lips, fingers or toes, might have them breathe into a paper bag
Renal system
 maternal renin, plasma renin, and angiotensiogen – important in uteroplacental blood flow
Trauma to bladder
Blood and lymph drainage impaired from presenting part

30. Maternal Response con. GI system Immune system
Gastric motility and absorption 
Emptying time is  causing  risk of aspiration
Glucose levels  causing  insulin levels
More food in their stomach which sometimes comes up…
Immune system
WBC 25 – 30,000 stress response

31. Pain Causes of pain Dilatation of cervix Hypoxia of uterine muscle
This is what causes pain. When they are contracting as hard as they can contract they’re not getting oxygen which will cause pain
Stretching of lower uterine segment
Pressure on adjacent structures
Distention of vagina
Uterine contractions
Delivery of placenta
Episiotomy repair

32. Factors Affecting Response to Pain
Preparation for birth – childbirth classes
Respond by what is acceptable to culture
Some cultures it’s ok for woman to go nuts and yell, some cultures they’re supposed to be stoic and not express pain. Sign of weakness or whatever, but this doesn’t mean that they aren’t feeling pain.
Fatigue and sleep deprivation
Fatigued woman has less energy and it will be harder to get them to focus on what we need them to do.
Previous experience
Anxiety

33. Fetal Response to Labor
Heartrate changes
Early decelerations
 intracranial pressure causes vagal response
During labor
Late decelerations
 uteroplacental blood flow
Variable decelerations
Cord compression
Acid-Base Status in Labor
As uterine contractions increase, pH decreases slowly in response to hypoxia
Blood flow is decreased to the baby during contractions
Hemodynamic changes
Fetal BP and placental reserves protective mechanism during anoxic periods