INTRAPARTAL PERIOD Methods of Pain Management 1.

Discomfort during labor can be minimized if the woman comes in labor informed about what is happening and prepared with breathing exercises during labor. 2. Discomfort during labor can be minimized if the woman’s abdomen is relaxed and the uterus is allowed to rise freely against the abdominal wall with contractions. 3. Operates basically on the “Gate Control” theory of pain. To ease pain in one part of the body, the “gate” to this pain should be closed. THEORIES OF LABOR 1. Uterine Stretch Theory – any hollow muscular organ when stretched to capacity will contract and empty. 2. Oxytocin Stimulation Theory – as pregnancy nears term, oxytocin production by the posterior pituitary increases. Oxytocin causes contraction of the smooth muscles of the body. 3. Progesterone Deprivation Theory – progesterone being the hormone designed to promote pregnancy is believe to inhibit uterine motility. Since its amount is now decreasing, uterine contractions will then occur. 4. 4. Prostaglandin theory – it has been known that when the fetus has reached maturity, the fetal membranes produce large amounts of prostaglandin, a hormone that initiates uterine contractions. 5. 5. Theory of the Aging Placenta – as the placenta “ages”, it becomes less efficient, producing decreasing amount of progesterone. Because of the decrease blood supply in the placenta, the uterus contracts. PRELIMINARY SIGNS OF LABOR 1. Lightening Results in:  Relief of abdominal tightness and diaphragmatic pressure  Relief of respiratory discomfort  Increase frequency of urination as the gravid uterus impinges on the bladder  Increase in the amount of vaginal discharges  Shooting pain down the legs because of pressure on the sciatic nerve  Muscle spasms  Decreased fundal height 2. Increase in level of activity  The adrenal gland secretes large amounts of epinephrine or adrenalin about two weeks prior to labor.  This high level of adrenalin provides the woman with much energy. 3. Increase Braxton Hicks Contraction 4. Ripening of the cervix 5. Weight loss SIGNS OF TRUE LABOR 1. Uterine Contractions - The “pain” in uterine contractions results from:  Contraction of uterine muscles when in an ischemic state  Pressure on nerve ganglia in the cervix and lower uterine segment  Stretching of ligaments adjacent to the uterus and in the pelvic joints  Stretching and displacement of the tissues of the vulva and the perineum 2. Show 3. Rupture of membranes

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Differentiation between True and False Labor Contractions False Contractions 1. Begin and remain irregular 2. Felt first abdominally and remain confined to the abdomen and groin 3. Often disappear wit ambulation and sleep 4. Do not increase in duration, frequency or intensity 5. Do not achieve cervical dilatation True Contractions Begin irregular but become regular and predictable Felt first in lower back and sweep around to the abdomen in a wave Continue no matter what the woman’s level of activity Increase in duration, frequency and intensity Achieve cervical dilatation

Related terms:  Effacement  Dilatation In Primis, effacement occurs before dilatation In Multis, dilatation proceeds effacement Length of Normal Labor First Stage Second Stage Third Stage Primi 12 ½ hours 80 minutes 10 minutes ___________ 14 hours Multi 7 hours, 20 minutes 30 minutes 10 minutes _____________ 8 hours

Components of Labor  Passage  Passenger  Powers of Labor  Psyche Presentation Types: 1. Cephalic – vertex, brow, face, mentum 2. Breech – complete, frank, footling 3. Shoulder Position Possible Fetal Position 1. Vertex (Occiput) LOA,LOP,LOT,ROA,ROP,ROT 2. Breech (Sacrum) LSaA,LSaP,LSaT,RSaA,RSaP,RSaT 3. Face (Mentum) LMA,LMP,LMT,RMA,RMP,RMT 4. Shoulder - LAA,LAP,RAA,RAP Passenger  Structures of the Fetal Skull 1. Bones - frontal, parietal, occipital 2. Fontanels - Anterior and Posterior fontanel 3. Suture lines - sagittal, coronal, lambdoid suture

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Diameters of the Fetal Skull 1. Suboccipitobregmatic 2. Occitofrontal 3. Occipitomental Powers of Labor -uterotubal pacemaker  Uterine Change - Upper Uterine Segment - Lower Uterine Segment  Phases of Contraction - Increment - Acme - Decrement Aspects of Uterine Contraction  Duration (A – B)  Interval (B – C)  Frequency (A – C)  Intensity

9.5 cm 12 cm 13.5 cm

LABOR PROCESS Admission Procedures for the Laboring Client  Orientation to a birthing room  V/S assessment  Nursing and medical history and physical examination  Assessment of fetal heart rate  Vaginal examination  Urine specimen and necessary blood samples obtained  Explanation of fetal or uterine monitoring equipment to be used STAGES OF LABOR A. 1st Stage - Stage of Dilatation Phases of the First Stage of Labor * Latent/Preparatory phase -cervix dilates 0-3 cm -contractions lasting to 20-40 seconds -6 hours in a nullipara and 4 1/2 hours in multipara * Active/Accelerated Phase - cervix dilates from 4 to 7 cm - contractions lasting to 40-60 seconds occurring every 3-5 minutes - 3 hours in a nullipara and 2 hours in a multipara * Transition Phase - cervix dilates 8 to 10 cm - contractions lasting to 60-90 seconds occurring every 2-3 minutes Detailed Assessment During the First Stage of Labor Abdominal Assessment * fundic height * leopold’s maneuver * palpate the bladder Assessing Rupture of Membranes * by nitrazine paper test Vaginal Examination * to determine extent of cervical effacement and dilation Assessment of Pelvic Adequacy Sonography may be used at term to determine the diameters of the fetal head V/S Assessment

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Initial Fetal Assessment

Signs of Fetal Distress  High or Low FHR - Fetal bradycardia (<100/minute) - Fetal tachycardia (>180/minute)  Meconium-stained amniotic fluid  Fetal Thrashing  Fetal Acidosis – pH below 7.2 Maternal Danger Sign  Rising or Falling Blood Pressure  Abnormal Pulse  Inadequate or Prolonged Contractions  Pathologic Retraction Ring  Abnormal Lower Abdominal Contour  Increasing Apprehension  A. B. C. D. E. F. B. 2nd Stage – Stage of Expulsion Mechanism/ Cardinal Movements of Labor Descent – fetus goes down the birth canal. Flexion – as descent occurs, pressure from the pelvic floor causes the fetal chin to bend towards the chest. Internal Rotation –from AP to transverse, then AP to AP. Extension – as head comes out, the back of the neck stops beneath the pubic arch. The head extends and the forehead, nose, mouth and chin appear. External Rotation (Restitution) – anterior shoulder rotates externally to the AP position so that it is just behind the symphysis pubis. Expulsion – the delivery of the rest of the baby’s body.

Care of the Woman During the 2nd Stage of Labor  Preparing the Place of Birth  Positioning for Birth  Promoting Effective Second-Stage Pushing  Perineal Cleaning  Assist in Episiotomy Purposes of Episiotomy - to prevent prolonged and severe stretching of muscles supporting the bladder and rectum. - reduce duration of second stage of labor. - enlarge outlet in breech presentation or forceps delivery. Types: 1. Midline 2. Mediolateral C. 3rd Stage – Placental Stage  Placental Stage  Placental Expulsion Signs of Placental Separation  Calkin’s sign  Sudden gush of blood from the vagina  Lengthening of the cord Types of Placental Delivery  Schulze placenta  Duncan Placenta D. 4th stage – Recovery Stage Assessment:  Fundus

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Lochia Bladder Perineum Vital Signs Categories of Perineal Lacerations First degree – involves the vaginal mucous membrane and perineal skin. Second degree – involves not only the vaginal mucous membrane and perineal skin but also the muscles. Third degree – involves not only the vaginal mucous membrane, perineal skin and muscles but also the external sphincter of the rectum. Fourth degree – involves not only the vaginal mucous membrane, perineal skin, muscles and rectal sphincter but also the mucous membrane of the anus. Pharmacologic Pain Relief During Labor

• Pharmacologic management of pain during labor and birth includes analgesia, which reduces or decreases awareness of pain and anesthesia, which causes partial or complete loss of sensation. • Be sure to caution women not to take acetylsalicylic acid (aspirin) for pain in labor. Aspirin interferes with coagulation, increasing the risk for bleeding in the newborn or mother. Narcotic Analgesic • Narcotics are often given in labor because of their potent analgesic effect. Unfortunately, all the drugs in this category cause fetal CNS depression to some extent. Be sure to question an order for a narcotic if a woman is in preterm labor. • A preterm infant, because of possible lung immaturity, may have extreme difficulty coping with the added insult of respiratory depression at birth. • Narcotic Analgesic commonly used include meperidine hydrochloride (Demerol), morphine sulfate, nalbuphine (Nubain) • Meperidine is advantageous as an analgesic in labor because it has additional sedative and antispasmodic actions. Thus, it is effective in relieving pain and also helps to relax the cervix and give a feeling of euphoria and well-being.
Analgesics Commonly Used in Labor and Birth Type: Narcotic analgesic Drug: Meperidine (Demerol) Usual Dosage/Route: 25 mg IV, 50-100 mg IM q3-4 h; also epidurally Effect on Mother: Effective analgesic; feeling of well-being Effect on labor progress: Relaxation may aid progress during cervical relaxation. Will halt labor contractions if given too early Effect on Fetus or Newborn: Should be given 3 h away from delivery to avoid respiratory depression in newborn. Decreases beat-to-beat variability in FHR Type: Narcotic analgesic Drug: Nalbuphine (Nubain) Usual Dosage/Route: 10-20 mg IM q3-6 h, 0.3-3 mg/kg over 10-15 min IV Effect on Mother: Slows respiratory rate; effective analgesic Effect on labor progress: Causes mild maternal sedation Effect on Fetus or Newborn: Some respiratory depression may occur Type: Narcotic analgesic Drug: Morphine sulfate Usual Dosage/Route: Intrathecally 0.2-1 mg; 5 mg epidurally Effect on Mother: Pruritus; effective analgesic Effect on labor progress: Effect on Fetus or Newborn: Minimal effects Regional Anesthesia

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Regional anesthesia is the injection of local anesthetic to block specific nerve pathways. Regional anesthesia allows the woman to be completely awake and aware of what is happening during birth. They do not depress uterine tone, leaving the uterus capable of optimal contraction after birth, so help prevent postpartal hemorrhage.

Type: Lumbar Epidural Block Drug: Local anesthetic Usual Dosage/Route: Administered for the first stage of labor; with continuous block, anesthesia will last through delivery; injected at L3-4 Effect on Mother: Rapid onset in minutes; last 60-90 min; loss of pain perception for labor contractions and delivery; possible maternal hypotension Effect on labor progress: Will slow labor if given too early; obliterates pushing feeling, so second stage may be prolonged Effect on Fetus or Newborn: May be some differences in response in first few days of life • • • • Epidural blocks are advantageous for women with heart disease, pulmonary disease, diabetes and sometimes severe pregnancy-induced hypertension, because they make labor virtually pain free and reduce stress from the discomfort of labor to minimum. Because the woman does not feel contractions, her physical energy is preserved. Are acceptable for use in preterm labor because the drug has scant effect on the fetus. They allow for a controlled and gentle birth with less trauma to an immature fetal skull. Because the woman receives no systemic medication, the infant responds more quickly after birth than if narcotic analgesics were used. Local Anesthetics Local Infiltration. Local Infiltration is the injection of an anesthetic such as lidocaine (Xylocaine) into the superficial nerves of the perineum. The anesthetic is placed along the borders of the vulva. Local infiltration is used for episiotomy incision and repair. Pudendal Nerve Block. It is the injection of local anesthetic into the right and left pudendal nerves at the level of the ischial spine. The injection, made through the vagina with the woman in a lithotomy or dorsal recumbent position, provides relief of perineal pain during birth. Anesthesia achieved with this method is sufficiently deep to allow the use of low forceps during birth and an episiotomy repair. The onset of a pudendal nerve block takes 2 to 10 minutes; the effect lasts for approximately 60 minutes. Although the injection is only a local one, the fetal heart rate and the mother’s blood pressure should be checked immediately after the injection in case maternal hypotension occurs.

Type: Pudendal Block Drug: Local anesthetic Usual Dosage/Route: Administered just before delivery for perineal anesthesia; injected through vagina Effect on Mother: Rapid anesthesia through perineum Effect on labor progress: Non apparent Effect on Fetus or Newborn: Non apparent Type: Local infiltration of perineum Drug: Local anesthetic Usual Dosage/Route: Injected just before delivery for episiotomy incision Effect on Mother: Anesthesia of perineum almost immediately Effect on labor progress: Non apparent Effect on Fetus or Newborn: Non apparent

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