MCN – M4 - Care of the Mother and the Fetus during the Perinatal Period (Intrapartal Care – Part 1)

PRENATAL - nrsg given to pregnant Clients

INTRAPartal care- Pregnant clients in labor n delivery

- During PRENATAL Care, teach Mother abt ✩Breathing exercises, especially if [3rd trimester]

🖸PAIN pathway [ppt] ;; PAIN flows thru Pathways bc:

1st. Endings of small Peripheral nerve fibers detect a stimulus
2nd. Small nerve fibers Transmit to the cells in the Dorsal horn of the Spinal cord
3rd. Impulses pass thru a dense, interfacing network of cells in the Spinal cord (substantia gelatinosa)
4th. Immediately, A synapse occurs that returns the transmission to the peripheral site thru Motor nerve

a synapse occurs in a motor nerve that initiates a response at the peripheral site.
5th. Impulse then continues in the Spinal cord to reach the Hypothalamus & Cortex in the Brain
6th. Impulse is interpreted & perceived as PAIN
4. For example, a woman touches a hot stove, the impulse travels to the spinal cord, immediately returns to her fingers, and
the woman jerks her hand away from the stove burner.
5. After this short-circuit synapse, the impulse then continues in the spinal cord to reach the hypothalamus and cortex of the
brain.
6. The impulse is interpreted (e.g., the burner is hot) and is perceived as pain.
METHODS for PAIN MANAGMENT
I. GATING THEORY OF PAIN CONTROL
The gating theory of pain perception refers to gate control mechanisms in the substantia gelatinosa
- Capable of halting an impulse @ the level of the spinal cord so the impulse is NEVER perceived at the brain level
as pain—a process similar to closing a gate.
TECHNIQUES that can assist gating mechanisms include:
1. Cutaneous stimulation
- If large peripheral nerves next to an injury site are stimulated, the ability of the small nerve fibers at the injury
site to transmit pain impulses appears to decrease. Therefore, rubbing an injured part or applying
transcutaneous electrical nerve stimulation (TENS) or heat or cold to the site (cutaneous stimulation) are
effective maneuvers to suppress pain. Effleurage, or light massage used in the Lamaze method, also
accomplishes this.

2. Distraction. If the cells in the brain cortex that will register an impulse as pain are preoccupied with other stimuli, a pain
impulse canNOT register. Different childbirth classes use different breathing, vocalization, or focusing techniques such as
imaging to accomplish this. Breathing techniques NOT only furnish distraction but can increase oxygenation to the mother and
fetus.

🍏Methods to Manage PAIN in Childbirth p.314
Most approaches to ↓discomfort in labor are based on the ff 3 PRINCIPLES:
1. A woman needs to come into labor informed about what causes labor pain and prepared with breathing exercises to use to
minimize pain during contractions.
2. A woman experiences less pain if her abdomen is relaxed and the uterus is allowed to rise freely against the abdominal
wall with contractions.
3. Using the gating control theory of PAIN perception, distraction techniques can be employed to alter how pain is received
3. Reduction of anxiety. Pain impulses are perceived more quickly if a woman is anxious. The third technique of gating,
therefore, is to reduce patient anxiety as much as possible. Teaching a woman what to expect during labor is a means of
achieving this.
p. 317
○Effleurage - [ French= Light Abdominal massage]
○Focusing/ Imagery- “sensate focus”
- chek record
-
Focusing intently on an object (sometimes called “sensate focus”) is aNOTher method of keeping sensory input from reaching
the cortex of the brain (Chuang, Liu, Chen, et al., 2015). For example, a woman brings into labor a photograph of her partner
or children, a graphic design, or just something that appeals to her like an ocean scene she can concentrate on during
contractions. Other women use imagery by imagining they are in a calm place such as on a beach watching waves rolling in to
them or relaxing on a porch swing (Fig. 14.8). Be careful NOT to step into a woman’s line of vision during a contraction to
break her concentration on an object; also, don’t ask questions or try to talk to women while they are focused and breathing or
you will break their concentration.
🍏Methods to Manage Pain in Childbirth P.314 IV. GRANTLY DICK-READ METHOD
I. Gate Control Mechanisms – involves halting the impulse at the level of the spinal cord so the impulse is never - Fear leads to tension & →→ tension leads to →→→ PAIN
perceived at the brain level as a pain. - Achieves relaxation and reduced pain in labor by using abdominal breathing during contractions

3 Techniques: V. Lamaze Method (Ferdinand Lamaze)

a. Cutaneous stimulation - Based on stimulus-response conditioning,
b. Distraction - To be EFFECTIVE, Full concentration on breathing exercises during labor should be observed
c. Reduction of anxiety - PSYCHOPROPHYLACTIC METHOD = Preventing PAIN during labor (prophylaxis) by the use of mind
(psyche)
II. BRADLEY METHOD (PARTNER-COACHED) METHOD
- Pregnancy is a joyful natural process and stresses importance of the husband 6 MAJOR CONCEPTS of LAMAZE:
- Pain = ↓ by : ✓Abdominal breathing, ✓walking during Labor 1. Labor should begin on its own, NOT be induced.
2. Woman should walk, move around FREELY, and change positions thruout Labor.
III. PSYCHOSEXUAL METHOD (Sheila Kitzinger) 3. Woman should bring loved one, friend,/ doula(= special support N. to women in Labor) for continuous support.
- Stresses that pregnancy, labor and birth and the early newborn period are important points in woman’s life 4. Interventions that are NOT medically necessary should be avoided.
cycle 5. Women should be allowed to give birth in other positions.
- The program involved conscious relaxation and levels of progressive breathing encourages the woman “to 6. Mother and baby should be kept together after birth.
flow with” rather than struggle against contractions of labor. 7. 5.   Women should be allowed to give birth in other positions than on their
RELAXATION techniques back and should follow their body’s urges to push.
i. Conscious relaxation 8. 6.   Mother and baby should be kept together after birth; it is best for the
- relax the body so woman does NOT remain tense & Unnecessary muscle strain & fatigue [during labor]
ii. Cleansing breath mother, for the baby, and for breastfeeding
- woman breaths DEEPLY & then EXHALES DEEPLY

iii. Consciously controlled breathing

- Lvl 1 = slow chest breathing
- Lvl 2 =
- Lvl 3 =
- Lvl 4 =
- Lvl 5 = The learner will watch videos some methods to manage pain in childbirth
https://www.youtube.com/watch?v=bJ8wAgxdYqA - Elowyn's Birth Story // The Bradley Method //
Natural Hospital Birth
https://www.youtube.com/watch?v=TSuRnhfB2qA – Lamaze classes
https://www.youtube.com/watch?v=_3n9_FJ14NI – LAMAZE HEALTHY BIRTH – What you NEED to
Know!

Types of Birth Setting

Besides how to prepare for labor, choosing a birth setting is aNOTher important decision that a couple needs to make during
pregnancy (Alliman & Phillippi, 2016).

1. Hospital Birth (labor-birth-recovery postpartum rooms/ Labor-birth-recovery) (LBRPs)

2. Alternative Birthing Center
- Wellness-oriented childbirth facilities designed to remove childbirth from the acute care hospital setting while
providing enough medical resources for emergency care should complication of labor & birth arises.
- Woman = encouraged to express her own needs & wishes during labor, she can CHOOSE a Birth position, bring
her own Music/ distraction objects & partner can perform such tasks such as Cutting the cord, Woman remains [ 4-
lvl 4 crowning 24 hrs after birth ]

3. Home Birth
 - allows for family integrity, puts responsibility on the woman to prepare the house &
take care of her infant [after birth]
4. ALTERNATIVE METHODS of Birth
i. Leboyer – (from a warm, fluid-filled intrauterine environment to a noisy, air-filled brightly lit birth room creates a
major shock).
- The birthing room is darkened so there is no sudden contrast in light, keep room pleasantly warm, soft music
is played, infant handled gently, cord is cut late, place in a warm-H2O bath.
ii. Hydrotherapy & H2O Birth
- Reclining/ sitting in warm H2O labor can be soothing, feeling of weightless & relaxation can ↓ discomforts
- DISADVANTAGES: H2O contaminated w/ Mother’s fecal material, Aspiration, Maternal chilling
4. Prostaglandin Theory
- The relative progesterone deprivation and estrogen predominance set off production of cortical steroids which act
on lipid precursors to release arachidonic acid, and in turn, increase the synthesis of prostaglandins.
Prostaglandins, like oxytocin are known to stimulate uterine contractions.
-
- 1st: (↓) Progesterone Deprivation & (↑) Estrogen Predominances
- 2nd: Set-off production of cortical steroids
- 3rd: Act on LIPID precursors
- 4th: Releases arachidonic Acid = responsible for ↑Prostaglandins
- 5th: ↑s sysnthesis of prostaglandins (UTERINE CONTRACTION)

5. Unassisted Birthing 5. Theory of Aging Placenta

- FREEbirthing/ Couple birth = Woman giving Birth w/o H.C. provider supervision - The (↓)decrease of: (↓) Nutrients & (↓) Blood supply in the aging placenta causes UTERINE CONTRACTIONS
- It differs from Home birth…
- It needs NO medical supervision
🍏COMPONENTS OF LABOR p.328
A successful labor depends on 3 integrated concepts:
🍏THE LABOR PHENOMENON
LABOR
Series of events by the w/c the Uterine contractions & Abdominal pressure expel a Fetus & Placenta from a woman’s body
Series of continuous, progressive contractions of the Uterus w/c help the Cervix to open (dilate) & to thin (efface), allowing the
Fetus to move thru the birth canal

🍏THEORIES OF LABOR ONSET

Labor normally begins when a fetus is sufficiently mature to cope w/ extrauterine life yet NOT too large to cause mechanical
difficulties in delivery. However, the trigger that converts the random, painless Braxton Hicks contractions into strong,
coordinated, productive labor contractions is unknown. A # of theories have been proposed to explain why labor begins.
These include:

1. Uterine Stretch Theory

- Any hollow body organ when stretched to capacity will necessarily contract & empty bc of PRESSURE on nerve
endings & ↑d irritability of the Uterine musculature.
1. Passageway.
2. Oxytocin Theory. - route the of the Fetus to travel from the uterus through the cervix and vagina to the external perineum; bc these
- Oxytocin = effective stimulant of uterine contractions in late pregnancy & is commonly used to induce/ augment organs are contained inside the pelvis, the fetus must also pass between the pelvic ring.
labor. - Size of Maternal Pelvis: Diagonal conjugate (AP dm of the INlet) & Transverse dm outlet
- 1st: Nipples = stimulate
- 2nd: Nerve impulses travel from Nipple to the Hypothalamus - !! Check mo confe
- 3rd: Stimulates { posterior PG to produce Oxytocin - Cephalopelvic disproportion (CPD) – delivers thru CS delivery bc Fetus Head = BIG
- 4th: Causing UTERINE CONTRACTION
2. Passenger
3. Progesterone Deprivation Theory - If the fetus is of appropriate size and in an advantageous position and presentation.
- Progesterone = believed to inhibit Uterine motility/ Uterine Contraction - I. FETAL HEAD = body part that has the WIDEST DM
- The onset of labor in humans might result from w/drawal of progesterone @ a time of relative estrogen dominance - II. FETAL SKULL
- 1st: Progesterone deprivation i. Cranium = UPPERmost portion of the Skull
- 2nd: Onset of Labor 8 BONES:
- 3rd: w/drawal of progesterone Frontal
- 4th: @ a time of relative estrogen dominance.(UTERINE CONTRACTION) Parietal
Occipital CHECK CONFE
Sutures
 - Membranous spaces b/w Cranial bones
- allow for MOLDING (overlapping of the BONES)
o Sagittal suture line – joins the 2 Parietal bones of the skull
o Coronal suture – joins the Frontal bone & the 2 Parietal bones
o Lambdoid suture – joins the Occipital bone & 2 Parietal bones
o Frontal “Mitotic” suture – joins 2 Frontal bones, becomes the
{ Anterior continuation of the Sagittal suture

ii. Posterior Fontanelle

i. Anterior Fontanelle
Check confe

3. Power. This is supplied by the fundus of the uterus and implemented by uterine contractions, a process that causes
cervical dilatation and the expulsion of the fetus from the uterus.

4. Psyche. The woman’s psyche is preserved so afterward labor can be viewed as a positive experience.
Fetal position https://www.youtube.com/watch?v=ybWQCkElMiI – Cardinal movements of labor
- relation of the fetal presenting part to a specific quadrant of the woman’s Pelvis.
1. Descent/flexion
3 NOTATIONS to describe the FETAL POSITION 2. Internal rotation
1. Right [R] or Left [L] side of the maternal pelvis 3. Extension begins
2. Occiput (O), Mentum (M), Sacrum (Sa),/ Acromion process (A) : LANDMARK of the presenting part 4. External rotation
3. Anterior (A), Posterior (P),/ transverse (T) depending on whether the landmark is in front, back,/ side of the pelvis 5. Extension complete
6. Expulsion
POSITIONS - indicated by an abbreviation of 3 letters
o 1st letter = defines whether the landmark is pointing to the mother’s [R] or [L] D’FIERE
o Middle letter = denotes fetal landmark (O,M Sa, A) DESCENT
o Last letter = whether the landmarks points A, P, T - is the downward movement of the biparietal diameter of the fetal head within the pelvic inlet

LOA – 1st most common FLEXION

ROA – 2nd most common - fetal head reaches the pelvic floor, the head bends forward onto the chest, making the smallest anteroposterior
the one presented to the birth canal.
[Listen to 14mins]
INTERNAL ROTATION
Importance of Determining Fetal - the head enters the pelvis with fetal anteroposterior head diameter in a diagonal or transverse position. The head
Presentation and Position flexes as it touches pelvic floor and the occiput rotates until it is superior or just below the symphysis pubis
•
Could put a fetus at risk due to proportional EXTENSION
differences between fetus and pelvis - occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head
•
Membranes also are more apt to rupture early, EXTERNAL ROTATION
increasing possibility of infection - immediately after the head of the infant is born, the head rotates from the AP position assumed to enter the outlet
• back to the diagonal/ transverse position
Risk of fetal anoxia and meconium staining leading
to respiratory distress at birth EXPULSION
4 methods determining fetal position, presentation & - once Shoulders are born , the rest of the baby is born easily and smoothly bc of the smaller size
lie:
•
Inspection and palpation (Leopold’s maneuver) POWERS of LABOR
• Fundus  Implements UTERINE CONTRACTION causing Cervical DIALTION Expulsion Fetus & Placenta
Vaginal examination
• - After DILATION of the Cervix, the primary power = supplemented by the use of Abdominal muscles
Sonography
•
Auscultation of fetal heart tones PREMONITORY SIGNS of LABOR ;; PRELIMINARY SIGNS of LABOR [book],.,. @ CHP 12
1. Lightening.
- descent/ settling of the presenting part (usually fetal Head°) into the pelvic inlet(pelvis)
🍏MECHANISMS of LABOR w/c happens [10-14 days before labor] in PRIMIGravida & [1 day before labor] in a MULTIpara.
Cardinal Movements
- POSITION CHANGES - when the LARGEST dm of the presenting part passes the pelvic inlet, the head = said to be "ENGAGED."
- Passage of a fetus through the birth canal involves a number of different position changes to keep the smallest dm
of the Fetal head° always presenting to the smallest dm of the Birth canal. However, Lightening is heralded(asignals) by the following signs ;; Woman experiences [ppt]:
i. Relief of Dyspnea ;; Relief SOB/ Diaphragmatic pressure
!! Only seen in CEPHALIC.,. NOT seen in Breech ii. Relief of Abdominal TIGHTNESS
iii. ↑d frequency of voiding
The learner will watch a video on the cardinal movements of labor iv. ↑d amount of vaginal discharge
https://www.youtube.com/watch?v=odHEQNGph2Y – Cardinal movements v. ↑d Lordosis as the fetus enters the Pelvis & falls further {forward}. WALKING = ↑difficult & ↑Leg CRAMPING
vi. Increased varicosities
 vii. Shooting Leg PAINS bc of ↑pressure on the Sciatic nerve ii. Duration of contraction – this is time from moment the Uterus 1st begins to tighten
until it relaxes again.
2. Increased Lvl of Activity ;; ↑ in ENERGY [book] iii. Intensity of contraction – it may be mild moderate/ strong at its Acme.
- AWAKEN FULL of ENERGY/ sudden burst of maternal energy/activity
Bc of Epinephrine release = initiated by ↓ in Progesterone produced by the Placenta a. Mild contraction – the uterine muscle becomes somewhat tense, but can be indented with gentle
-also in preparation of the body of “labor” ahead. pressure.
b. Moderate contraction – the uterus becomes moderately firm and a firmer pressure is needed to
3. ↑d Braxton Hicks's contractions “practice contractions” in the last week/ days [ before labor ]. indent.
- FALSE Labor contractions, painless, irregular, abdominal.,., RELIEVED by ✰walking c. Strong contraction – the uterus becomes so firm that it has the feel of wood like hardness, and at
the height of the contraction, the uterus canNOT be indented when pressure is applied by the
4. Slight ↓ is maternal weight ;; Slight loss of Weight [book] examiner’s finger.
- Loss of weight is about 2-3 lbs.
- 1 to 2 days [ b4 the onset of labor ] bc of the ↓ in Progesterone level & probably loss of appetite. 2. Uterine Changes. As labor contractions progress, the uterus is gradually differentiated
into 2 distinct portions.
- sa book,, ↓Progesterone lvl = Body fluid is ↑easily excreted from the body These are distinguished by a ridge formed in the inner uterine surface, the physiologic retraction ring.
↑urine production = weight loss b/w 1 & 3 lb
Upper uterine segment – this portion becomes thicker and active, preparing it to exert the strength necessary to expel the
5. Softening or ”ripening” of the cervix fetus during the expulsion phase.
-Thruout pregnancy, Cervix = softer than usual,.,. similar to Consistency of an Earlobe ✰Goodell’s sign Lower uterine segment – this portion becomes thin walled, supple, and passive so that the fetus can pushed cut of the
-@ Term, Cervix becomes still softer as BUTTER SOFT uterus easily.
Contour of the uterus changes from a round ovoid to a structure markedly elongated in a vertical diameter than
horizontally. This serves to straighten the body of the fetus and place it in better alignment to the cervix and pelvis.

SIGNS OF TRUE LABOR 1. Cervical changes. There are 2 changes that occur in the cervix.
1. [TRUE] CONTRACTIONS – Begin IRREGularly, but become Regular n Predictable
[FALSE] CONTRACTIONS – Begin & Remain IRREGular Effacement. This is the shortening and thinning of the cervical canal to paper-thin edges to primiparas, effacement is
accomplished before dilatation begins while with multiparas, dilatation may proceed before effacement is complete.
2. [TRUE] C – Felt 1st in [Lower back] n sweep around to the Abdomen in a wave Dilatation. This refers to the enlargement of the cervical canal from an opening a few millimeters wide to one large
[FALSE] C – Felt 1st [Abdominally] n remain confined to the Abdomen & Groin enough (approximately 10 cm.) to permit passage of the fetus.

3. [TRUE] C. – Continue NO matter wat the woman’s lvl of activity Dilatation occurs for two reasons. First, uterine contractions gradually increase the diameter of the cervical canal
[FALSE] C. – Often disappear w/ Ambulation/ sleep lumen by pulling the cervix up over the presenting part of the fetus. Second, the fluid-filled membranes press
against the cervix.
4. [TRUE] C. - ↑ in DURATION, FREQUENCY & INTENSITY 5. [TRUE] C. – achieves Cervical DILATION
[FALSE] C. – Do NOT ↑ in D, F/ I [FALSE] C. – do NOT 4. Show. This is the blood-tinged mucus discharged from the vagina because of pressure of the descending fetal part on the
cervical capillaries, causing their rupture. Capillary blood mixes mucus when operculum is released.
1. Uterine Contractions. p. 763 @ CHP 12 [book, pdf]
- surest sign that labor has begun is the initiation of effective, productive, involuntary uterine contractions. Rupture of the membranes of bag of waters. This is a sudden gush or a scanty slow seeping of amniotic fluid from the vagina.
The color of the amniotic fluid should always be NOTed. At term, this is clear, almost colorless and contains white
There are 3 PHASES of UTERINE CONTRACTIONS: [40 mins] specks of vernix caseosa. Green staining means it has been contaminated with meconium, a sign of fetal distress.
a. Increment / Crescendo – intensity of the contraction ↑s. Yellow staining may mean blood incompatibility while pink staining may indicate bleeding.
b. Apex / Acme – the height/ peak of the contraction.
c. Decrement / Decrescendo – intensity of the contraction ↓s. Once membranes have rupture, labor is inevitable, meaning to say that uterine contractions will occur within next
!! Frequency ? 24 hours. The initial nursing action is for patients with ruptured membranes are:
!! INTERVAL – from the Time of end of 1 contraction to the Beginning of the next Contraction
- it ↓as Labor progresses 1. NOTify physician.
2. Lie patient to bed to ensure that the fetus is NOT impinging on the cord.
3. Check the fetal heart rate to determine for fetal distress.
CHARACTERISTICS of Contractions: 4. If the patient claims she can feel a loop of the cord coming out of her vagina (umbilical cord prolapse),
i. Frequency of contraction – this is timed from the beginning of 1 contraction to the lower the head of the bed (Trendelenberg postion) in order to release pressure on the cord. Also apply
beginning of the next. sterile saline-saturated gauze to prevent drying of the cord, if needed.
 If labor does NOT occur spontaneously at the end of 24 hours after membrane rupture, it will
be induced, provided the woman is estimated to be at term.

Activity 5. Critical Thinking

The student will answer the question “What will you do if a woman in labor tells
“I’m feeling as if I’m losing a grasp on things?” Do you consider this as a normal
reaction during labor or NOT and why? The answers will be posted in the
discussion board.