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Intrapartum

BC3 - Maternity

QuestionAnswer
The 5 P's of successful labor Passageway, Passenger, Powers, Psyche, Position
Passageway refers to the maternal pelvis
The pelvic inlet the pelvis brim is bordered by the linea terminalis
transverse diameter the largest diameter of the pelvic inlet, its adequacy is determined by the diagonal conjugate
diagonal conjugate distance between the sacral promontory and the lower margin of symphysis pubis
Pelvic Outlet measurement that really counts
Pelvic types Gynecoid, Android, Arthropoid, Platypelloid
Gynecoid Round, female pelvic type; Classic - what you want to have - only 50% have it; outlet wide
Android male - not adequate for childbirth
Anthropoid narrow side to side, long front to back; usually ok for childbirth w/ assist (vacuum or forceps)
Platypelloid Flattened, not adequate; precipatace deliver (fast <3 hrs); Risk for hemorrhage for mom; O2 deprivation for baby
Fetal Attitude *Important role in delivery process; relationship of fetal parts to one another; the problems come with deviation from the normal fetal attitude of flexion
Normal fetal attitude Flexion - back of fetus flexed; chin flexed on chest; thighs flexed up; arms & legs crossed
Fetal Lie The relationship of the long axis of the fetus to that of the mother (want baby to be longitudinal)
Fetal Presentation The portion of the baby's body that lies nearest the external os of the cervix (the presenting part what the examiner is feeling - hopefully its the head 96%)
If fetal presentation is the bottom Breech birth
If shoulder or breech presentation C-Section
effacement thinning of the cervix; described in %; 10% not much; 80-90% is good
4 / 80 / -1 4=dilation; 80=effacement; -1 above ischial spine
Hardest part to deliver the fetal skull
Sinciput brow
Vertix **should present - the area between the anterior and posterior fontanelle
Occiput area of fetal skull occupied by the occipital bone, beneath the posterior fontanelle
Mentum fetal chin
Presentation can be (3) cephalic, breech, shoulder
Cephalic Presentation head first (further classified by fetal attitude)
Vertex (cephalic presentation) *most common - head completely flexed on chest, the smallest diameter of head presents
Military (cephalic presentation) top of the head presents
Brow (cephalic presentation) head partly extended - sinciput is presenting part
Face (cephalic presentation) may have risk for CP d/t nerve damage
Breech presentation Bottom first
Complete (breech presentation) thighs & knees completely flexed
Frank (breech presentation) thighs are flexed on hips (feet in air by head)
Footling (single & double) foot is dangling
Engagement occurs when the largest diameter of presenting part (hopefully the head) reaches or passes through the pelvic inlet (confirms adequacy of inlet - not outlet)
Station refers to the relationship of the presenting part to the imaginary line between the ischial spines (narrowest part the fetus must pass through)
0 Station = ischial spines
Negative station above the ischial spines (0 to -5)
Positive station below the ischial spines (0 to +5)
Fetal position the exact relationship of the presenting part to the maternal pelvis
Primary Powers The uterine contractions
Secondary Powers Maternal abdominal muscles used during the pushing stage
Acme The peak of the contraction
Decrement The letting up of the contraction
Duration The time from the beginning to the end of a contraction
Frequency From the beginning to the beginning of another
Increment The building up of the contraction
Intensity The strength of the contraction
Mechanisms of Labor & Birth (Cardinal Movements) Engagement, Descent, Flexion, Internal Rotation, Extension, External Rotation, Expulsion
Why monitor I & O if mom has an epidural - offer bedpan - may have to straight cath
Monitor VS after epidural - BP for 5-10 minutes; after delivery every 15 minutes
Observe ROM for color, odor, amount and consistency of amniotic fluid
After ROM check FHR often for evidence of prolapsed cord
Observe for hypotensive syndrome If BP falls, position mom on left side, increase IV fluids, Oxygen at a few Liters
Supine hypotension late decelerations
Fetal assessment during L & D include Inspection (fetal lie); Palpation (Leopolds Maneuvers); Auscultation of FHR (monitor)
Leopolds Maneuvers 4 external abdominal palpations
Position for Leopolds Maneuvers Lay on back with shoulders slightly raised on a pillow and knees drawn up a little
Sources of pain during labor dilation/stretching of cervix; emotional tension; hypoxia of uterine muscle cells during contraction; stretching of lower uterine segment; pressure of presenting part on organs/structures; distension of vagina & perineum
Factors affecting pain perception Cultural background, self concept, fatigue, attention and distractions
Non-Pharmacologic Measures Effleurage; Distraction; Controlled breathing; Relaxation techniques
Effleurage Light abdominal stroking in a circular motion - downward
Distractions include reading, TV, cards
Analgesia absence of sensibility to pain, relife of pain, without loss of consciousness
Demerol Alleviates pain during 1st stage of labor; acts in 5-10 min of IV admin; lasts up to 3 hours
Maternal S/E of Demerol respiratory depression, N/V, hypotension, drowsiness
Fetal S/E of Demerol respiratory if given within 2 hours of delivery
Stadol and Fentanyl "takes the edge off"- fairly decent - doesn't eliminate pain - can be given anytime during
Anesthesia Loss of feeling or sensation
Lumbar epidural injection of medication into epidural space in the lumbar regions at levels L2 - L5
When is lumbar epidural done usually after a cervical dilation of 4-5 cm to prevent slowing down of labor
Lumbar epidural provides analgesia for what stages of labor without direct adver effects on fetus 1st and 2nd stages
If lumbar epidural is done too late won't feel the need to push
Disadvantages of lumbar epidural maternal hypotension (monitor BP q 15 min until stable); decreased urge to push; risk of increased need for forceps; risk of dural puncture
Spinal injection of medication into the CSF in the spinal cord - needle penetrates meninges - more chance of s/e
S/E of spinal anesthesia postspinal headache; urinary retention, increased maternal hypotension
When can a spinal affect the newborn if too much time elapses between anesthetic agent and birth
Pudendal Block injection into the pundendal nerves (femoral area) - relief to perineum for episiotomy
Local Infiltration anesthesia is injected into the nerves of teh perineum - main use is for pain caused by the stretching perineum
How long could it take to establish a baseline FHR 5-10 minutes
Baseline FHR the average rate when the woman is not in labor or is between contractions
Baseline FHR (#bpm) between 110-160 bpm (120-160 is normal)
Tachycardia (FHR) above 150 bpm
Possible causes of FHR tachycardia infection, anxiety from mom, medications
Bradycardia (FHR) below 110 bpm
Possible causes of FHR bradycardia heart/cardiac block - not enough O2
Variability the normal irregularity of the cardiac rhythm - internal fetal monitoring measures this best
Accelerations occur in breech presentations
Accelerations are the basis for the nonstress test and occur with fetal movements, indication fetal well being (want to see irregularities)
Accelerations should be seen with every contraction (GOOD)
Decelerations may be benign or ominous - down but comes back up
Early deceleration occur in response to compression of the fetal head (head compression) - OK to have during labor
Late deceleration caused by uteroplacental insufficiency. Deceleration begins after the contraction is well established and persists after contraction ends
Late deceleration Not getting enough O2 - possibly b/c of mom's position, so reposition on Left side, Inc fluids, elevate HOB - if continues > C-section
Late deceleration could be a sign of fetal distress
Variables are caused by compression of the umbilical cord - Do not mirror uterine contraction - No pattern > reposition
Reassuring FHR patterns Baseline FHR in normal range of 110-160 with average variability; accelerations; early decelerations; mild variables
Non-Reassuring FHR patterns Progressive inc or dec in baseline FHR; Tachycardia above 160; progressive dec in baseline variability; severe variable decels; repetitive late decels; total absence of variability; prolonged decels of any kind; severe bradycardia
Created by: okrecota on 2007-11-08



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