Study Guide for Exam 2, Intrapartum

The five Ps of Intrapartum Labor and birth processes.

Passenger:
1) Lie, presentation, attitude:
Fetal lie is the relation of the long axis of the fetus to that of the
mother, and is either longitudinal or transverse.
Occasionally, the fetal and maternal axis may cross at a 45degree angle, forming an oblique lie, which is unstable and
always becomes longitudinal or traverse during the course of
labor.
Fetal presentation: it is the presenting part that portion of the
fetal body that is either foremost within the birth canal or in
closet proximity to it. It can be felt through the cervix on vaginal
examination. Accordingly, in longitudinal lies, the presentencing
part is either the fetal head or breech, creating cephalic and
preach presentations, respectively. When the fetus lies with long
axis transversely, the should is the presenting part and is felt
through the cervix on vaginal examination.
Attitude: In the later months of pregnancy the fetus assumes a
characteristic posture described as attitude or habitus. As a rule,
the fetus forms an ovoid mas that corresponds roughly to the
shape of the uterine cavity. The fetus becomes a folded or bent
upon itself in such a manner that the back becomes markedly
convex; the head is sharply flexed so that the chin is almost in
contact with the chest.
2) Fetal Position- (be able to draw diagram and identify where
baby is based on description of position of head in maternal
pelvis).
Position refers to the relationship of an arbitrarily chosen portion
of the fetal presenting part to the right or left side of the
maternal birth canal. Accordingly, with each presentation there
may be two positions, right or left. Because the presenting part
may be in either the left or right position, there are left and right
occipital, left and right mentum, and left and right sacral
presentations.

Passage: The whole pelvis, cervix and vagina

Powers: UCs Primary involuntary uc contractions, Secondarypushing

Position: Describes landmarks of the presenting part of the feus

to the mothers body. R / L side of maternal pelvis. Landmark
O=Occiput M=mentum, S=Sacrum or acromion (scapula SC)
process A. Anterior=A, posterior = P, or transverse (T), side of
maternal pelvis.

Psyche: reduce her anxiety/fear/ambivalence

3) Stages of labor, phases of the first stage of labor, and

associated characteristics of the contraction pattern
during each stage.
The first stage of labor is from the onset of regular contractions
to the full dilation of cervix. The first stage is significantly longer
than the second and third stages combined. The second stage
last from full dilation of the cervix to the birth of the fetus. You
know birth is close when the vulva bulges and encircles the head
of the fetus. The third stage of labor last from the delivery of the
fetus to the delivery of the placenta. The fourth stage is recovery
and lasts about 2 hours after the delivery of the placenta

4) Differences between the stages and nursing care

associated with each stage.
Early First Stage of Labor: (Latent):0-10 cm dilated. Pt feels able
to cope with the discomfort. May be relieved that labor has finally
started. Is able to express feelings of anxiety. Beginning cervical
dilation and effacement.
Assessment:
Triage nurse, phone call, walk in
Identifying who may be in labor
Admitting women in active labor vs. early or latent
phase
Comfort measures
In hospital assessment:

Interview-review prenatal data

UCs (onset, timing, strength, ROM, describe
Physical VS, FHR moniteoring, UCs Leopolds
maneuver, cervical alarm check
Labs- UA, CBC, ABO Rh type and cross match, GBS
status, SROM Nitrizin, Amnisure.
Admission:
Gown, collect labs, monitor, IV start, fluid bolus, eat?
Leopolds maneuver : Determines fetal presentation and
position;
Longitudinal/tranverse, where is fetal back, where are
small parts/extremities? What is the inlet? Does in confirm
what I found in the fundus?
Encourage ambulation Uterine contraction increase in
frequency in contractions allow pt to change positions frequently,
to relieve fatigue, and increase comfort of laboring client.
Walking is good at this point as long as the water has not broken.
Pt may be hungry, May have bowel movements and frequency of
urination.
Position changes:
o Supine w/wedge
o Squat
o Hands and knees
o Lateral
o Birth ball
o Peanut ball (very good if mom has epidural)
o Laboring in tub
Emotional support, physical care and comfort measures
o Helping maintain control
o Listening
o Advocating
o Conserving energy
o Encouraging efforts

Second stage; Complete dilation (10cm) to birth of baby

May still be hungry, she feels her body moving into a regular
rhythm.
Time frames: nullip 2-3 hours , multip 1-2 hours (longer in some
cases)
Latent phase of second stage:
o Laboring down
o Passive descent
Active phase of stage two
o Actively pushing (descent)

o Usually begins around +1 station

Positioning Mom
Frequent position changes
Using gravity
Lithotomy
Upright positioning
Sitting, kneeling, squatting
Lateral positioning
Semi-recombant
Standing
Preparing for birth:
Delivery table (see figure 19-17)
Prepare/set up warmer, check O2 equiptment,
resuscitation equipment, extra personnel if
resuscitation is anticipated.
Mechanism of vertex presentation:
Crowning
Birth of head
Birth of body and extremities
Do not use fundal pressure to assist birth!!!
Third Stage: Delivery of placenta
Nursing interventions:
Assist with delivery of placenta
Reviewed signs of placental separation in lecture 5,
please see
Pitocin bolus iv (20-40 U Pit in 500-1000ml LR)
Fundal massage
Other medications PRN to help control bleeding
and/or manage PPH (will cover in complications)
Fourth Stage: (1-2 hrs after birth; up to 4 hrs) bonding,
Nursing interventions:
VS q15min-1st hr,
VS q30 min second hour, then hourly after that.
Palpate/massage fundus Q15 min for 1st hour.
Assess Vaginal bleeding
Assess perineum
o Perineum care, numbing spray, ice, tucks,
Encourage bonding and breastfeeding
Comfort measures:
Heated blanket
Provide food and liquids
Encourage rest
Encourage breastfeeding in first hour as infant will be alert

 Skin to skin contact

Bonding
Evaluate mom/baby interactions
5) Differences between a laboring primipara vs a laboring
multipara (approx. duration of stages of labor, relative to
parity)
Primipara much longer effacement and dialation, and can take up
to 20 hours.
The first stage of labor is the longest and most difficult to predict.
This is specific to the fetus descending into the pelvic cavity. In
multipara, the descent is much faster. The proceeding stages
are similar to primip and multip.
6) Maternal sensations during the second stage of labor :
Calmness and Determination. No longer modest. Either
gradually or suddenly gets urge to push. Usually more alert and
may become more talkative between contraction. May be very
tired and might sleep between contractions. Begins with
complete dilation, 10 cm.
7) True labor vs Braxton hick contractions
True labor :
Progressive cervical dilation
Regular contractions, increasing in intensity
Progressive or descent of presenting part
Pain is not relieved by ambulation or by resting.
Braxton Hicks:
Lack of cervical dilation or effacement
Irregular contractions do not increase in frequency,
duration, and intensity.
Pain maybe relieved by ambulation or rest.
8) Station, what is station when fetus engaged, what is
station when crowning (or just prior to crowning)? How
might the perineum and vagina appear at the time of
birth?
9) Know how to interpret a cervical exam and the meaning
of the percentage when determining effacement.
In a cervical exam for instance if the report is 3 cm with 30 %, -2;
this would be interpreted as the cervix is 3 cm dilated, with 30 %
of cervix effaced (thining) and the 2 means, the presenting part
is 2 cm above the ischial spines.
10)
Difference between primary and secondary powers
in the second stage of labor.
Primary powers are concerned with dilation and effacement,
while secondary powers are concerned with expulsion of the
fetus.

11)
Effects of uteroplacental insufficiency on the fetus,
as seen on the fetal monitoring strip, effect of supine
hypotension on the fetus?
12)
Visceral vs somatic pain, stage of labor is more
likely to experience which type?
13)
Nursing care support measures for labor pain,
including back labor? Fourth P of Labor:
Positionhelp mom change positions frequently. Supine
position put pressure on abdominal aorta, no Bueno. Any upright
position will increase cardiac ability. Help pt with slow paced
breathing and relaxation exercises. Rubbing her back will help
with gate controlled pain. Specific to lower back pain,
counterpressure against the sacrum may help in alleviating pain.
Alternative approaches to relaxation:
o Aromatherapy
o Massage
o Hypnosis
o Biofeedback
14)
Nitrous oxide, Fentanyl, Naloxone.
Nitrous oxide
Fentanyl
Naloxone is an opioid antagonist. Pain will return to patient
once given. It is also given to the newborn to stop the effects of
the opiods used in birth process.
15)
Anxiety in labor and its effect on labor and pain
perception.
Anxiety increases pain and its perception. Calming the mom is
important to keeping pain under control. P number 5 Psyche
reduce her anxiety/fear/ambivalence.
16)
Epidural, placement, nursing care before during and
after placement.
Epidural are not usually given until pt is dilated to 4-5 cm. as to
not slow labor progress.
17)
Complications associated with the epidural:
Hypotension
Drug reaction
Total spine neurologic sequelae
Spinal headache
Nausea, shivering, and urinary retention
Ineffective anesthesia
Inform pt her ability to move freely will be limited, she may
experience orthostatic hypotension and dizziness, higher body
temperature may also occur.
18)
Contraindications for epidural:

Patient refusal
Uncorrected hypovolemia
Increased intracranial pressure
Infection at the site
Allergy to local anesthetic
Coagulopathy
Platelet count < 100,000
Uncooperative patient
Spine abnormalities and surgeries
Sepsis
Unstable spine from trauma
Positioning problems
General anesthesia (controversial)

19)
Fetal monitoring, know VEAL CHOP
V- variable
C Cord Compression
E -Early decels
H- Head Compression
A -Accels
O-K
L- Late Decels
P- Placental insufficiency
20)
Variability, define categories of variability.
Variability is irregular waves or fluctuation in the baseline FHR of
two cycles per minute or greater.
Catagories: Absent, minimal moderate, and marked.
Absent: d
21)
Category of tracing (NICHD 3-tier system), DR C
BRAVADO acronym, practice charting strips
Category
o
o
o
o

I: Normal FHR Tracing

Baseline 110-160 bpm
Moderate baseline variability
Late or variable decelerations absent
Reflective of normal acid/base balance in fetus

Category II: Indetermininate FHR Tracing

Not all tracings are I or III, so are placed in this category:
Examples:
Minimal or marked variability
Absent variability w/o recurrant variable or late
decelerations
Absence of induced accels with fetal stim
Recurrent variable decels with mimimal or
moderate variability
Recurrent late decels with moderate variability

 Variable decels w/ slow return to baseline,

overshoots or shoulders (will leap after decel)
Prolonged decelerations
DR - Determine Risk (low, med, high risk)
C Contractions: timing, regular, frequency, variation
Bra- Fetal Heart rate Baseline
V Variability
A- Accels
D Decels
O overall (category I, II, III)
Category III: Abnormal FHR Tracing
Absent variability and any of the following:
Recurrent late decelerations
Recurrent variable decelerations
Bradycardia
Sinusoidal pattern
o Fetal anemia, Fetal Rh disease aka
Hydrops Fetalis
o Narcotics
o Fetal asphyxia/hypoxia
o Fetal infection
o Fetal Cardiac Anomolies
22)

Steps of intrauterine resuscitation:

Reposition mom
Give IV fluids
O2 10 liter by rebreather mask
Stop Pitocin
Administer Terbutaline PRN
Notify Dr if steps do not resolve problem.
Ephedrine if low BP and causing late decels
Amnio-infuser for variable decels. (through IUPC)

23)
Absent or decreased variability and methods of fetal
stimulation
1. Fetal scalp stimulation and
2. 2. Vibro Acoustal (Probe w/buzzer)
24)
Rupture of membranes (ROM)(know normal TACO for
ROM), prolonged rupture of membranes and associated risks

25)
Uterine atony; define, and when post partum is a
woman most likely to experience increased bleeding due
to atony?
Atony of the uterus, also called uterine atony, is a serious
condition that can occur after childbirth. It occurs when the
uterus fails to contract after the delivery of the baby, and it can
lead to a potentially life-threatening condition known as
postpartum hemorrhage.
After the delivery of the baby, the muscles of the uterus normally
tighten, or contract, to deliver the placenta. The contractions
also help compress the blood vessels that were attached to the
placenta. The compression helps prevent bleeding. If the muscles
of the uterus dont contract strongly enough, the blood vessels
can bleed freely. This leads to excessive bleeding, or
hemorrhage.
26)
Signs of placental separation.
Placental abruption may or may not be painful and may even
remain asymptomatic in rare cases. Apart from vaginal bleeding
(in revealed abruption), classic signs include:
Back pain [6]
Abdominal cramping and pain
Abdominal tenderness
Rapid uterine contractions [7]
Uterine tenderness
Pallor
Disproportionately enlarged uterus
Nausea and vomiting
Restlessness
27)
Effects of breastfeeding on the uterus post partum,
what hormone influences effects on uterus.
Breastfeeding assists in Uterine contaction back to normal size.
Oxytocin influences the uterus post birth
28)
Review drug calculations: determine mL per hour and
drip rates for oxytocin augmentation of labor (hint poitocin
administered in mU/min, what is mL per hour? Know how to set
up equation)
Oxytocin; 20-40 U per 500-1000 ml of LR