IV. INTRAPARTAL CARE A. Basic 1. Theories on the onset of labor: a.

Uterin Stretch Theory The idea is based on the concept that any hollow body organ when stretched to its capacity will inevitably contract to expel its contents. The uterus, which is a hollow muscular organ, becomes stretched due to the growing fetal structures. In return, the pressure increases causing physiologic changes (uterine contractions) that initiate labor. b. Oxytocine Theory Pressure on the cervix stimulates the hypophysis to release oxytocin from the maternal posterior pituitary gland. As pregnancy advances, the uterus becomes more sensitive to oxytocin. Presence of this hormone causes the initiation of contraction of the smooth muscles of the body (uterus is composed of smooth muscles c. Prostaglandin In the latter part of pregnancy, fetal membranes and uterine decidua increase prostaglandin levels. This hormone is secreted from the lower area of the fetal membrane (forebag). A decrease in progesterone amount also elevates the prostaglandin level. Synthesis of prostaglandin, in return, causes uterine contraction thus, labor is initiated. d. Progesterone Deprivation Theory Progesterone is the hormone designed to promote pregnancy. It is believed that presence of this hormone inhibits uterine motility. As pregnancy advances, changes in the relative effects estrogen and progesterone encourage the onset of labor. A marked increase in estrogen level is noted in relation to progesterone, making the latter hormone less effective in controlling rhythmic uterine contractions. Also, in later pregnancy, rising fetal cortisol levels inhibit progesterone

production from the placenta. formation initiates labor. e. Aging Placenta Theory

Reduce

progesterone

Advance placental age decreases blood supply to the uterus. This event triggers uterine contractions, thereby, starting the labor. 2. 4 Ps of Labor: The passenger, the powers and the psyche. All of these must work together in synchronicity to achieve a successful, vaginal birth. a. The Passageway (a.k.a The Pelvis): Major pelvic bones include the innominate bones (formed by the fusion of the ilium, ischium, and pubis around the acetabulum), the sacrum, and the coccyx. DIVISIONS: Pelvis is arbitrarily divided into halves the false pelvis and the true pelvis. False pelvis: wide broad area btw. the iliac crests andamp; has no major clinical significance for Landamp;D. The pelvic inlet is the top opening of the pelvis. This is the part the babys head enters first. The pelvic outlet is where the babys head (and body!) exits mom. These dimensions need to be sized sufficiently to allow baby to maneuver comfortably through the pelvis for birth. The tailbone (sacrum or coccyx) needs to be sufficiently mobile to be gently pressed back out of the way when baby moves through. Your sacroiliac joint allows this nutation or counternutation of the sacrum. The symphisis pubis is a cartilaginous joint in the front of the pelvis. It also needs to be properly mobile to help the pelvis flex to allow baby to pass through. The relaxin hormone in the body helps both the tailbone and the symphisis pubis become more mobile to facilitate birth b. The Passenger: (Fetus) PASSENGER (FETUS): Biological influences a pregnancy that terminates during the 38-42 week gestation is likely to indicate

a healthy fetus. Mechanical influences Fetal head Fetopelvic relationships Cardinal movements. The baby needs to be positioned properly to make it through the pelvis. The optimal position for birth is Occiput Anterior (OA). However, babies can be born vaginally in a number of positions. c. The Powers: Uterine labor ctx. of the myometrium. Ctx.phase consists of a descending gradient: The wave begins in the fundus (greatest # myometrial cells). Then moves downward through the corpus of the uterus. Intensity of ctx.diminishes from fundus to cervix. Retraction phase. These are your contractions and your additional efforts for pushing. Your contractions need to be strong enough to dilate the cervix and aid the baby in his decent. They need to be at regular intervals, moving closer together and increasing in strength throughout labor. On the flip side, they cant be too strong, or too intense or you have a case of fetal distress and / or a mom who cant cope with her contractions without medical interventions. If the contractions are too weak or not at regular enough intervals, your care provider might suggest using Pitocin (synthetic oxytocin) to amp them up. d. The Psyche: The Psyche is another word for you your emotional state during birth. If mom is afraid, tense, stressed out, angry, feels unsafe or unsupported, she will not likely do well during birth. For some, the fear is intense enough to schedule a c-section and to avoid a vaginal birth all together. For others, it may prevent cervical dilation, fetal decent, or prevent mom from pushing effectively. (Think Ina Mays Sphincter Law). A good emotional state helps mom cope with the pain effectively; helps her tune in to her body; helps guide her to her babys needs and allows the other 3 Ps to sync up effectively. A mom whos psyche is healthy, strong and who has good support during labor, will have a good birth. Regardless of the medical interventions she may need, she will ride her labor to a birth experience she will remember with a strong heart and a peaceful mind.

There is no one P that can work without the others. All four must be working properly for baby to join the world in the way they are intended. The Ps can be influenced by moms movements, position, her care provider, her support people, and medical intervention. Birth is a complicated, multifaceted, lifechanging event. Get yourself in a good head-space and you will be able to work with issues that may arise with the Passageway, the Passenger and the Powers. e. Preliminary Signs of Labor: a. Lightening The process in which he babys head usually begin to slide down lower into the pelvis as the uterus becomes soft. This process allows the mother to breathe more easily. Some women experience the dropping of their babys weeks before the baby is born. During this process, the woman feels freer and breathing becomes easier but many suffer from pelvic and lower back pain or discomfort. There are certain women who dont notice it at all. This usually occurs a week or two before into a labor. For first time mothers and maybe a day or two before labor for women who have already have children. b. Engagement c. Resting Instinct d. Braxtan-hicks contraction This is known as false labor or practice contractions and are sporadic uterine contractions that sometimes start around 6 weeks however are not usually felt until the second trimester or third trimester of pregnancy. They should be infrequent, irregular, and involve only mild cramping. e. Decrease with of the pregnant mother f. Rippening and softening g. Presence of show

h. Rapture of the bag of water i. Effacement j. Station k. Survical Dilation f. Stages of labor: a. First Stage - onset of regular contraction to full dilation

Phase One (LATENT) - dilatation is 0 - 3 cm; duration is 10 - 30 sec; interval is 5 - 30 mins; intensity is mild to moderate Phase Two (ACTIVE) - dilatation is 4 - 7 cm; duration is 30 - 40 sec; interval is 3 -5 mins; intensity is moderate to strong Phase Three (TRANSITION) - dilatation is 8 - 10 cm; duration is 45 - 90 sec; interval is 2 - 3 mins; intensity is strong Nursing Care for First Stage of Labor 1. 2. 3. 4. 5. 6. monitor V/S and FHR every 15 mins bed rest for ruptured membrane empty the bladder pain relief teach breathing techniques maintain safety

b. Second Stage of Labor - from full dilation to delivery of the fetus (30-60 mins for primigravida and 20 mins for multipara)

Phase One - station is 0 to +2; contraction is 2 to 3 mins apart Phase Two - station is +2 to +4; contraction is 2 to 2.5 mins apart with urgency to bear down Phase Three - station is +4 to birth; contraction is 1 to 2 mins apart;fetal head visible, increased urgency to bear down

Nursing Care for Second Stage of Labor 1. transfer to delivery room for 8-9 cm dilation for multigravidas and full dilation for primiparas 2. monitor V/S and FHR 3. prepare perineal area 4. encourage pushing with contractions 5. immediate newborn care c. Third Stage of Labor - from delivery of infant to delivery of placenta

5 - 30 mins sudden gush of blood lengthening of the cord rising of the fundus globular uterus

Nursing Care for Third Stage of Labor 1. 2. 3. 4. 5. assess for placental separation inspection of placenta monitor V/S initiate breastfeeding administer oxytoxin and antilactation agents as ordered 6. sending cord blood to laboratory if mother is Opositive or Rh-negative 7. allow bonding d. Fourth Stage of Labor - time from delivery of placenta to homeostasis (first 4 hours after delivery of the placenta) Nursing Care for Fourth Stage of Labor 1. 2. 3. 4. 5. 6. monitor V/S every 15 mins take fundal height, position and consistency assess for lochia check perineum perform perineal care from front to back post partum care