MATERNAL- NEWBORN NURSING: causing physiologic changes (Uterine

INTRAPARTUM PERIOD Contraction) that initiate labor.

OVERVIEW: OXYTOCIN THEORY

Intrapartum care: - Pressure on the cervix stimulates the hypophysis
- The intrapartum care extends from the beginning to release oxytocin from the maternal posterior
of contractions that cause cervical dilation to the pituitary gland. As pregnancy advances, the
1st to 4 hours after delivery of the newborn and uterus becomes more sensitive to oxytocin.
placenta Presence of this hormone causes the initiation of
- Intrapartum care refers to the medical and contraction of the smooth muscles of the body
nursing care given to a pregnant woman and her (uterus is composed of smooth muscles)
family during labor and delivery.
GOALS OF INTRAPARTUM CARE PROGESTERONE DEPRIVATION THEORY
1. to promote physical and emotional well being in the - Progesterone is the hormone designed to
mother and fetus promote pregnancy. It is believed that presence
2. to incorporate family centered care concepts into the of this hormone inhibits uterine motility. As
labor and delivery experience. pregnancy padvances, changes in the relative
effects estrogen and progesterone encourage the
FACTORS AFFECTING THE INTRAPARTUM onset of labor. A marked increase in estrogen
EXPERIENCE level is noted in relation to progesterone making
the latter hormone less effective in controlling
1. previous experience with pregnancy rhythmic uterine contractions, also in later
2 cultural personal expectations pregnancy, rising fetal cortisol levels inhibit
3. pre-pregnant health and biophysical preparedness for progesterone production from the placenta.
childbearing Reduce progesterone formation initiates
4. motivation for childbearing labor
5. socioeconomic readiness
6. age of mother PROSTAGLANDIN THEORY
7. partnered vs unpartnered status -in the latter part of pregnancy,fetal membranes and
8. extent of prenatal care uterine decidua increase prostaglandin levels. This
9. extent of childbirth education hormones is secreted from the lower area of the fetal
membrane (forebag). A decrease in progesterone
PHENOMENA AND PROCESS OF LABOR AND amount also elevates the prostaglandin level. Synthesis
DELIVERY of prostaglandin, in return, cause uterine contraction
thus, labor is initiated.
Onset of labor
1. labor is the process by which the product the products THEORY OF AGING PLACENTA
of conception are expelled from the body as a result of - ADVANCE PLACENTAL AGE DECREASES
regular, progressive, frequent, and strong uterine BLOOD SUPPLY to the uterus. This event
contractions triggers uterine contractions , thereby, starting
the labor.
2. theoretically, labor is thought to result from: Maternal factor Theories Fetal factor Theories
a. progesterone deprivations Uterine muscles stretch Placental aging and
b. oxytocin stimulation causing release of deterioration triggers
c.fetal endocrine control prostaglandin initiation of contractions
d.uterine deciduas activation
Pressure on the cervix Fetal cortusol, produced by
THEORIES OF LABOR stimulates nerve (plexma?) the adrenal and acts on the
Although the exact mechanism that initiates labor is causing the release of placenta to reduce
unknown. Theories have been proposed to explain how oxytocin by maternal progesterone formation and
and why labor occurs pituitary gland. This is increase prostaglandin
known as the ferguson
reflex
UTERINE STRETCH THEORY
- The idea is based on the concept that any hollow
body organ when stretched to its capacity will Oxytocin stimulation Prosta produced by fetaln
inevitably contract to expel its contents. The inceases slowly during membranes (amnion and
uterus, which is a hollow muscular organ, pregnancy, (rinse??) Chorion) and the deciduas
becomes stretched due to the growing fetal dramatically during labor stimulates contractions.
structures, in return, the pressure increases and peaks during the 2nd When arachidonic acid
stage of labor . oxy and stored in the fetal a. side of maternal pelvis (left, right and
prsta work together to membranes is released at transverse)
inhibit Ca-binding in muscle term, it is converted to b. presenting part (occiput, sacrum, scapula and
cells, raising intracellular Ca prostaglandin. mentum)
and thus activations
contractions. c. part of the maternal pelvis ( anterior,
posterior)
Estrogen-progesterone shift-
estrogen excites the uterine power- this refers to the frequency, duration, and
responses and progesterone strength of uterine contractions to cause complete
quiets the uterine response. cervical effacements and dilatation.
Placental factors- refers to the placental insertion
Psyche- refers to the psychological state, available
FACTORS AFFECTING LABOR
support systems, preparations for childbirth, experiences
and coping strategies.
Passageway. This refers to the adequacy of the pelvis
and birth canal is allowing fetal descent. Factors include.
SIGNS AND SYMPTOMS OF IMPENDING
A. type of pelvis (gynecoid, android, anthropoid or
LABOR (PREMONITORY SIGNS)
platypelloid)
1. lightening- is the descent of the fetus and uterus into
b. structure of pelvis (true pelvis vs. false pelvis)
the pelvic cavity 2 to 3 weeks before the onset of labor.
c. pelvic inlet diameters
d. pelvic outlet diameters
2. Braxton hicks contractions are irregular- intermittent
e. ability of the uterine segment to distend, the cervix to
contractions that have occurred throughout pregnancy.
dilate, and the vaginal canal and introitus to distend
Becomes uncomfortable and produce a drawing pain in
the abdomen and groin.
Passenger. This refers to the fetus and its ability to
move through the passageway which is based on the
3. cervical changes- include softening, “ripening” and
following
effacement of the cervix that will cause expulsion of the
a. size of the fetal head and capability of the head to
mucus plug (bloody show) and heavy vaginal discharge.
mold to the passageway
B fetal presentation. The part of the uterus that enters
4. rupture of amniotic membranes-may occur before
the maternal pelvis first( cephalic [vertex, face, brow]
onset of labor
breech [ frank, single or double footling, complete or
shoulder [ transverse lie]
5. burst of energy- or increased tension and fatigue.
Occurs before onset of labor
PRESENTATIONS
A. CEPHALIC- head is presenting part -95-96%
6. weight loss- of about 1-3 lbs in 2-3 days before the
1. may be vertex, face or brow
onset of labor
2. vertex is most common and most favorable for
delivery. Head is sharply flexed in the pelvis with chin
7. urinary frequency- returns
near chest.
8 backache
CHARACTERISTICS OF TRUE VS. FALSE LABOR
b. Breech. Buttocks or lower extremities are the
presenting part. TRUE LABOR FALSE LABOR
Types: CONTRACTIONS CONTRACTIONS
a. complete or full- buttocks and feet present (baby in Contractions are regular, Contractions are irregular
squatting position) increase in frequency,
b. frank- buttocks only presenting or legs are extended duration and intensity,
shortening of interval
against anterior trunk with feet touching face
c. incomplete- one or both feet or knees presenting, Pain radiates from back Pain restricted in the
footing, single or double, or knee presentation. around the abdomen abdomen

FACTORS AFFECTING LABOR (PASSENGER) Contraction does not Contraction may lessen
decrease with rest or with act./rest
Fetal attitude. This refers to the relationship of fetal activity/walking
parts to one another
Progressive effacement Cervical changes donot
Fetal position. This refers to the relationship of a
and dilatation of cervix occur yet
particular reference point of the ppresetning part and the
maternal pelvis with a sense of three letters.
STAGES OF LABOR  The 3rd stage of labor begins with delivery of the
newborn and ends when the placenta separates
1ST STAGE (DILATATIONAL STAGE) from the wall of the uterus and delivered thru the
- This starts from the onset of regular contractions vagina. This stage is the shortest stage of labor.
which cause progressive cervical dilatation and It may last from a few minutes to 20 minutes
effacement. It ends when the cervix is  It occurs in 2 phases:
completely effaced and dilated. Its average o Placental expulsion
duration is 12 hrs in primigravida and 6 hrs in o Placental separation: signs include when
multigravida. The first stage of labor is the:
composed of 3 phasess. Latent, active and  Uterus becomes globular
transition phase.  Fundus rising in the abdomen
 lengthening of the cord
3 PHASES 1ST STAGE OF LABOR  gushing of blood
 contraction of the uterus controls uterine
LATENT- phase that begins at the onset of regularly bleeding and aids with placental separation and
perceived uterine contractions and ends when rapid expulsion
cervical dilatation begins  generally oxytocic drugs (methylergonovine
maleate) are administered to help the uterus
ACTIVE- Cervical dilatation occurs more rapidly, contract.
increasing from 4 to 7 cm
2 PLACENTAL MECHANISMS
TRANSITION- contractions reach their peak of
intensity , occurring every 2 to 3 mins. With a duration 1. SCHULTZE MECHANISM- placental
of 60-90 secs. And causing maximum cervical dilatation expulsion with the fetal surface presenting. More
of 8-10cm common (shiny schultze). The placenta detaches
from a central point and slips down into the
2ND STAGE OF LABOR (EXPULSIVE STAGE) vagina through the hole in the amniotic sac; the
fetal surface appears at the vulva, with the
 The 2nd stage of labor begins when the cervix is membranes trailing behind like an inverted
completely dilated (open) and ends with the umbrella as they are peeled off the uterine wall.
birth of the newborn. (5 cm) (fetal side)
 Contractions push the fetus down the birth canal,
and the woman may feel intense pressure, 2. DUNCAN MECHANISM- passage of the
similar to an urge to have a bowel movement. placenta from the uterus with the rough side
 To push with each contraction is encouraged with cotyledons & is the maternal side. (placenta
 Duration may among primiparas (longer) and coming out “dirty Duncan” increases risk of
multiparas (shorter) hemorrhage bcos it usually means placenta was
 This stage should be completed within 1 hr after attached lower in the uterus. (5cm) (maternal
complete dilatation side)
 Contractions are severe 2-3 mins. Intervals, with
a duration of 50-90 secs. PAIN DURING LABOR AND DELIVERY
 The newborn exits the birth canal with help from
the following cardinal movements or - pain during labor is caused by contractions of
mechanisms of labor the muscles of the uterus and by pressure on the
o Descent cervix
o Flexion - other causes of pain during labor include
o Internal rotation pressure on the bladder and bowels by the
o Extension fetus’s head and the stretching of the birth canal
o External rotation (restitution) and vagina.
o Expulsion - Pain during labor is different for every woman.
 “crowning” occurs when the newborn’s head or It varies widely from woman to woman and
presenting part appears in the vaginal opening even from pregnancy to pregnancy. Woman
 Episiotomy (surgical incisionin perineum ) experience labor pains differently--- for some, it
maybe done to facilitate delivery and prevent resembles, menstrual cramps: for others, severe
lacerations of the perineum. pressure; and for others, extremely strong waves
that feel like diarrheal cramps.
3RD STAGE OF LABOR (PLACENTAL STAGE) - It is often not the pain of each contraction on its
own that woman find the hardest, but the fact
that the contractions keep coming--- and that as
 labor progresses, there is less and less time 2. intermittent- periods of relaxation between
between contractions to relax. contractions. Intervals allow the client to rest and also
allow adequate circulation of uterine blood vessels and
FORCES OF LABOR oxygenation of fetus.
3. distinguish between true labor (contractions are
 Muscular contractions primarily of muscles of regular, painful, and continue with walking) and
uterus and secondarily of abdominal muscles Braxton hicks (regular, painful, but go away with
 Uterine muscles contract during 1st stage and walking)
bring about effacement and dilatation of the 4. discomfort starts in low back , radiates to abdomen
cervix. 5. as labor progresses, intensity increases.
 Abdominal muscles come into play after
complete cervical dilatation and help expel the CONTRACTIONS DIVIDED INTO 3 PERIODS OF
baby--- voluntary bearing down effort, urge to INTENSITY
push. 1. increment : increasing intensity
 Contraction of levator ani muscles 2. acme: peak or full intensity
3. Decrement: decreasing intensity
DURATIONS OF LABOR

VARIES DEPENDING ON IDIVIDUAL:

AVERAGE.
1. primipara: up to 18 hrs; some may be shorter , others
longer
2. multipara; up to 8 hrs, some shorter, other longer

LENGTH OF LABOR DEPENDS ON:

1. Effectiveness of consistent contractions: contractions
CONTRACTIONS ARE MONITORED FOR
must overcome resistance of cervix.
FREQUENCY, DURATION AND
2. amount of resistance baby must overcome to adapt to
INTENSITY
the pelvis.
1. frequency – measured by timing the
3. stretching ability of soft tissue
contraction from the beginning of one
4. preparation and relaxation of client. Fear and anxiety
contraction to the beginning on the next.
can retard progress.
2. duration- beginning of contraction to the
completion of the contraction. Connot be
Important to judge rate of progress: should be
measured exactly by feeling with the hand
regular, progression of uterine contraction, progressive
3. intensity- cannot be measured by feeling;
effacement and dilatation of the cervix and progressive
must be measured by the internal fetal
descent of the presenting part.
monitoring device. Usually refers to contractions
at the beginning of labor, peaks at about 25mm
FETAL STATION
Hg. At the end of labor, it may reach 50-75 mm
 Degree to which presenting part has descended
Hg.
into pelvis is determined by the station--- the
4. contractions may be described as mild,
realationship between the presenting part and the
moderate or intense.
ischial spines.
 Assessed by vaginal or rectal examination.
PURPOSE OF CONTRACTION
Measured in numerical terms:
- To propel presenting part forward
 1. At level of spines: 0 station
- To bring about effacement and dilatation of the
 2 above level of spines: -1 -2 -3
cervix
 3. Below level of spines: +1 +2 +3
CHANGES IN THE UTERUS
OTHER TERMS USED TO DENOTE STATION
A. UTERUS usually becomes differentiated in two
1. high- presenting part not engaged
distinct portions as labor progresses.
2. floating- presenting part freely movable in inlet of
1. Upper Portion- contractile, becomes thicker
pelvis or may be movable in inlets of pelvis
2. Lower portion – passive, becomes thinner and more
3. dipping- entering pelvis
expanded.
4. fixed- no longer movable in inlet but not engaged
5. engaged- biparietal plane passed thru the pelvis
B. boundary between the two segments is termed the
“physiologic retraction ring”
UTERINE CONTRACTIONS
A. contractions
1. involuntary- cannot be controlled by will of client
EFFACEMENT AND DILATATION  A major goal of this method is the avoidance of
A. EFFACEMENT- thinning process by which cervical medicines unless absolutely necessary.
canal is progressively shortened to complete obliteration.  The Bradley method also focuses on good
Progresses from a structure of 1-2cm long to almost nutrition and exercises during pregnancy and
complete obliteration relaxation and deep- breathing techniques as a
B. DILATATION- process by which external os method of coping with labor.
enlarges from a few millimeters to aprroxiamtely 10 cm  Although, the Bradley method advocates a
C. all that remains of the cervix after effacement and medicine free birth experience, the classes do
dilatation is a paper-thin circular opening about 10 cm in discuss unexpected complications or situations
diameter like emergency cesarean sections.
D. primiparas efface, then dilate, multiparas efface and
dilate at the same time. IPM
3 intervetions aimed at supporting the client during labor
INTRAPARTUM PAIN MANAGEMENT maybe helpful these include:
Overview: A. providing info about progress of labor
1. the 2 main goals of IPM are: B. reinforcing techniques learned in prepared
a. to provide maximal relief of pain with childbirth classes
maximal safety for the mother and fetus C. directing birthing methods, abdominal lifting,
b. to facilitate L/D as appositive family pushing, relieving external pressure , distractions,
experience cutaneous stimulation and relaxation

2. pain relief maybe achieved by using prepared NON PHARMACOLOGIC PAIN MANAGEMENT
childbirth (Lamaze) analgesics or regional anesthesia DURING LABOR INCLUDE:
 Hypnosis
THINNGS TO HELP WITH PAIN DURING  Yoga
LABOR BEFORE OR DURING PREGNANCY:  Meditation
 Walking
 Regular and reasonable exercise can help
 Massage or counter pressure
strengthen muscles and prepare the body for the
 Changing position
stress of labor.
 Taking a bath or shower
 Exercise also can increase the endurance
 Listening to music
 A safe exercise plan for prescribed the doctor
 Childbirth classes, will help learn different
PHARMACOLOGIC PAIN MANAGEMENT
techniques for handling pain, from visualization
DURING LABOR INCLUDE:
to stretches designed to strengthen the muscles 1. narcotic analgesics- provides effective pain relief and
that support the uterus. slight sedation the dosage is kept to the smallest
 The 2 most common childbirth philosophies in effective dose
the U.S are the Lamaze technique and Bradley Opiod antagonist (such as naloxone- Narcan) should be
method available in case of respi. Depression in the mother or
LAMAZE TECHNIQUE newborn
 The Lamaze philosophy teaches that birth is a
normal, natural and healthy process and that 2. barbiturates- cause maternal sedation and relaxation.
woman should be empowered to approach it Not given during active phase of labor
with confidence.
 Lamaze classess educate women about the ways 3. Tranquilizers- decrease the anxietyand apprehension
to decrease perception of pain, such as through associated with pain and sometimes relieve the nausea
relaxation techniques, breathing exercises, associated with narcotic analgesics
distraction or massage by a supportive coach. Given once the newborn is out
 Lamaze takes a neutral position towards pain
medicine, encouraging women to make an 4. regional anesthesia- types include spinal, epidural,
informed decision about whether it is right for paracervical, and pudendal blocks and local infiltration
them. Blocks and provides pain relief with injected anesthetics
agents at sensory nerve pathways
THE BRADLEY METHOD Common brand names: Bupivacaine hydrochloride(
 Also called husband-coached birth sensorcaine)
 Emphasizes a natural approach to births and the Lidocaine Hydrichloride
active participation of the baby’s father as birth (lidocaine)
coach