Health Promotion Of The Intrapartal Client

Front 1

Factors affecting labor--remembered as the five "P's"

Back 1

passenger (fetus and placenta)
passageway (birth canal)
powers (contractions)
position of the mother and psychological response

Front 2

Passenger--the movement of the passenger, or fetus, through the birth canal is determined by several interacting factors:

Back 2

the size of the fetal head
fetal presentation
fetal lie
fetal attitude
fetal position

Front 3

Size of the fetal head

Back 3

Because of its size and relative rigidity, the fetal head has a major effect on the birth process. During labor, after rupture of membranes, palpation of fontanels and sutures during vaginal examination reveals fetal presentation, position, and attitude.

Front 4

Two most important fontanels: anterior and posterior

Back 4

anterior fontanel, larger of the two is diamond shaped, about 3 cm by 2 cm and lies at the junction of the sagittal, coronal, and frontal sutures. It closes by 18 months after birth.
Posterior fontanel: lies at the junction of the sutures of the two parietal bones and the once occipital bone, is triangular, and is about 1 cm by 2 cm. It closes 6 to 8 weeks after birth.
Sutures and fontanels make the skull flexible to accomodate the infant brain, which continues to grow for some time after birth.

Front 5

Fetal presentation

Back 5

Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term.

Front 6

Three main presentations

Back 6

cephalic (head first) 96% of births
breech (buttocks or feet first) 3% of births
shoulder presentation 1% of births

Front 7

Presenting part

Back 7

cepahlic presentation -- usually the occiput; in a breech presentation -- it is the sacrum; in a shoulder presentation -- it is the scapula

Front 8

Factors that determine the presenting part

Back 8

fetal lie
fetal attitude
extension or flexion of the fetal head

Front 9

Fetal lie

Back 9

Lie is the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother.

Front 10

Two primary lies

Back 10

longitudinal, or vertical in which the long axis of the fetus is parallel with the long axis of the mother.
Transverse, horizontal or oblique, in which the long axis of the fetus is at a right angle diagonal to the long axis of the mother.

Front 11

Fetal Attitude

Back 11

Attitude is the relation of the fetal body parts to each other.

Front 12

Attitude: general flexion

Back 12

normally the back of the fetus is rounded so that the chin is flexed on the chest, the thighs are flexed on the abdomen, and the legs are flexed at the knees. The arms are crossed over the thorax, and the umbilical cord lies between the arms and the legs.

Front 13

Fetal Position

Back 13

Position is the relation of the presenting part (occiput, sacrum, mentum (chin), or sinciput [deflexed vertex]) to the four quadrants of the mother's pelvis

Front 14

Critical factors in Labor

Back 14

Power -- contraction
Passage -- pelvis shape and configuration
Passenger -- fetus, movements and position
Psyche -- emotional system involved

Front 15

Power

Back 15

Primary muscle is uterus, abdominal muscles secondary
Physiology of contraction
Increment, acme, decrement
Relationship to effacement and dilation of cervix

Front 16

Powers

Back 16

Involuntary and voluntary powers combine to expel the fetus and placenta from the uterus. Involuntary uterine contractions, called the primary powers, signal the beginning of labor. Once the cervix has dilated, voluntary bearing-down efforts by the woman, called the secondary powers, augment the force of the involuntary contractions.

Front 17

Terms used to describe these involuntary contractions

Back 17

Frequency--the time from the beginning of one contraction to the beginning of the next
Duration--(length of contraction)
Intensity--(strength of contraction)

Front 18

Primary Powers

Back 18

are responsible for the effacement and dilation of the cervix and descent of the fetus.

Front 19

Effacement of the cervix

Back 19

means the shortening and thinning of the cervix during the first stage of labor.
Only a thin edge of the cervix can be palpated when effacement is complete.

Front 20

Dilation of the cervix

Back 20

occurs by the drawing upward of the musculofibrous components of the cervix, caused by strong uterine contractions.
Stretch receptors in the posterior vagina cause release of endogenous oxytocin that triggers the maternal urge to bear down, or the Ferguson reflex.

Front 21

Secondary powers

Back 21

As soon as the presenting part reaches the pelvic floor, the contractions change in character and become expulsive. The laboring woman experiences an involuntary urge to push. She uses secondary powers (bearing-down efforts) to aid in expulsion of the fetus as she contracts her diaphragm and abdominal muscles and pushes.

Front 22

Secondary powers

Back 22

have no effect on cervical dilation, but they are of considerable importance in the expulsion of the infant from the uterus and vagina after the cervix is fully dilated. Studies have shown that pushing in the second stage is more effective and the woman is less fatigued when she begins to push only after she has the urge to do so rather than beginning to push when she is fully dilated without an urge to do so.

Front 23

Four basic types of pelvis

Back 23

Gynecoid (the classic female type)
Android (resembling the male pelvis)
Anthropoid (resembling the pelvis of anthropoid apes
Platypelloid (the flat pelvis)

Front 24

Gynecoid Pelvis

Back 24

The gynecoid pelvis is the most common (50% of all women)
Best opportunity for vaginal birth

Front 25

Android Pelvis

Back 25

Sacrum is prominent less chance for vaginal birth (23% of all women)
Usual mode of birth -- cesarean

Front 26

Anthropoid

Back 26

24% of all women -- Fair chance of vaginal birth

Front 27

Platypelloid

Back 27

3% of all women -- poor chance of vaginal birth

Front 28

Passenger -- Station

Back 28

Station is the relation of the presenting part of the fetus to an imaginary line drawn between the maternal ischial spines and is a measure of the degree of descent of the presenting part of the fetus through the birth canal. The placement of the presenting part is measured in cm above or below the ischial spines.
Birth is imminent when the presenting part is at +4 to +5 cm. The station of the presenting part should be determined when labor begins so that the rate of descent of the fetus during labor can be accurately determined.

Front 29

Passenger -- Engagement

Back 29

Engagement is the term used to indicate that the largest transverse diameter of the presenting part (usually the biparietal diameter) has passed through the maternal pelvic brim or inlet into the true pelvis and usually corresponds to station 0. Engagement often occurs in the weeks just before labor begins in nulliparas and may occur before or during labor in multiparas. Engagement can be determined by abdominal or vaginal examination.

Front 30

Leopolds's Maneuvers (Abdominal Palpation)

Back 30

Leopold's maneuvers are performed with the woman lying on her back. These maneuvers help identify the following: (1) number of fetuses; (2) presenting part, fetal lie, and fetal attitude; (3) defree of the presenting part's descent into the pelvis; and (4) expected location of the PMI of the fetal heart rate (FHRs) on the woman's abdomen.

Front 31

Leopold's Maneuvers

Back 31

Wash hands
Ask woman to empty bladder
Position woman supine with one pillow under her head and with her knees slightly flexed.
Place small rolled towels under woman's right or left hip to displace uterus off major blood vessels (prevents supine hypotensive syndrome)

Front 32

Leopold's Maneuvers--If right-handed, stand on woman's right, facing her.

Back 32

1. Identify fetal part that occupies the fundus. The head feels round, firm, freely movable, and palpable by ballottement; the breech feels less regular and softer. This maneuver identifies fetal lie (longitudinal or transverse) and presentation (cephalic or breech).

Front 33

Leopold's Maneuvers

Back 33

2. Using palmar surface of one hand, locate and palpate the smooth convex contour of the fetal back and the irregularities that identify the small parts (feet, hands, elbows). This maneuver helps identify fetal presentation.

Front 34

Leopold's Maneuvers

Back 34

3. With right hand, determine which fetal part is presenting over the inlet to the true pelvis. Gently grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly. If the head is presenting and not engaged, determine the attitude of the head (flexed or extended).

Front 35

Leopold's Maneuvers

Back 35

4. Turn to face the woman's feet. Using both hands, outline the fetal head with the palmar surface of the fingertips. When the presenting part had descended deeply, only a small portion of it may be outlined. Palpation of the cephalic prominence helps identify the attitude of the head. If the cephalic prominence is bound on the same side as the small parts, this means that the head must be flexed and the vertex is presenting. If the cephalic prominence is on the same side as the back, this indicates that the presenting head is extended and the face is presenting.
Document fetal presentation, position, and lie and whether presenting part is flexed or extended, engaged, or free floating,

Front 36

Examples of fetal vertex (occiput)

Back 36

Occiput defined -- The back part of the skull. On the fetal head, it is used to determine the position of cephalic presentations in relation to the front, back, or side of the maternal pelvis.

Front 37

Examples of fetal vertex (occiput)

Back 37

ROP -- Right occipitoposterior
LOP -- Left occipitoposterior
ROT -- Right occipitotransverse
LOP -- Left occipitotransverse
ROA -- Right occipitoanterior
LOA -- Left occipitoanterior

Front 38

Stages of Labor

Back 38

premonitory
first stage
second stage
third stage
fourth stage

Front 39

Stages of Labor

Back 39

Labor is considered "normal" when the woman is at or near term, no complications exist, a single fetue presents by vertex, and labor is completed within 18 hours. The course of normal labor, which is remarkably constant, consists of (1) regular progression of uterine contractions, (2) effacement and progressive dilation of the cervix, and (3) progress in descent of the presenting part. Four stages of labor are recognized.

Front 40

The first stage of labor

Back 40

The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. Commonly the onset of labor is difficult to establish because the woman may be admitted to the labor unit just before birth, and the beginning of labor may be only an estimate. The first stage is much longer than the second and third combined.

Front 41

The first stage of labor

Back 41

The first stage of labor has been divided into three phases: a latent phase, an active phase, and a transition phase.

Front 42

The first stage of labor

Back 42

During the latent phase, there is more progress in effacement of the cervix and little increase in descent.

Front 43

The first stage of labor

Back 43

During the active phase and the transition phase, there is more rapid dilation of the cervix and increased rate of descent of the presenting part.

Front 44

The second stage of labor

Back 44

The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The second stage takes an average of 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman.

Front 45

The third stage of labor

Back 45

The third stage of labor lasts from the birth of the fetus until the placenta is delivered. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born. After it has separated, the placenta can be delivered with the next uterine contraction. The duration of the third stage may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. The risk of hemorrhage increases as the length of the third stage increases.

Front 46

The fourth stage of labor

Back 46

The fourth stage of labor arbitrarily lasts about 2 hours after delivery of the placenta. It is the period of immediate recovery, when homeostasis is reestablished. It is an important period of observation for complications, such as abnormal bleeding.

Front 47

The Seven Cardinal Movements of the Mechanism of Labor

Back 47

The seven cardinal movements of the mechanism of labor that occur in a vertex presentation are engagement, descent, flexion, internal rotation, extension, external rotation (restitution), and finally birth by expulsion. Although these movements are discussed separately, in actuality, a combination of movements occurs simultaneously. For example, engagement involves both descent and flexion.

Front 48

Engagement

Back 48

When the biparietal diameter of the head passes the pelvic inlet, the head is said to be engaged in the pelvic inlet. In most nulliparous pregnancies, this occurs before the onset of active labor because the firmer abdominal muscles direct the presenting part into the pelvis. In multiparous pregnancies, in which the abdominal musculature is more relaxed, the head often remains freely movable above the pelvic brim until labor is established.

Front 49

Descent

Back 49

Descent refers to the progress of the presenting part through the pelvis. Descent depends on at least four forces: (1) pressure exerted by the amniotic fluid, (2) direct pressure exerted by the contracting fundus on the fetus, (3) force of the contraction of the maternal diaphragm and abdominal muscles in the second stage of labor, and (4) extension and straightening of the fetal body.

Front 50

Degree of descent

Back 50

The degree of descent is measured by the station of the presenting part. As mentioned, little descent occurs during the latent phase of the first stage of labor. Descent accelerates in the active phase when the cervix has dilated to 5 to 7 cm. It is especially apparent when the membranes have ruptured.
In a first-time pregnancy, descent is usually slow but steady; in subsequent pregnancies descent may be rapid.

Front 51

Progress in descent

Back 51

Progress in descent of the presenting part is determined by abdominal palpation (Leopold maneuvers) and vaginal examination until the presenting part can be seen at the introitus.

Front 52

Flexion

Back 52

As soon as the descending head meets resistance from the cervix, pelvic wall, or pelvic floor, it normally flexes, so that the chin is brought into closer contact with the fetal chest. Flexion permits the smaller suboccipitobregmatic diameter (9.5 cm) rather than the larger diameter to present to the outlet.

Front 53

Internal Rotation

Back 53

The maternal pelvic inlet is widest in the transverse diameter; therefore the fetal head passes the inlet into the true pelvis in the occipitotransverse position. The outlet is widest in the antereoposterior diameter, however; therefore for the fetus to exit, the head must rotate. Internal rotation begins at the level of the ischial spines but is not completed until the presenting part reaches the lower pelvis. As the occiput rotates anteriorly, the face rotates posteriorly.

Front 54

Extension

Back 54

When the fetal head reaches the perineum for birth, it is deflected anteriorly by the perineum. The occiput passes under the lower border of the symphysis pubis first, and then the head emerges by extension: first the occiput, then the face, and finally the chin.

Front 55

Restitution and External Rotation

Back 55

After the head is born, it rotates briefly to the position it occupied when it was engaged in the inlet. This movement is referred to as restitution. The 45-degree turn realigns the infant's head with her or his back and shoulders. The head can then be seen to rotate further. This external rotation occurs as the shoulders engage and descend in manuevers similar to those of the head. As noted earlier, the anterior shoulder descends first. When it reaches the outlet, it rotates to midline and is delivered from under the pubic arch. The posterior shoulder is guided over the perineum until it is free of the vaginal introitus.

Front 56

Expulsion

Back 56

After birth of the shoulders, the head and shoulders are lifted up toward the mother's pubic bone and the trunk of the baby is born by flexing it laterally in the direction of the symphysis pubis. when the baby has completely emerged, birth is complete, and the second stage of labor ends.

Front 57

Physiological adaptations of pregnancy: Cardiovascular changes

Back 57

During each contraction, an average of 400 mL of blood is emptied from the uterus into the maternal vascular system. This increases cardiac output by about 12% to 31% in the first stage and by about 50% in the second stage. The heart rate increases slightly. Changes in the woman's blood pressure also occur. Blood flow, which is reduced in the uterine artery by contractions, is redirected to peripheral vessels. As a result, peripheral resistance increases, and blood pressure increases. During the first stage of labor, uterine contractions cause systolic readings to increase by about 10 mm Hg; assessing blood pressure between contractions therefore provides more accurate readings. During the second stage, contractions may cause systolic pressures to increase by 30 mm Hg and diastolic readings to increase by 25 mm Hg, with both systolic and diastolic pressures remaining somewhat elevated even between contractions. Therefore the woman already at risk for hypertension is at increased risk for complications such as cerebral hemorrhage.

Front 58

Valsalva maneuver

Back 58

The woman should be discouraged from using the Valsalva maneuver (holding one's breath and tightening abdominal muscles) for pushing during the second stage. This activity increases intrathoracic pressure, reduces venous return, and increases venous pressure. The cardiac output and blood pressure increase and the pulse slows temporarily. During the Valsalva maneuver, fetal hypoxia may occur. The process is reversed when the woman takes a breath.

Front 59

Physiological adaptations of pregnancy: Cardiovascular changes

Back 59

Some peripheral vascular changes occur, perhaps in response to cervical dilation or to compression of maternal vessels by the fetus passing through the birth canal. Flushed cheeks, hot or cold feet, and eversion of hemorrhoids may result.

Front 60

Physiological adaptations of pregnancy: Respiratory changes

Back 60

Increased physical activity with greater oxygen consumption is reflected in an increase in the respiratory rate. Hyperventilation may cause respiratory alkalosis (an increase in pH), hypoxia, and hypocapnia (decrease in carbon dioxide). In the unmedicated woman in the second stage, oxygen consumption almost doubles. Anxiety also increases oxygen consumption

Front 61

Physiological adaptations of pregnancy: Renal changes

Back 61

During labor, spontaneous voiding may be difficult for various reasons: tissue edema caused by pressure from the presenting part, discomfort, analgesia, and embarrassment. Proteinuria of +1 is a normal finding because it can occur in response to the breakdown of muscle tissue from the physical work of labor.

Front 62

Physiological adaptations of pregnancy: Gastrointestinal changes

Back 62

During labor, gastrointestinal motility and absorption of solid foods are decreased, and stomach-emptying time is slowed. Nausea and vomiting of undigested food eaten after onset of labor are common. Nauses and belching also occur as a reflex response to full cervical dilation. The woman may state that diarrhea accompanied the onset of labor, or the nurse may palpate the presenceof hard or impacted stool in the rectum.

Front 63

Physiological adaptations of pregnancy: Endocrine changes

Back 63

The onset of labor may be triggered by decreasing levels of progesterone and increasing levels of estrogen, prostaglandins, and oxytocin. Metabolism increases, and blood glucose levels may decrease with the work of labor.
Accurate assessment of the mother and fetus during labor and birth depends on knowledge of these expected adaptations so that appropriate interventions can be implemented.

Front 64

Physiological adaptations of pregnancy: Renal changes

Back 64

During labor, spontaneous voiding may be difficult for various reasons: tissue edema caused by pressure from the presenting part, discomfort, analgesia, and embarrassment. Proteinuria of +1 is a normal finding because it can occur in response to the breakdown of muscle tissue from the physical work of labor.

Front 65

Physiological adaptations of pregnancy: Gastrointestinal changes

Back 65

During labor, gastrointestinal motility and absorption of solid foods are decreased, and stomach-emptying time is slowed. Nausea and vomiting of undigested food eaten after onset of labor are common. Nauses and belching also occur as a reflex response to full cervical dilation. The woman may state that diarrhea accompanied the onset of labor, or the nurse may palpate the presenceof hard or impacted stool in the rectum.

Front 66

Physiological adaptations of pregnancy: Endocrine changes

Back 66

The onset of labor may be triggered by decreasing levels of progesterone and increasing levels of estrogen, prostaglandins, and oxytocin. Metabolism increases, and blood glucose levels may decrease with the work of labor.
Accurate assessment of the mother and fetus during labor and birth depends on knowledge of these expected adaptations so that appropriate interventions can be implemented.