rupture of membranes (ROM)-spontaneous ROM can initiate labor or can occuranytime during labor, most commonly during thetransition phase-labor usually occurs within 24 hr of the ROM-prolonged ROM >24 hr before delivery of fetus canlead to an infection.amniotic fluid: appearance,volume-watery, clear, pale yellow/straw-colored-500-1,200 mLtrue labor vs. false labor -contractions-true labor: contractions regular-false labor: contractions irregular-true labor: intensity↑with walking-false labor: intensity↓with walkingtrue labor vs. false labor - pain-true labor: lower back pain-false labor: epigastric pain, above umbilicus12. Intrapartum Basics
Leopold maneuversabdominal palpation to determine presentation andposition of fetus and aid in location of fetal heartsounds-# of fetuses-presenting part-fetal lie-fetal attitude-degree of descent-location of fetus' back to assess for fetal hearttonesstages of labor-1st stage: onset of regular contractions (true labor)→full effacement and dilation-2nd stage: cervix fully dilated→birth-3rd stage: birth→placenta delivery-4th stage: placenta delivery→4 hrs after birth3 phases of 1st stage-latent phase-active phase-transition phase12. Intrapartum Basics
Upgrade to remove adsOnly $3.99/monthcervical dilation each phase of1st stage-latent: 0-3 cm-active: 4-7 cm-transition: 8-10 cmrate of cervical dilation-primigravida: 1 cm/hr-multigravida: 1.5 cm/hrlatent phase: contractionfrequency and duration-frequency: 5-30 min (ATI), 10-30 min (text)-duration: 30-45 secactive phase: contractionfrequency and duration-frequency: 3-5 min-duration: 40-70 sectransition phase: contractionfrequency and durationATI, NCLEX:-frequency: 2-3 min-duration: 45-90 sectext:-frequency: 1.5-2 min-duration: 60-90 secsecond stage: contractionfrequency and duration-frequency: 1-2 min-duration: 60-90 secpt behavior: latent phasetalkative and eagerpt behavior: active phase (2)-anxiety-feelings of helplessness12. Intrapartum Basics
pt behavior: transition phase(3)-feels out of control-"cannot continue"-irritability, frustrationphysical signs of transitionphase (3)-urge to push-rectal pressure, feels need to have BM-nausea, vomitinglength of 1st stage-primigravida: 8-10 hr-multigravida: 2-10 hrlength of 2nd stage-primigravida: 30 min-2 hr (<2 hr)-multigravida: 5-30 min (<1 hr)(birth of baby)length of 3rd stage5-30 min(placenta)assessment of contractions (4)-frequency-duration-intensity-resting tone of uteruscontraction frequencybeginning of 1 contraction to beginning of nextcontraction durationtime between beginning to end of same contractioncontraction intensitystrength of contraction at its peak, assessed bypalpationresting tone of uterinecontractionstone of uterine muscle between contractions12. Intrapartum Basics
Upgrade to remove adsOnly $3.99/monthfrequency of assessment (BP,pulse, respirations) duringlatent phaseevery 30-60 minfrequency of assessmentduring active phaseevery 30 minfrequency of assessmentduring transition phaseevery 15-30 minnursing interventions duringlabor (5)-mother/fetal monitoring
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