NCM107j: Care of Mother, Child, Adolescent-Well Clients (Maternal)

MODULE: INTRAPARTUM

MS. GERTRUDES M. MAICO – COLLEGE OF NURSING

1ST SEMESTER | S.Y. 2022 – 2023
o Latent phase – Onset of labor with slow
NORMAL LABOR cervical dilation to – 4cm and variable
• Labor – the onset of regular painful contractions duration.
with progressive effacement and dilation of the o Active phase – Faster rate of cervical change,
cervix. Also defined as that occurring after 28 1-1.2 cm/hour, regular uterine contractions.
completed weeks of gestation. 2. Stage of Expulsion – Begins with complete
o Preterm Labor – Before 37 weeks cervical dilation and ends with delivery of fetus.
o Full term Labor – After 37 weeks ➢ Second Stage: The birth of an infant
COMPONENTS OF LABOR o Contractions are close together, 2-3 minutes
1. Power - refers to uterine contractions and apart.
maternal pushing efforts. o Mother will have urge to push
2. Passage - refers to the maternal pelvis that the o You will see the infant’s head crowning during
baby passes through during labor. contractions
3. Passenger - refers to the fetus and placenta. o There is no time for transport, you will need to
4. Psyche – refers to the client’s psychological assist with delivery
status during labor. How a mother controls their 3. Placental stage – begins immediately after fetus
emotions during labor. is born and ends when the placenta is delivered.
o Coping skills; Anxiety, fear, stress; and Labor 4. Maternal Homeostatic Stabilization - Begins
support after the delivery of the placenta and continues
NURSING CARE DURING LABOR AND BIRTH for one to four hours after delivery.
• Assessment on admission o Profuse bleeding could lead to hypovolemic
• Focused Assessment shock.
• Fetal assessment • Spontaneous Rupture of Fetal Membranes
o Gestational age of the fetus (SROM) – is any time beyond the 28th week of
o Leopold’s maneuver pregnancy but before the onset of labor.
o Fetal movement and FHR o After 37 weeks – Term PROM
o Status of membrane o Before 37 weeks – Preterm PROM
• Maternal assessment (vital signs) especially for • Premature Rapture of Membranes (PROM) - a
infection of hypertension rupture (breaking open) of the membranes
STAGES OF LABOR (amniotic sac) before labor begins.
• Lightening – The point when your baby drops o Rupture of membranes for >24 hours before
lower in your belly and settles deep in your pelvis. delivery is called prolonged rupture of membranes
For first time moms, Lightening can occur a few ➢ Fourth Stage:
weeks before your baby’s birth; for second-timers o Observe the vital signs
it may take place only a few hours before labor o Do uterine Massage
begins. o Close observation every 15 minute for the next
• “show” or “bloody show” – refers to the few hour
drops of blood or pinkish vaginal stain that occurs o Repair of an episiotomy of any laceration
when the mucous that plugs the uterus during o Palpate the abdomen to assess and monitor
pregnancy dissolves. uterine tone and size
o This plug seals the cervix and prevents bacteria MECHANISMS/CARDINAL MOVEMENT OF
from moving into the uterus. NORMAL LABOR
1. Stage of Cervical Dilation – Begins with onset • As the fetus descends, soft tissue and bony
of regular contractions and ends with complete structures exert pressures which force the fetus to
dilation. negotiate the birth canal by a series of passive
o Latent – Active – Transitional movements
(0-3cm) – (4-7cm) – (8-10 cm) Principles:
➢ First stage: Two Phases • Descent takes place throughout the labor
• Whichever part leads and first meets resistance of
the pelvic floor, will rotate forwards until it comes
under the symphysis pubis
• Whatever emerges from the pelvis will pivot around
the pubic bone
• Engagement – occurs when the widest part of the
fetal’s head has entered the pelvis. This process
start at the last few weeks of pregnancy to the
period of starting of labor.
• Flexion - Presenting diameters of fetal head
presenting to maternal pelvis are optimized.
• Station – Degree of descent of the presenting part
of the fetus. Measured in centimeters from the
ischial spines in negative and positive numbers.
Figure 2: passage through the birth canal
o -5 is a floating baby
o 0 station is said to be engaged in the pelvis
o +5 is crowing

Figure 3: Station

AMNIOTIC FLUID
• Too much of amniotic fluid leakage can be an
indicative of a complication such as
Oligohydramnios or premature rapture of the
membranes (PROM).
• Polyhydramnios – High level of amniotic fluid
o In the second trimester, it is found in about
1 per 200 pregnancies.
• Oligohydramnios – Low level of amniotic fluid
• Anhydramnios - No amniotic fluid
• About 600 mL of amniotic fluid surrounds the baby
at full term (40 weeks gestation).
• Leaking if amniotic fluid/bag indicates that the
cervix is open

CERVICAL EFFACEMENT & DILATION

• Effacement – The gradual thinning, shortening,
and drawing up of the cervix, measured in
percentages from 0 to 100%.
Figure 1: Normal Labor mechanism
• Dilation – The gradual opening of the cervix
measured in centimeters from 0 to 10 cms.
 MOULDING • Android – Heart shaped or triangular pelvic inlet
• The bones of the fetal head can move closer due to prominent sacrum. Pelvis funnels from
together or overlap to help the head fit through the above downwards.
pelvis. Partial bones overlap occipital and frontal • Platypelloid – Leads to cephalic-pelvic
bones. disproportion. Brim oval transversely. Short-cone
• Moulding can be staged from +1 to +4, +1 - +3 shallow pelvis.
being normal and +4 being cause for some → Factors influencing the size and shape of
concern. the pelvis
POWER o Developmental Factor: Hereditary or congenital
• Contractions – Supplied by fundus of uterus. o Racial factor
Involuntary, may become stronger as labor progresses. o Nutritional Factor: malnutrition results in small
→ Uterine contractions pelvis
o Duration - From beginning of one o Sexual factor: As excessive androgen may
contraction to the end of same contraction produce android pelvis
o Frequency – From beginning of one o Metabolic factor: as rickets and osteomalacia
contraction to the beginning of another o Trauma, diseases or tumors of the bony pelvis,
contraction legs, or spines
o Interval – Resting time between contractions PASSENGER
allows for placental perfusion. • Cephalic Presentation – Head enters birth canal
first, Face is backward (towards the mother’s
spine), arms are crossed, chin and neck are bent
forward (down towards chest).

→ False vs True Labor

• False Labor
o Benign and irregular contractions
o Felt first abdominally and remain confined to
the abdomen and groin
o Often disappear with ambulation and sleep
o Do not increase in duration, frequency, or
intensity
• True Labor
o Benign irregularly but become regular and
predictable
o Felt first in lower back and sweep around to the
abdomen in a wave
o Continue no matter what the women’s level of
activity
o Increase in Duration, frequency, and internsity
PASSAGE
• Lumbosacral Pain (LSP) – Low back pain. The
ligaments in your body naturally become softer and MALPRESENTATION
stretch to prepare you for labor. • Malpresentation is a presentation that is not
•Gynecoid – Most ideal for vaginal delivery. cephalic.
Rounded or slightly ovel inlet. Straight pelvic • As pregnancy continues, a baby usually turns
sidewalls with roomy pelvic cavity. naturally into the head first position.
• Anthropoid – Pelvic inlet is long oval. Straight • The most commonly encountered malpresentation
pelvic sidewalls. May cause difficulty in labor. Long in pregnancy is breech presentation.
and narrow sacrum.
 o Breech means that the baby is lying bottom first presenting the maternal surface of the placenta
or feet first in the womb, instead of in the usual on expulsion. “Dirty Duncan”
head first position. → What to do before delivery of the
placenta?
FETAL DISTRESS 1. Look for signs of placental separation
→ Complication during labor-fetal distress o Lengthening of the umbilical cord outside
oIntrauterine pressure > 75 mmHg o The uterus becomes firm and globular
oContraction > 90 seconds o The uterus rises in abdomen
oContraction occurring 2 mins or less apart o A gush of blood
oFetal bradycardia, tachycardia, or decreased 2. Assess the uterus
variability o To exclude an undiagnosed twin
oIrregular FHR o To determine a baseline fundal height
oMeconium-stained amniotic fluid o To detect the signs of placenta separation
oArrest in progress of the labor o To detect an atonic uterus
oMaternal fevel
oFoul-smelling vaginal discharge
oVaginal Bleeding
→ Signs of fetal distress
o Tachycardia or bradycardia
o Late decelerations, variable decelerations, or
prolonged deceleration
o Loss of variability
o Increased fetal activity
o Excessive molding or caput-succedaneum
formation
o Meconium stained amniotic fluid in cephalic
presentation
• Caput succedaneum - Diffuse edematous
swelling of the soft tissues of the scalp that may
extend across the suture lines.
• Involution – The return of the uterus to a
o It is secondary to the pressure of the uterus or
nonpregnant state after childbirth. Begins
vaginal wall
immediately after expulsion of the placenta with
oIt resolves within several days
contraction of uterine smooth muscles.
• Cephalohematoma – Collection of blood between
• Episiotomy - A cut (incision) made in the tissue
the periosteum and skull of newborn
between the vaginal opening and the anus during
o Does not cross suture lines
childbirth.
o Caused by rupturing of the periosteal bridging
• Methergine - Used as an Oxytocic to prevent or
veins due to friction and pressure during labor
treat bleeding from the uterus that can happen after
o Lasts 3 – 6 weeks
childbirth. Check blood pressure first before
• Meconium Stained Baby
administering, if blood pressure is high, do not
o Airway needs to be cleared to avoid aspiration
administer.
of meconium
POST PARTUM HEMORRHAGE
o Suction and clear airway before infant needs to
• Uterine Inversion – A life threatening
take that first breath
complication in third stage in which the uterus is
turned inside out partially or completely.
PLACENTA
• Rupture uterus
• The Shultz mechanism - The placenta may
separate from the central area to the borders • Lacerations and hematoma
with inversion so that the fetal surface presents o Hematoma – Accumulation of blood in a particular
first. “Shiny Shultz” vaginal area. May be in the vagina, vulvar, or
retroperitoneal.
• Mathew Duncan mechanism - The progress of
placental separation inward from the edges,
• Uterine atony (atony of the uterus) occurs when
your uterus doesn't contract (or tighten) properly
during or after childbirth.
→ Management of uterine atony
o Remove the causes of uterine atony
o Uterine massage
o Use of oxytocin
o Uterine packing
o Ligation of pelvic artery
o Internal iliac artery embolization
o A hysterectomy may be done as a last resort.
• Pseudocyesis – Also known as “false pregnancy”,
this is a psychological condition in which a
woman believes that she is pregnant even when
pregnancy is not present.