47385717 intrapartal care
TRANSCRIPT
-
8/3/2019 47385717 Intrapartal Care
1/37
care of a pregnant woman from the onset
of labor to the completion of the fourth
stage of labor with the expulsion of the
placenta.
-
8/3/2019 47385717 Intrapartal Care
2/37
The Process of Labor Four Ps
Theimage cannotbe displayed.Your computer may nothave enough memory toopen theimage, or theimagemay havebeen corrupted.Restartyour computer,and then open thefileagain.I fthe red x stillappears,you may haveto deletetheimageandthen insertitagain.
-
8/3/2019 47385717 Intrapartal Care
3/37
1. Labor: coordinated sequence of
involuntary uterine contractions
2. Delivery: actual even of birth
-
8/3/2019 47385717 Intrapartal Care
4/37
Powers
Passageway
Passenger
Psyche
-
8/3/2019 47385717 Intrapartal Care
5/37
1. The forces acting to expel the fetus
2. Effacement: shortening and thinning of
the cervix during the first stage of labor
3. Dilation: enlargement of cervical os andcervical canal during first stage.
4. Pushing efforts of mother during second
stage.
-
8/3/2019 47385717 Intrapartal Care
6/37
the mothers rigid bony pelvis and the softtissues of the cervix, pelvic floor and vagina.
-
8/3/2019 47385717 Intrapartal Care
7/37
False Pelvis
The false pelvis is
the shallow
portion above thepelvic brim
The false pelcis
supports the
abdominal viscera
True Pelvis
The true pelvis lies
below the pelvic
brim
The true pelvis
consists of the
pelvic inlet, mid-
pelvis and pelvic
outlet
-
8/3/2019 47385717 Intrapartal Care
8/37
-
8/3/2019 47385717 Intrapartal Care
9/37
-
8/3/2019 47385717 Intrapartal Care
10/37
Normal female pelvis
Transversely rounded or blunt
Most favorable for successful labor andbirth
-
8/3/2019 47385717 Intrapartal Care
11/37
Oval shaped
Adequate outlet with a normal ormoderately narrow pubic arch
-
8/3/2019 47385717 Intrapartal Care
12/37
Wedge-shaped or angulated
Seen in males
Not favorable for labor
Narrow pelvic planes can cause slow
descent and midpelvis arrest
Theimage cannotbed isplayed.Your computer may nothaveenough memory toopen theimage,or theimage may havebeen corrupted.Restart your computer,and then open thefile again.If thered x stillappears,you may havetodeletethe imageand then insertit again.
-
8/3/2019 47385717 Intrapartal Care
13/37
Flat with an oval inlet
Wide transverse diameter but shortantero-posterior diameter, making outletinadequate.
-
8/3/2019 47385717 Intrapartal Care
14/37
: the Fetus
-
8/3/2019 47385717 Intrapartal Care
15/37
This is the relationship between the
presenting part of the baby -- the head,shoulder, buttocks, or feet -- and two
parts of the mother's pelvis called the
ischial spines. Normally the ischial spines
are the narrowest part of the pelvis.
They are a natural measuring point for
the delivery progress.
If the presenting part lies above the
ischial spines, the station is reported as anegative number from -1 to -5 (each
number is a centimeter). If the
presenting part lies below the ischial
spines, the station is reported as a
positive number from +1 to +5. The baby
is said to be "engaged" in the pelvis when
it is even with the ischial spines at 0
-
8/3/2019 47385717 Intrapartal Care
16/37
This is the relationship between the head
to tailbone axis of the fetus and the head
to tailbone axis of the mother. If the two
are parallel, then the fetus is said to be
in a longitudinal lie. If the two are at 90-
degree angles to each other, the fetus is
said to be in a transverse lie. Nearly all
(99.5%) fetuses are in a longitudinal lie.
-
8/3/2019 47385717 Intrapartal Care
17/37
The fetal attitude describes the
relationship of the fetus' body parts to
one another. The normal fetal attitude is
commonly referred to as the fetal
position. The head is tucked down to the
chest, with arms and legs drawn in
towards the center of the chest.
Abnormal fetal attitudes may include a
head that is extended back or other body
parts extended or positioned behind the
back. Abnormal fetal attitudes can
increase the diameter of the presenting
part as it passes through the pelvis,
increasing the difficulty of birth.
-
8/3/2019 47385717 Intrapartal Care
18/37
Cephalic (head-first) presentation:Cephalic presentation is considered normaland occurs in about 97% of deliveries. Thereare different types of cephalic presentation,which depend on the fetal attitude.Rarely, the fetus' head is extended back, andthe chin, face, or forehead will present firstdepending on the degree of extension. This is amore difficult delivery, because this is not thesmallest part of the fetus' head. It may resultin a need for cesarean delivery.
A cesarean delivery may be recommended forany of the fetal positions other than cephalic.Breech presentation:Breech presentation is considered abnormaland occurs about 3% of the time. A completebreech presentation occurs when the buttockspresent first, and both the hips and knees areflexed. A frank breech occurs when the hipsare flexed so the legs are straight and
completely drawn up toward the chest. Otherbreech positions occur when either the feet orknees come out first.Shoulder presentation:The shoulder, arm, or trunk may present first ifthe fetus is in a transverse lie. This type ofpresentation occurs less than 1% of the time.Transverse lie is more common with prematuredelivery or multiple pregnancies.
-
8/3/2019 47385717 Intrapartal Care
19/37
The mother may experience anxiety or fear.It is the mental preparation of the mother
for labor and deliver.
-
8/3/2019 47385717 Intrapartal Care
20/37
True Labor Contraction increase in
duration and intensity. Discomfort that begins
in the back andradiates to the front ofthe abdomen.
Walking intensifiescontraction.
Cervical dilatation andeffacement areprogressive.
Resting or relaxing inwarm water does notdecrease the intensityof contractions.
False Labor Irregular contractions
that do not increasein duration andintensity.
Discomfort that is feltprimarilu in theabdomen
Contractions that arenot affected orlessened by walking,rest or warm water.
No change(contraction)
Contractions thatproduce no effect oncervix
-
8/3/2019 47385717 Intrapartal Care
21/37
Leopolds Maneuver is preferably
performed after 24 weeks gestation when
fetal outline can be already palpated.
-
8/3/2019 47385717 Intrapartal Care
22/37
Instruct woman to empty her bladder first.
Place woman in dorsal recumbent position,
supine with knees flexed to relax abdominal
muscles. Place a small pillow under the headfor comfort.
Drape properly to maintain privacy.
Explain procedure to the patient.
Warms hands by rubbing together. (Coldhands can stimulate uterine contractions).
Use the palm for palpation not the fingers.
-
8/3/2019 47385717 Intrapartal Care
23/37
Purpose Procedure Findings
First Maneuver:
Fundal Grip
To determine fetal part lying in the
fundus.
To determine presentation.
Using both hands, feel for the fetal
part lying in the fundus.
Head is more firm, hard and round
that moves independently of the
body.
Breech is less well defined that movesonly in conjunction with the body.
Second Maneuver:
Umbilical Grip
To identify location of fetal back.
To determine position.
One hand is used to steady the uterus
on one side of the abdomen while the
other hand moves slightly on a
circular motion from top to the lower
segment of the uterus to feel for the
fetal back and small fetal parts.
Use gentle but deep pressure.
Fetal back is smooth, hard, and
resistant surface
Knees and elbows of fetus feel with a
number of angular nodulation
Third Maneuver:
Pawliks Grip
To determine engagement of
presenting part.
Using thumb and finger, grasp the
lower portion of the abdomen above
symphisis pubis, press in slightly and
make gentle movements from side to
side.
The presenting part is not engaged if
it is not movable.
It is not yet engaged if it is still
movable.
Fourth Maneuver:
Pelvic Grip
To determine the degree of flexion of
fetal head.
To determine attitude or habitus.
Facing foot part of the woman,
palpate fetal head pressing
downward about 2 inches above the
inguinal ligament.
Use both hands.
Good attitude if brow correspond
to the side (2nd maneuver) that
contained the elbows and knees.
Poor atitude if examining fingers
will meet an obstruction on the same
side as fetal back (hyperextended
head)
Also palpates infants anteroposterior
position. If brow is very easily
palpated, fetus is at posterior position
(occiput pointing towards womans
back)
-
8/3/2019 47385717 Intrapartal Care
24/37
Provides a focus during contractions,
interfering with pain sensory transmission.
Begin with simple breathing patterns and
progress to more complex ones as needed. Promote relaxation and oxygenation.
-
8/3/2019 47385717 Intrapartal Care
25/37
First stage (stage of dilatation)
2 to full dilation
-
8/3/2019 47385717 Intrapartal Care
26/37
y Latent Phase
Cervical dilatation is 0 to4cm
Uterine contractionsoccur every 15 to 3omminutes and are 20 to 40second in duration and ofmild intensity
Mothe is talkative andeager to be in labor
Interventions
Encourage mother andpartner to participate incare
Assist with comfortmeasures changes ofposition (left sidelying), ambulation.
Keep mother andpartner informed ofprogress
Offer fluids and icechips
Encourage voiding every1 to 2 hours.
-
8/3/2019 47385717 Intrapartal Care
27/37
Active Phase
Cervical dilatation is 4to 7cm
Uterine contractionsoccur every 2 to 5 mins.And are 30 to 50 secondsin duration andmoderate intensity.
Mother may experiencefeelings of helplessness
Mother becomes restlessand anxious ascontractions becomestronger
Interventions:
Encouragemaintenance of
effective breathingpatterns.
Provide a quietenvironment
Keep mother and
partner informed ofprogress.
Promote comfort withbackrubs, sacralpressure, pillowsupport and position
changes. Instruct partner in
effleurage/back rub
-
8/3/2019 47385717 Intrapartal Care
28/37
Transition Phase
Cervical dilation is 7 to10cm
The uterine contractionsoccur every 2 to 3 minutesand are 45 to 90 seconds induration and of strongintensity.
Mother becomes tired, is
restless and irritable andfeels out of control
Interventions:
Envoucare rest betweencontractions
Wake mother at beginningof contraction so she can
begin breathing pattern Keep mother and partner
informed of progress
Provide privacy
Offer fluids and ice chipsand ointment dry lips
Encourage voiding every 1to 2 hours.
-
8/3/2019 47385717 Intrapartal Care
29/37
Monitor maternal V/S
Monitor FHR via:
Doppler
Fetoscope
Electronic fetal monitor
Assess FHR before, during, and after contraction, noting that the normal FHR
is 120 to 160 bpm Monitor uterine contractions by palapation or monitor, determining frequency,
duration, and intensity.
Assess status of cervical dilataion and effacement.
Assess fetal station, presentation, and position by Leopolds Maneuvers.
Assist with pelvic examination and prepare for Nitrazine test and a fern test
Nitrazine test - used to test vaginal pH during late pregnancy to determine the
breakage of the amniotic sac.W
hile vaginal pH is normally acidic, a pH above7.0 can indicate that the amniotic sac has ruptured
Fern Test - test for estrogenic activity in which cervical mucus smears form afernlike pattern at times when estrogen secretion is elevated, as at the timeof ovulation.
Assess the color of the amniotic fluid if the membranes have ruptured becausemeconium-stained fluid can indicate fetal distress.
-
8/3/2019 47385717 Intrapartal Care
30/37
> complete dilation to expulsion
-
8/3/2019 47385717 Intrapartal Care
31/37
1. Assessment cervical dilation is complete
progress of labor is measured bydescent of fetal head through thebirth canal (changes in fetal station)
uterine contractions occur every 2 to3 minutes, lasting 60 to 70 75seconds, and the intensity is strong.
Increase in bloody show occurs
Mother feels urge to bear down,assist mother in pushing efforts.
Interventions:
Perform assessments every5minutes
Monitor maternal v/s
Monitor FHR Assess FHR before, during and after
contractions
Monitor uterine contractions bypalpation or monitor, determiningfrequency, duration, and intensity.
Provide mother withencouragement and praise and
provide rest between contractions Keep mother and partner informed
Maintain privacy
Provide ice chips and ointment fordry lips
Assist mother into a position thatpromotes comfort and assistspushing efforts, such as lithotomy,
semi-sitting,kneeling, side-lying, orsquatiting.
Monitor for sighs of approaching,birth, such as perineal bulging orvisualization of the fetal head.
Prepare for birth.
-
8/3/2019 47385717 Intrapartal Care
32/37
- delivery of newborn to delivery of
placenta
-
8/3/2019 47385717 Intrapartal Care
33/37
contractions occur untilthe placenta is born
placental separationand expulsion occur.
Birth of placental occursto 5 to 15 minutes afterbirth of the baby
Schultz mechanism:
margin of placentaseparates, and the dull,red, rough maternalsurface emerges fromthe vaginal first.
Duncan mechanism:
margin of placentaseparates, ans the dullred, rough maternalsurface emerges fromthe vagina first
Interventions: Assess maternal v/s
Assess uterine status
Provide parents with anexplanation regardingbirth of the placenta
Following birth of theplacenta, uterine fundusremains firm and is
located two fingerbreathsbelow the umbilicus
Examine placenta forcotyledons andmembranes to verify thatis intact.
Asses mother for shivering
and provide warmth Promote a parental-
neonatal attachement.
-
8/3/2019 47385717 Intrapartal Care
34/37
Calkins sign - the change of shape of the
uterus from discoid to ovoid, indicating
placental separation from the uterine wall.
Lengthening of the cord Sudden gush of blood
-
8/3/2019 47385717 Intrapartal Care
35/37
> placenta to hemostasis
-
8/3/2019 47385717 Intrapartal Care
36/37
Assessment blood pressure returns to pre-labor
level
pulse is slightly lower than duringlabor
fundus remains contracted, in themindline,1 to 2 fingerbreadths belowthe umbilicus
Lochia (. Discharges from the vaginaof mucus, blood, and tissue debris,following childbirth.) is moderate orscant is red; vagina discharge withmucus
Lochia rubra bloody red in color,1-3 days after birth
Lochia serosa brownish 4-6 after
birth Lochia alba whitish in colo, 7-10
days after birth
Interventions:
Perform maternal assessmentsevery 15 minutes for 1 hour, every3o mins for 1 hour, and hourly for 2hours
Provide warm blankets
Apply ice packs to perineum
Massage the uterus if needed andteach the mother to massage theuterus
Provide breast-feeding support asneeded
-
8/3/2019 47385717 Intrapartal Care
37/37