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intrapartum
- begins with onset of contractions
- lasts until the explusion of the placenta
- labor
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factors that may trigger labor
- maternal factors:
- -uterine muscles
- -increased pressure on the cervix
- -increased estrogen
- -decrease progesterone
- -stimulation of oxytocin (natural hormone)
- fetal factors:
- -placenta ages (starts to calcify)
- -prostaglandin synthesis
- -increase in fetal cortisol
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components of the process of labor
- -powers (contractions)
- -passage (passageway)
- -passenger (fetus)
- -psyche (womans response)
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primary and secondary source of powers
primary force: uterine muscle contraction for dilation and effacement of cervix
secondary force: abdominal muscles to push once the cervix is fully dilated
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The Powers
-frequency: beginning of one contraction to the next
-duration: time from the beginning of the contraction to the end
- -intensity: strength of the contraction (not pain, just how hard the abdomen is )
- palpate using fingertips
- mild
- moderate
- strong
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Phases of Contractions (The Powers)
- 1) increment: ascending build up of contraction
- -begins in fundus
- -spreads through uterus
2) acme: peak of intensity
3) decrement: descending or relaxation of uterus
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Types of bony pelvis
- 1) gynecoid (best)
- 2) android
- 3) anthropoid (2nd best)
- 4) platypelloid
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Stations
relationship with the ischial spines to the presenting part of the fetus and assists in assessing for fetal decent during labor
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The Passenger
fetal head can either hinder childbirth or make it easier. if it can pass through the pelvis, then the rest of the body can too.
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front and back fontinal
front=diamond
posterior=triangle
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fetal attitude
- posture
- -relationship of the fetal parts to one another
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fetal lie
refers to the long axis (spine) of the fetus in relationship to the long axis of the woman
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2 primary lies:
longitudinal=long axis of fetus and mom are parallel
transverse=long axis of fetus is perpendicular to the long axis of the mom
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fetal presentation
- -cephalic-head first
- -vertex, brow, face presentation
- -breech- pelvis first
- -complete, frank, footling
- -shoulder- shoulder
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relationship of presenting part and maternal pelvis
engagement occurs when presenting part reaches or passes through the pelvic inlet
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fetal positions:relationships
- refers to the relationship of the presenting part to the front, sides or back of the maternal pelvis. Three notations to describe:
- 1) R or L
- 2) landmark of the presenting part: occiput, scrum, etc.
- 3) anterior, posterior, transverse
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The Psyche: labor
a journey into the unknown that is uncertain, irrevocable, and uncontrollable
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The 5th P
maternal position
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lightening
the descent of the fetus into the true pelvis that occurs about 2 weeks before term in 1st time pregnancies
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braxton hicks contractions
false contractions
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effacement
cervical dilation
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bloody show
- mucous plug is expelled with softening/effacement/dilation
- -spontaneous rupture of membranes
- -notify MD
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spontaneous rupture of membranes
may occur before the onset of labor but typically during labor
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stages of labor
1, 2, 3, 4
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stage 1
begins with first true labor contraction and ends with complete dilation of cervix
- latent phase: contractions last 30-45 sec., frequency 5-10 min, not uncomfortable, mild intensity
- -cervix dilates 0-3 cm
- -woman is able to cope
- active phase: cervix dilates 4-7 cm, contractions reach peak and intensity
- -best time to have an epidural
- -every 2-5 mins, 45-60 sec duration, discomfort increases
- transition phase: (hardest part)
- -cervix dilates from 8-10 cm
- -contractions 1-2 mins, 60-90 sec duration, most difficult and painful, becomes restless, tired, changes in positions, fears being alone
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2nd stage
- -begins when cervix is completely dilated, ends with delivery of infant
- -contractions 1-2 min, duration 60-90 sec
- -increase in bloody show
- -urge to push
- -perineum flattens, with bulging rectum and vagina
- -delivery imminent when crowning occurs
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3rd stage
- -begins after delivery of infant and ends with delivery of placenta
- -as uterus contracts down after delivery, the placenta is gradually separated from the uterine wall
- -lasts up to 30 mins.
schultz mechanism: 80% deliver the fetal surface first (shiny shultz)
duncan mechanism: 20% the maternal surface first (dirty duncan)
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4th stage
- -after delivery of placenta
- -immediate postpartal period
- -4 hrs
- -physiologic readjustment from 1-4 hours after birth
- -blood loss 250-500 ml
- -Sl decrease in bp, increase in HR
- -woman thirst, hungry
- -shaking chills
- -may have urinary retention
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local anesthesia
- accomplished by injection anesthetic agent into the inracutaneous, subcutaneous and intramuscular area of the perineum
- -generally used at time of birth
- -simple and practically free from complications
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Pudendal
- transvaginal injection of anesthetic agent into pudendal nerve
- -provides perineal anesthesia for end of first stage, second stage, birth and epis/laceration repair
- -east to administer
- -doesnt affect maternal or fetal VS
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epidural anesthesia
injection of an anesthetic agent into the epidural space to provide pain relief during labor or C/S
advantages: provides good pain control intrapartum and postpartum, minimal if any med reaches fetus
disadvantages: maternal hypotension, fetal hypoxia, labor progress may be slowed, pushing efforts may be less effective, sometimes difficult to locate epidural space
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spinal anesthesia (intrathecal)
injection of an anesthetic agent directly into the spinal fluid in the spinal canal to provide anesthesia for a vaginal birth or c/s
advantages: immediate onset of anesthesia, provides good pain control for intra and postpartum, minimal if any med reaches fetus, uses smaller drug volumes.
disadvantages: maternal hypotension, fetal hypoxia, spinal headache, reduces ability to push, temporary paralysis of affected areas, high spinal
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general anesthesia
induced unconsciousness accomplished by intravenous meds and inhalation agents used for cesarean birth and surgical interventions for complications
advantages: rapid induction may be necessary in cases of severe fetal distress, good uterine relaxation, patient is comfortable and unaware of surroundings during procedure
disadvantage: fetal depression, risk of aspiration, pos-op nausea/vomitting common, post op pain control not as effective, delays bonding and breastfeeding
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