Intrapartum: Mother & Fetal Well Being during Labor & Delivery

BY: Richard Benedict S. Roxas, R.N, MD

1. Mother’s Well being during Labor & Delivery

a. Power of the mother – energy critical

(Antepartum preparation such as exercise and endurance preparation, nutrition dictates amount
of power the mother can have)
b. Passageway – Uterus, Pelvis
a. Uterine Contraction
b. Blood Volume (Blood)
c. Pain
c. Psychological  Fear, Anxiety
d. Vital Signs:
Temperature: Elevation:
1. Rupture of Amniotic Sac  Lasting 2-3 hours duration may increase PGE
2. Dehydration or loss blood volume
3. Drugs: Anesthetics (PGE1 analogue, Morphine, Aspirin)
4. Allergic Reaction (Blood transfusion) (Histamine  H1 Vasodilation  increase blood flow)
5. Infection (B streptococcal infection)  TNF alpha & Endotoxin
e. NPO  Women in Labor it is restricted to give DRUGS, FOOD, WATER except, Ice chips.
 ASPIRATION RISK?  WRONG in NSVD but in CS correct.
 Decreased GASTRIC EMPTYING TIME due abdominal pressure in the uterus.
 Drugs may delay its effect/ fails to reach in the duodenal area for absorption

ALL MOTHERS that is no PRENATAL check up: HIV, Syphillis, Hep B infection suspect
f. Hemodynamic Status: Fluid Volume Overload (By Dr. Roxas)
a. Combination of Dextrose & Oxytocin  WATER RETENTION specially in higher dosage of
OXYTOCIN.
 DOSAGE 10U-20U incorporated to Lactate Ringers Solution and NEVER BOLUS (okay ka
lang?)
Hypervolemia:
1. Gas exchange  Accumulation of excess fluids in the alveoli (crackles)
2. Increases Blood Pressure
3. Increase Heart Rate: Bainbridge Reflex  Chest pain? , MI? increases the work load heart
4. Cerebral Edema  affect consciousness , seizure
5. Hyponatremia  Dilution of the sodium
6. Induced Dilutional Anemia  RBC diluted with retained fluid.  Hypoxia (kasama fetus)

g. Elimination: Distended Bladder (Emptied)  Can Obstruct & Delay Engagement  ( Straight
Catheterization never permanent or with urine bag except CS with urine bag)
Tumatae  Critical during 3rd stage Labor (IRE-IRE)

Target: Avoid soiling and contaminating the site.

h. Blood Pressure:
a. Hypertension : Possible Etiology
1. Consider Urinalysis to detect the presence of albumin (may also related with reduced
osmotic pressure  Edema) (MGT: Magnesium SO4 for Eclampsia)
2. Blood volume overload (drug induced oxytocin action with dextrose) (MGT. withhold Drug,
& fluid restriction)
3. Stress related events (Epinephrine release)  Alpha 1 (Vasoconstriction) (MGT: Modify
Stress)
4. Can be also related with acute blood volume loss/dehydration (Due to RAAS activation)  (
(MGT: rehydrate the patient)
b. Hypotension  May reduce blood flow in the uterus that may cause fetal hypoxia
Calcium Channel Blockers: (Drugs can be given in pregnancy)
1. May cause vasodilation effects (hypotension)
2. Cardiac Depression (Reduce Cardiac Rate)
3. Relax the Uterus
4. Reflex Tachycardia (Baroreceptor Reflex)
ACE inhibitors:
1. Critical for embryogenesis (ACE) if inhibited may cause malformations during 1 st, 2nd
trimesters.
Beta Blockers:
1. Blocks beta receptors that may cause the following effects:
a. Uterus: B1 blocking effect  Uterine contractions
b. Bronchi: B2 blocking effect  Bronchoconstriction
c. Heart : B1 Blocking effect  Bradycardia
d. Pancreas  B1 blocking action in the alpha cell  Insulin Release  Hypoglycemia

Diagnostics for Mother Labor:

1. CBC specifically (Hgb for baseline) (Neutrophil/WBC  artifacts depends case expected increase 
hemoconcentration due to water loss & Cell Damage, it doesn’t always mean infection but rather
sometimes can be infection  THIS BASED on the History of Mother)
2. Urinalysis  UTI, Critical Albumin (Hypertension in Pregnancy)
3. Cross Matching MANDATORY (magkamatayan na! it should be present in the chart)& optional (Rh +
etc)  Possible EMERGENCY Blood Transfusion
4. UTZ final  Dictates position fetus and presentation
5. Vaginal IE (Cervix)  effacement & dilation (3cm of cervical dilatation with uterine contraction &
bloody show  ACTIVE LABOR)  NURSING SAFETY ang pinaguusapan dito? HA!
6. Optional: Hepatitis A/B Antigen, ELISA, VDRL  FOR NO PRENATAL CHECK UP
7. RBS (for DM mothers)
8. Culture (optional)  Vaginal Discharges like Gonorrhea?
9. Tocodynometer  Uterine contraction & Feta Heart Rate
10. Pulse Oximeter  Well perfused areas (PaCo2, PaO2)
2. Fetal Well Being:
1. Uteroplacental Blood Flow  Assess the Partograph
What are the possible events may alter this process?
1. Deceleration of the Heart Rate (Compression fetal head/cord compression)
2. Position of the Placenta (Previa?)
3. Attachment of the Placenta (Early Abruption)
4. Maturity of the Placenta (Postmaturity Factors)
5. Position of the fetus  May compress the placental attachment (UTZ/LEOPOLDS)
2. Biophysical Profile: 10 perfect
1. Fetal Movement
2. Heart Rate (110-120 / 120-160/ 160 above) ( use Doppler UTZ, Tocodynometer tracing,
Stet  GOOD LUCK SAYO nasan ang
pagkasosyal mo? But important also
if the gadgets is not feasible)
Tachycardia:
A. Drugs
(Terbutaline: Beta agonist : B1 heart  TACHY)
(Atropine SO4: Muscarinic receptor blocker  VAGAL BLOCKING EFFECT TACHY)
Bradycardia:
 Contraction uterus, Fetal head compression, Fetal Distress
3. Fetal Tone & Breathing: Paradoxical Chest Compression  Chest wall retracts, Abdomen
rises)
4. Amniotic Fluid
Oligohydramnios  Konte
a. Indicate renal failure/agenesis suspect
b. PROM (Premature Rapture of Membrane)
Polyhydramnios 
a. May indicate esophageal atresia
Amniotic Fluid:
Color:Straw colored (Normal)
Amber/Dark: Fetal Hypoxia, Fetal Death
Thick Secretions: Infection
Green Color: Meconium Stained
Port wine Color: Abruptio Placenta
5. Placental Position
3. Drugs that is given to the Mother:
1. Oxytocics (PGE1, Methergine, Oxytocin)
- Uterine Contractions  Reduce in the placenta  Asphyxia
- Can compress umbilical cord
- Detachment of the Placenta
- Vagal Stimulation in the fetal head (Bradycardia)
- promotes progress labor
2. Tocolytics  Relaxes uterus
 a. Magnesium Sulfate(Calcium antagonist)  DOC Preterm Labor, Preeclamsia,
Seizure/Eclampsia
1. Urine output monitoring  <0.5cc/kg/hr  retention mg+  Toxicity (Proper
hydration, Urine Catheter)
2. Deep Tendon Reflex  Loss  Magnesium invasion in the calcium voltage gated ion
channel of the presynaptic cleft that prevents chemical synapse.
3. Respiratory Rate ( loss of DTR, this inhibit the release of ACH in the presynaptic cleft
that paralyze the muscle : Respiratory Muscle)
4. Blood Serum Level should not greater from the acceptable value
5. Anticipate Calcium Gluconate (Antidote)

b. Nifedipine (CCB))
c. Terbutaline  Beta Agonist
B1: Heart  Tachycardia (fetal bradycardia)  Notice na may Fetal Distress
B1: Uterus  Relaxation uterus  Uteroplancental circulation
B1: Insulin Inhibition  Hyperglycemia due to glucagon relaese
B2: Bronchodilation
3. Muscarinic Blocker: Atropine Sulfate
Heart: Tachycardia effect (blocks the vagal stimulation m2 L side)
4. Maturity Status: Immaturity/Postmaturity  AOG by UTZ
a. Respiratory : Pneumonocyte Type 2 maturity (Surfactant & L/S ratio) (produce surfactant)
 Compliance of the Alveoli to enhance recoil  PREVENTS Atelectasis (Contractive Type)
 COLLAPSE OF THE ALVEOLI)
DANGER: Atelectasis, Contractive Type
 INTERVENTION: Dexamethasone  DNA synthesis and maturity of the P.Type2
Artificial Surfactant
Incubator
Intubation
KABAONG  If all fails
5. Fetal Distress

Diagnostics:
1. Vibro-acoustic Stimulation  100-105 db  stimulate sympathetic that is Norepinephrine
release that stimulates the B1 receptor of the R side heart

a. Bradycardia: Does the fetus sleeping? Drug Induced?Fetal Distress?

2. Tocodynometer  Heart Rate, Uterine Contraction

3. Doppler UTZ  Very Accurate (Maternal & Fetal side)
4. Pulse Oximeter (Scalp)
5. pH Blood Monitoring  Umbilical Cord
6. Visualization of the Amniotic Fluid  Meconium Staining
7. UTZ
8. Leopold’s Maneuver
9. pH amniotic Fluid (Alkaline)
Neonatal Resuscitation  ITS PEDIA CONCERN (later, tama na muna)

POSTPARTUM MOTHERS: by DR. ROXAS

Important target: Establish bonding of mother and neonate and promote well being

A. Well being of the Mother:

a. Episiotomy and or Surgical incision via CS section

1. PAIN critical factor  most of the patients are given with Analgesics
a. ASPIRIN is not given (Cyclooxigenase pathway inhibitor it targets both TXA2 & PGE)
b. Paracetamol and Mefenamic Acid is best (PGE targets only)
c. Non pharmacological ways such as Hot-sitz bath, peri-lamp may reduce pain and hasten dryness
but risk burn injury is imminent
2. Infection is most likely  Antibiotics can be given to the patient, and antiseptics can be given
3. Impaired urinary elimination/incontinence  After the surgical procedure and damage to the
passage ways may cause edema, this may obstruct the out-flow of urine.
a. Hot sitz bath may help
b. Catheterization
c. Urine may contaminate the site if episiotomy is present not CS

4. Elimination through defecation: After CS, Intestinal ileus may be present due to the anesthesia
a. NPO until bowel movements/ flatulence is present
b. If peristaltic movement is present diet can resume. (Fiber is preferable)
c. Laxative can be give only if constipation is present
5. Body image: the change of vaginal canal.

b. Breast Changes: Breast Feedings

1. Importance of breast feeding should be employed (B_R_E_A_S_T_F_E_E_D_I_N_G)
a. Uterine contraction to prevent uterine atony & bleeding
b. Hasten involution of uterus
c. Nutritional & immunologic transfer, siempre samahan ng INFECTION transfer
d. Digestion of proteins for neonate and its bacterial contents
e. Bonding
2. Contra-indications of Breast feedings:
a. Patients with confirmed viral infections (HIV/Hep B)
b. Patients who take drugs that can be transferred through cell membrane
c. Mastitis, Breast Ca (Talaga? Sususo ka pa din? Aswang ka ba?)
d. Congenital anomaly in breast
e. Esophageal atreasia for baby NAMAN!
3. If feasible (Philippine setting only) Foster mothers can help to solve problems
a. Breast feeding in bank
b. Foster parents (Risk for infection transfer)
 c. Bottle feeding

4. Blood Loss Replacement:

a. Resuscitation with Lactate ringers solution
b. Hemoglobin count is important parameter postpartum (normal 14mg/dl)
- Blood Transfusion is necessary if hemodynamic status is greatly seen such as the following:
1. Reflex tachycardia
2. Severe hypotension
3. Severe Easy Fatigability
4. No urine output (Anuria)  ARF
5. Confusion states
6. Tachypnea  Chemoreceptor reflex ( accumulation H+ ions)
1 BAG of PRBC = 250 cc
1 BAG of PRBC = Can raise 1 mg/dl of hemoglobin
Example: if postpartum period that Hgb level is 10mg/dl  GIVE 4 PRBC but not given at once (
this depends with physicians goals)
c. Iron supplementation for uncomplicated with minimal Hgb loss. Acceptable blood loss in NSD is
<500cc.  Iron supplements should be given every day for 3 months and follow-up check up is
important.
7. Correction of electrolyte losses if feasible only.
6. Follow-up Check up
a. Perineal, Cervical, Vaginal stability
b. Resuming Sexual Intercourse
c. Follow-up Vaccines and Treatment
d. Neonatal Check-up C/O pediatrician (vaccination schedules, infant formula, anthropometrics
etc)
e. Planning for next Pregnancy?  FACTORY KA BA?
f. Parenting Roles & safety in the house and management

Nursing Diagnosis Related Concepts:

For Patients who is idiot about Labor and Delivery Aspects

1. Health Seeking Behaviors related to Learning more about childbirth and Newborn Care
2. Ineffective coping related to lack of a support person
3. Anxiety related to absence of significant other
4. Decisional conflict related to lack of information about advantages and disadvantages of child birth
settings.
5. Anxiety related to role impending birth event and ability to welcome sibling
Case1: For Patients who is in active labor with 3m cervical dilatation, uterine contractions and bloody
show: UTANG NA LOOB CHECK THE HISTORY
- Activity Intolerance
- Acute Pain
- Impaired Tissue Perfusion  Uteroplacental blood flow problem if + uterine contraction?
- Risk for infant sudden death syndrome
- Deficient fluid volume (Amniotic Fluid Losses, Blood Loss)
- Hyperthermia (Ruptured Amniotic Fluid for several hours )
- Excess fluid volume (Oxytocin +D5)
- Aspiration (Dental Dentures/Saliva)
- Risk for latex allergy response
- Risk for unstable blood glucose
- Bowel Incontinence
- Constipation
- Impaired urinary elimination
- Urinary retention
- Risk for contamination
- Risk for falls
- Risk for infection
- Risk for injury
- Sleep deprivation
- Anxiety
- Death anxiety
- Disturbed body image
- Fear
- Powerlessness

1. Activity intolerance
2. Impaired physical mobility
3. Ineffective airway clearance
4. Risk for infant sudden death syndrome
5. Acute Pain
6. Deficient fluid volume
7. Hyperthermia
8. Excess fluid volume
9. Impaired skin integrity
10. Ineffective breast feeding
11. Risk for aspiration
12. Risk for latex allergy response
13. Risk for unstable blood glucose
14. Bowel Incontinence
15. Constipation
16. Impaired urinary elimination
17. Urinary retention
18. Risk for contamination
19. Risk for falls
20. Risk for infection
21. Risk for injury
22. Sleep deprivation
23. Disturb thought process (post partum blues)
24. Anxiety
25. Death anxiety
26. Disturbed body image
27. Fear
28. Powerlessness
29. Care giver role strain
30. Impaired parenting
31. Ineffective role performance
32. Risk for impaired role parenting
33. Risk for suicide
34. Impaired tissue perfusion

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