Intrartum/Intrapartal Period

1. The intrapartum period extends from the beginning of contractions that cause cervical dilation to the first 1 to 4
hours after delivery of the newborn and placenta.
2. A series of physiological and mechanical processes by which all the products of conception are expelled from the
birth canal.
3. Intrapartum care refers to the medical and nursing care given to a pregnant woman and her family during labor and
delivery.
4. Woman in labor is called the PARTURIENT.

GOALS OF INTRAPARTUM CARE

1. To promote physical and emotional well-being in the mother and fetus.
2. To incorporate family-centered care concepts into the labor and delivery experience.

FACTORS AFFECTING THE INTRAPARTUM EXPERIENCE

1. Previous experience with pregnancy
2. Cultural and personal expectations
3. Pre-pregnant health and biophysical preparedness for childbearing 
4. Motivation for childbearing
5. Socioeconomic readiness
6. Age of mother
7. Partnered versus unpartnered status
8. Extend of parental care
9. Extend of childbirth education

PHENOMENA AND PROCESS OF LABOR AND DELIVERY

I. ONSET OF LABOR

Initiation of Labor
1. Labor is the process by which the fetus and products of conception are expelled as the result of regular, progressive,
frequent, strong uterine contractions.
2. The exact mechanism that initiates labor is unknown.
3. Theories include:
A. Uterine stretch theory – Uterus becomes stretched and pressure increases, causing physiologic changes that
initiate labor.
B. Oxytocin stimulation – The pressure of the fetal head on the cervix in late pregnancywill stimulate the PPG to
secrete oxytoxin.
C. Progesterone deprivation - As pregnancy advances, progesterone (uterine mucle relaxant) is less effective in
controlling rhythmic uterine contractions that normally occur. In addition, there may also be an actual decrease
in the amount of circulating progesterone.
D. Prostaglandin, Estrogenic and Fetal Hormone Theory
a. There is increased production of prostaglandins by fetal membranes and uterine decidua as
pregnancy advances.
b. In later pregnancy, the fetus produces increased levels of cortisol that inhibit progesterone
production from the placenta.
c. Initiation of labor is said to result from the release of arachidonic acid produced by steriod
acstion sonlipid precursors. Arachidonic acid is said to increase prostaglandin synthesis
which causes uterine contraction.
E. Aging Placenta – as the palcenta matures blood supply will be diminished causing uterine contraction.

II. SIGNS AND SYMBOLS OF IMPENDING LABOR

(Premonitory signs)
1. Lightening is the descent/dipping/dropping/settling of the fetus and uterus into the pelvic cavity.
 Engagement should not be confused with ligthening.
 Engagement occurs when presenting part passes through the pelvic brim.
 For Primis occurs earlier or 2 weeks before labor
 Multis occurs a day before labor or on a day of labor.
 Signs of lightening:
a. Relief of dyspnea
b. Relief of abdominal tightness
c. increase in urinary frequency, varicosities, pedal edema due to pressure on the bladder and pelvic girdle
 Criteria True labor False labor
Contractions Regular, progressive Irregular, non-progressive
d. shooting pains down the legs because of pressure on the sciatic nerve
Discomfort Lumbo-sacral rafdiating to the front, Abdominal
e. increase amount of vaginal discharge
increasing intensity
2. Braxton hicks contractions occur 3 to 4 weeks before labor are irregular, intermittent contractions that have
Cervix throughout With
occurred progressivebecome
the pregnancy; cervicaluncomfortable,
dilation and produce
No cervical dilation
a drawing and
pain in effacement
the abdomen and groin
effacement the most important
and does not dilate the cervix. Relieve by walking and enema.
3. difference and effacement of the cervix that will cause explosion of the mucus
Cervical changes include softening “ripening”
Walking Generally
plug (bloody show) and increased vaginal intensified
discharge. Generally unaffected
4. Enemaof amniotic membranes
Rupture Generally
may occurintensified
before the onset of labor if Generally
the woman unaffected
suspects that her membranes
Show Present and increasing Absent
have ruptured, she should contact her health care provider and go to the labor suite immediately so that she may
Medication
be Not easily
examined for prolapsed cord –disrupted by medications
a life-threatening condition forGenerally
the fetus.relieved by mild sedation
5. Burst of energy or increased tension and fatigue may occur before the onset of labor because of hormone
epinephrin
6. Weight loss of about 1 to 3 pounds may occur 2 to 3 days before the offset of labor.
7. Urinary frequency returns.
8. Backache may increase due to fetal pressure
9. Diarrhea may occur.
10. False labor contractions may occur

True and False Labor Contractions

III. PHYSIOLOGIC ALTERATION IN LABOR

1. Dilatation : progressive opening/widening of the cervical os
a. Expressed in cm
b. Described as opening, widening, enlarging or increase in diameter
c. Specifically refering to external cervical os
d. 10 cm is fully dilated cervix – the end of the first stasgse sof labor
2. Effacement: thinning and obliteration of the cervical canal
a. Expressed in %
b. Described a thinning, shortening or narrowing
c. 100% effacement means the cervix is fully effaced – cervical canl is paper-thin or absent
75% effacement means the cervix has become ¼ of its original length
50% effacement means the cervix has become ½ of its original length
25% effacement means the cervix has become ¾ of its original length
3. Physiologic retraction ring: Is formed at the boundary of the upper and lower uterine segments.
In difficult labor when the fetus Is larger than the birth canal, the round ligaments of the uterus become tense
during dilatation and expulsion causing abdominal indentation called BANDL’S pathological retraction ring, a
danger sign signifying impending rupture of the uterus if not managed.

IV. FACTORS AFFECTING LABOR

1. POWER
A. The primary Power: Uterine Contraction
 This refers to the frequency duration and strength of uterine contraction to cause complete cervical
effacement and dilation.
 Successful labor also depends on uterine contractions occurring at regular intervals and having adequate
intensity.
 Uterine contractions are involuntary, rhythmic, and intermittent.
 Uterine contractions cause vasoconstriction of the umbilical cord vessels; considered normal.
  Uterine contractions increase in intensity, frequency, and duration as labor progresses due to stretching
of the cervix.

 During uterine contractions, the active upper portion of the uterus becomes thicker and shorter,
whereas the lower uterine segment stretches and becomes thinner and longer (referred to as fundal
dominance).
 At the completion of a contraction, the upper uterine segment retains its shortened, thickened cell size
and, with each succeeding contraction, becomes thicker and shorter. As a result, the upper uterine
segment never totally relaxes during labor. Cells of the lower uterine segment become thinner and
longer with each contraction. This mechanism is greatly responsible for the progress of the fetus
through the birth canal.
 The differentiation point between the upper and lower uterine segment is known as the physiologic
retraction ring.

 Phases of Uterine contractions

 Increment (cresendo): the phase of increasing or building up of contraction, the longest phase
 Acme (apex): the height/peak of uterine contraction
 Decrement (decresendo): the phase of decreasing contratiuon or letting up the late phase
Peak

Relaxation

Increment decrement
A B C D

 From A – B: Duration. The period from the beginning of increment to the completion of decrement of
the same contraction. Expressed in “seconds”. The normal maximin duration is 90 seconds during
transition phase and second stage of labor
 From A – C: Frequency. The period of the time from the beginning of one contraction to the beginning of
the next contraction. Expreed in “every________minutes”.
 From B – C : Interval: The period from the decrement of the first to the increment of the second
contraction

 Intensity – refers to the strength of uterine contraction during acme; can be determined by palpation.
 Palpation – placing the hand lighlt on the fundus with the fingers spread; described as mild, moderate, and
strong by judging the degree of indentability/depressability of the uterine wall during acme
a. Strong – when the uterine fundus is very frim and cannot be indented with fingers
b. Moderate - when the fundus is difficult to indent
c. Mild – when fundus i s tense but can be indented easily with fingertips
B. The secondary powers
 Maternal bearing down
 Cervical Dilatation: 10 cm
 Fetal station: +1; low enough to stimulate Ferguson reflex: maternal involuntary urge to push stimulated
by strech receptors in the pelvic floor
 Correct pushing: take a deep breath as soon as the next contraction begins, and then with the breath held,
exert a downward pressure exactly as though she were straining at stool
 Discourage prolong maternal breath holding of more than 6 seconds, during pushing. Support involuntary
pushing, granting, groaning, exhaling, or breath-holding for less than 6 seconds.
 Have 4 or more pushes per contraction
 Intraabdominal pressure: as the women pushes the intraabdominal pressure increases

2. PASSAGEWAY
 This refers to the adequacy of the pelvis and birth canal in allowing fetal descent
 Successful labor and delivery depend on adequate pelvic dimensions, adequate fetal dimensions and
presentation, and adequate uterine contractions.
 The pelvis is composed of four bones:
 Two innominate bones (hip bones) form the sides and front.
- 3 Parts of 2 Innominate Bones
a. Ileum – lateral side of hips
 Iliac crest – flaring superior border forming prominence of hips
b. Ischium – inferior portion
 Ischial tuberosity where we sit – landmark to get external measurement of pelvis
c. Pubes – ant portion – symphisis pubis junction between 2 pubis
  1 sacrum – posterior portion – sacral prominence – landmark to get internal measurement of pelvis
 1 coccyx – 5 small bones compresses during vaginal delivery

 These factors include:

a.    Type of pelvis (gynecoid, android, anthropoid, or platypelloid)
 Gynecoid - round, wide, deeper most suitable (normal female pelvis) for pregnancy
 Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow, deep transverse
arrest of descent of the fetus and failure of rotation of the fetus are common
 Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow, may allow for easy
delivery of an occiput-posterior presentation of the fetus;
 Platypelloid – flat AP diameter – narrow, transverse – wider, arrest of fetal descent at the pelvic inlet is
common
b. Structure of pelvis (true versus false pelvis)
 False pelvis – lies above an imaginary line called the linea terminalis or pelvic bri. Function of the false
pelvis is to support the enlarged uterus.
 True pelvis lies below the pelvic brim or linea terminalis; it is the bony canal through which the fetus
must pass. It is divided into three planes: the inlet, the midpelvis, and the outlet.
 Inlet:
- Upper boundary of the true pelvis bounded by upper margin of symphysis pubis in front, linea
terminalis on sides, and sacral promontory (first sacral vertebra) in back.
- Largest diameter of inlet is transverse
- Smallest diameter of inlet is anteroposterior. Anteroposterior diameter is most important
diameter of inlet: measured clinically by diagonal conjugate, distance from lower margin of
symphysis to the sacral promontory (usually 5½ inches [14 cm])
- Obstetric (true) conjugate, distance between inner surface of symphysis and sacral promontory
measured by subtracting ½ to ¾ inch (1.5 to 2 cm) (thickness of symphysis) from the diagonal
conjugate. Adequate diameter is usually 11.5 cm. This is the shortest anteroposterior diameter
through which the fetus must pass.
 Midpelvis:
- Bounded by inlet above and outlet below true bony cavity. Contains the narrowest portion of the
pelvis.
- Diameters cannot be measured clinically.
- Clinical evaluation of adequacy is made by noting the ischial spines. Prominent spines that
protrude into the cavity indicate a contracted midpelvic space. The interspinous diameter is 4
inches (10 cm).
 Outlet:
- Lowest boundary of the true pelvis.
- Bounded by lower margin of symphysis in front, ischial tuberosities on sides, tip of sacrum
posteriorly.
- Most important diameter clinically is distance between the tuberosities (> 4 inches
 Important Measurements at the 3 plane of pelvis for anteroposterior diameters
1. Diagonal Conjugate – measure between sacral promontory and inferior margin of the
symphysis pubis.Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC – 11.5
cm=true conjugate).estimated on vaginal examination. Widet anteropoterior diameter at
outlet.
2. True conjugate/conjugate vera – measure between the anterior surface of the sacral
promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm
3. Obstetrical conjugate – smallest AP diameter. Pelvis at 10 cm or more.
4. Tuberoischi Diameter – transverse diameter of the pelvic outlet. Ischial tuberosity –
approximated with use of fist – 8 cm & above.
 Pelvic Dimensions
 Adequate pelvic inlet (anteroposterior diameter; normal shape).
 Adequate midpelvis (ischial spines do not protrude into bony canal).
 Adequate outlet (adequate distance between tuberosities; mobile coccyx).
 Adequacy of pelvic dimensions determined by pelvic examination during pregnancy and again
with the onset of labor.
3. PASSENGER.
 This refers to the fetus and its ability to move through the passage way
 Important fetal dimensions influenced by fetal size, posture/attitude, lie, and presentation. Fetal position is also
an important factor in successful labor.
i. Fetal head
 It is the most important part of the fetus because it is:
a. Largest part of the body
 b. Most frequent presenting part
c. Least compessible of all parts
 In approximately 95% of all births, the fetal head presents first. The sutures and fontanelles provide
important landmarks for determining fetal position during a vaginal examination
 Bones of the fetal skull:
a. Occipital bone posteriorly
b. Two parietal bones on the sides.
c. Two temporal bones anteriorly.
d. Two frontal bones anteriorly.
 Sutures of the fetal skull; membranous spaces between the bones of the fetal skull: allows the bones to
move and overlap, changing the shape of the fetal head in order to fit the birth canal, a process called
molding
a. Frontal suture is between the two frontal bones.
b. Sagittal between the two parietal bones.
c. Coronal between the frontal and parietal bones.
d. Lambdoidal between the back of the parietal bones and the margin of the occipital bone.
 Fontanelles are irregular spaces formed where two or more sutures meet.
a. Anterior fontanelle – largest fontanelle; junction of the sagittal, frontal, and coronal sutures.
Closes by age 12 – 18 months; diamond shaped.
b. Posterior fontanelle – located where the sagittal suture meets the lambdoidal (smaller than
anterior). Closes at age 6 to 8 weeks/ 2 – 3 months; triangle shaped.
ii. Fetal Size
 Size of the fetal head and capability of the head to mold the passageway.
 With excessive size, fetal skull bones may not be able to override enough to be accommodated in the
bony pelvic cavity.
iii. Fetal presentation
 The part of the fetus enters to maternal pelvis first.
 Whichever portion of the fetus is deepest in the birth canal and is felt on vaginal examination is referred
to as the presenting part; this determines fetal presentation.
 Presentation can be:
A. Vertical
1. Cephalic presentation. Classified according to the relationship between the head and body of the
fetus ordinarily, the head is flexed sharply so that the chin is in contact with the thorax. 95 % of
term deliveries.
a. Vertex or occiput- occipital fontanel is the presenting part, completely flexed upon the
fetal chest
b. Face presentation- fetal neck sharply extended occiput and back come in contact,
hyperexted with the chin presenting.
c. Sinciput- partially flexed with the anterior fontanel or bregma presenting, moderately
flexed.
d. Brow- partially extended,
 Brow and sinciput almost always converted into vertex or face by flexion and extension,
failure leads to dystocia
2. Breech 3% of term births
a. Frank/ Incomplete – the hips maybe flexed and the knees extended
b. Complete – the fetus’ knees and hips both maybe flexed, positioning the thighs on the
abdomen and calves on the posterior thighs
c. Footling– extension of the knees and hips
 Single – one leg unflexed and extended; one foot presenting
 Double - legs unflexed and extended, feet are presenting
B. Horizontal Transverse Lie
1. Shoulder, or compound (hand/arm presenting same time as vertex [head] or hand presenting same
time as breech.

iv. Fetal position

 The relationship of a particular reference points of the presenting part and the maternal pelvis / Standard
landmarks for the fetal presenting part.
 Refers to the relationship of the presenting part to the right or left side of maternal birth canal
 A three-letter abbreviation is used to describe the relationship of the presenting part to the maternal
pelvis:
- Identify which side the presenting part is facing in the pelvis: R (right) or L (left).
- Identify the landmark that is presenting:
1. O (occiput, or head) – 2/3 of all vertex presentations- LO position
 2. S (sacrum) – breech
3. Sc (scapula, or shoulders)
 In shoulder presentation, the acromion is the portion of the fetus chosen for orientation
with the maternal pelvis
 The acromion or back of the fetus may be directed posteriorly or anteriorly and superiorly
and inferiorly
4. M (mentum, or chin) - face
- Identify the direction the presenting part is facing in the pelvis:
 A (anterior or front)
 P (posterior or back)
 T (transverse)

- DIAGNOSIS OF FETAL PRESENTATION AND POSITION

Methods used to diagnose fetal presentation and position
1. Abdominal palpation (Leopold Maneuvers)
 First maneuver - to determine fetal presentation (longitudinal axis) or the part of the fetus
(fetal head or breech) that is in the upper uterine fundus.
While facing the woman, place the hands on top and side of the uterus (fundus) and palpate.
Note the size, shape, and consistency of what is in the fundus (upper portion of the uterus).
The head feels smooth, hard/firm, and round, freely movable and ballotable. A breech feels
irregular, rounded, softer, and is less mobile.
 Second maneuver - to determine the fetal position or identify the relationship of the fetal back
and the small parts to the front, back, or sides of the maternal pelvis. Still facing the woman,
place hands on either side at the middle of the abdomen. While one hand stabilizes the one
side of the uterus, the other hand pushes the contents of the abdomen toward the other hand
to stabilize the infant for palpation. Next, palpate, applying gentle but deep pressure, beginning
at the midline near the fundus and continue down the side (posteriorly) toward the woman's
back. Continue down the abdomen to the symphysis pubis. Determine what fetal body part lies
on the side of the abdomen. Reverse the hands and repeat the maneuver. If firm, smooth, and
a hard continuous structure, it is likely to be the fetal back; if smaller, knobby, irregular,
protruding, and moving, it is likely to be the small body parts (extremities).
 Third maneuver - to determine the portion of the fetus that is presenting. While facing the
woman, grasp the part of the fetus situated in the lower uterine segment between the thumb
and middle finger of one hand. Using firm, gentle pressure, determine if the head is the
presenting part. Pay close attention to the size, contour, and consistency of the presenting
part. The head will feel firm and globular. If not engaged into the pelvis, the presenting part is
movable. If immobile, engagement has occurred. This maneuver is also known as Pallach's
maneuver or grip.
 Fourth maneuver - to determine fetal attitude or the greatest prominence of the fetal head
over the pelvic brim. In this maneuver, the examiner faces the woman's feet. The examiner
places his or her hands on the sides of the uterus, below the umbilicus and pointing them
toward the symphysis pubis. The examiner then presses deeply with the fingertips facing in the
direction of the pelvic inlet (toward the symphysis pubis) and begins to feel for the cephalic
prominence. If the cephalic prominence is felt on the same side as the small parts, it is usually
the sinciput (fetus' forehead), and the fetus will be in vertex or flexed position. If the cephalic
prominence is felt on the same side as the back, it is the occiput (or crown), and the fetus will
be vertex or slightly extended position. If the cephalic prominence is felt equally on both sides,
the fetus' head may be in a military position (common in posterior position). Then move the
hands toward the pelvic brim. If the hands converge (come together) around the presenting
part, it is floating. If the hands diverge (stay/move apart), the presenting part is either dipping
or engaged in the pelvis.
2. Vaginal examination
 Explain the procedure to the woman. Place her in a lithotomy position.
 Conduct examination gently, under aseptic conditions.
 Evaluate the following:
a. Condition of cervix
 Hard or soft (in labor, cervix is soft).
 Effaced and thin or thick and long (in labor, cervix is thin and effaced). Measured in
percentages from 0% to 100%.
 Easily dilatable or resistant.
 Closed (fingertip, < 1 cm) or open (dilated); degree of dilation, measured in
centimeters from 1 to 10 cm (complete dilation).
b. Presentation
  Breech, cephalic (head), or shoulder.
 Caput succedaneum (edema occurring in and under fetal scalp) present (small or
large).
 Station identified: engaged, floating.
c. Positions
 Cephalic presentation (identification of the sagittal suture and of its direction).
 Location of posterior fontanelle.
d. Membranes intact or ruptured
 Amount and color of fluid.
 Passage of meconium; consistency of meconium (eg, thin, thick, particulate matter)
 Odor.
 Bulging.
 Rupture usually increases frequency and intensity of uterine contractions.
 ROM may be contraindicated in presence of vaginal bleeding, premature labor, or
abnormal fetal presentation or position.
e. Perineum
 Assess for ulcerations or vesicles that might indicate sexually transmitted disease,
such as syphilis or genital herpes.
 Note: If these are present, stop the examination and notify the primary care provider.
f. Auscultation
g. Imaging studies (UTZ)
 Uses in the first trimester of pregnancy include:
a.Early confirmation of pregnancy and determination of the estimated date of confinement.
b.Diagnosis of an ectopic pregnancy.
c. Detection of an intrauterine device.
d.Evaluation of placental location.
e.Diagnosis of a multiple gestation.
f. Guidance for chorionic villus sampling (CVS).
 Uses in the second and third trimester include:
a. Evaluation of fetal growth, weight, and gestational age.
b. Evaluation of the placenta for placenta previa or separation associated with vaginal bleeding.
c. Evaluation of fetal presentation and position.
d. Evaluation of fetal abnormalities.
e. Evaluation of fetal viability.
f. Determination of the Biophysical Profile (BPP) Score.
g. Evaluation of amniotic fluid volume.
h. Guidance for amniocentesis or fetal blood sampling.
v. Fetal posture/attitude
 Relationship of the fetal parts to trunk or to one another
 In later months of pregnancy the fetus assumes a characteristic posture described as attitude or habitus
to accommodate to the uterine cavity.
a. Flexion
b. Extenion
 The fetus forms an ovoid mass that corresponds roughly to the shape of the uterus
- the fetus becomes folded upon itself that the back becomes markedly convex
- head flexed so that chin is in contact with the chest
- thighs are flexed over the abdomen
- legs are bent at the knees
- arches of feet rest upon the anterior surfaces of the legs
 Flexed head allows smallest diameter of fetal head (occiput) to present and pass through the birth canal
vi. Fetal lie
 Fetal lie is the relation of the long axis of the fetus to that of the mother
1. Longitudinal  99% of labors at term: has two alsternatives
 The fetal head will present (cephalic presentation)
 or the buttocks or feet will present (breech presentation
2. Transverse – the shoulder presents
 Predisposing factors for transverse lies:
1. multiparity
2. Placenta previa
3. Hydramnios
4. uterine anomalies
3. Oblique lie – the fetal and the maternal axes may cross at a 45 degree angle, unstable the fetus is
in an angle off the transverse lie
 4.
vii. Fetal station
 Relationship of the ischial spines, the single most important landmark of the pelvis
 Measures how far the presenting part has devcended into the pelvis --- measures the degree of descent
- Floating : unengaged presenting part
- Station 0: presenting part at the level of ischial spines
- Minus station: if the presenting part is above the level of the ischial spines, the station is expressed s
negative number.
- Plus station : if the presenting part is below the ischial spines (outlet , the station is expressed as positive
number
- Station +3 or +4 : synonimous to crowning ( encircling of the largest diameter of the fetal head by the
vulvar ring)
4. Psyche/Person – psychological state when the mother is fighting the labor experience
 Cultural Interpretation
 Preparation – considers as avaluable tranquilizer during the birth process
 Support System – the presence of the husband in the labor and delivery room can provide emotional
support – less anxiety – less emotional tension – less pain perception
 Past Experience

V. STAGES OF LABOR
Normal Length of Labor

Stages of Labor Primipara Multipara

First 12 ½ hours 7 hours, 20 minutes
Second 80 minutes 30 minutes
Third 10 minutes 10 minutes
Total 14 hours 8 hours

1. First Stage of Labor (Stage of Cervical Dilation)

 Begins with the first true labor contractions and ends with complete effacement and dilation of the cervix (10 cm
dilation).
 Power/forces: Involuntary uterine contractions
 It is composed of a latent, an active, and a transition phase.
i. Latent phase (early):
 Dilates from 0 to 3 cm.
 Dilatation is minimal because effacement is occuring
 Contractions are usually every 5 to 20 minutes, lasting 20 to 40 seconds, and of mild intensity.
 The contractions progress to about every 5 minutes and establish a regular pattern.
 Best time to seek admission to the hospital
 Mother is excited with some degree of apprehension but still with ability to communicat
 Nursing Care:
o Encourage walking - shorten 1st stage of labor
o Encourage to void q 2 – 3 hrs – full bladder inhibit contractions
o Breathing – chest breathing
o Hospital admission:
a. Personal data
b. OB Hx
o General physical examination
a. Effacement and dilatation
b. Station
c. Presentation
d. Position
ii. Active phase:
 Dilates from 4 to 7 cm.
 Rapid increase in duration, frequency and intensity of contractions
 Contractions are usually every 2 to 5 minutes; lasting 30 to 50 seconds and of mild to moderate intensity.
 After reaching the active phase, dilation averages 1.2 cm/hour in the nullipara and 1.5 cm/hour in the
multipara.
 Mother fears losing control of herself, less talkative, more anxious,restless
 Nursing Care:
o Monitoring and evaluating important aspects
a. Uterine contractions
b. Blood pressure
 should not be taken during contraction
 should be taken at least every half hour
 should be taken immediately when woman complainv of headache – same, just let mother
rest; increase, refer immediately to the doctor
c. Fetal Heart Rate (FHR)
 Fetal heart tone sounds like a clock ‘ticking’ distinctly
 Should not be mistaken with uterine souffle (synchronizes with maternal pulse rate)
 Should not be taken during uterine contraction
 Auscultate the FHR every 30 minutes during the first stage latent; every 15 minutes during first
stage active and stage transition; every 5 to 15 seconds.
 Possible Fetal heart tone location on the abdominal wall and the Point of Maximim
Impulse(PMI)
a. Cephalic (Vertex, Brow, and Chin): the PMI is usually below the umbilicus and along the side of the
fetal back.
 Left occipitoanterior (LOA) and Left occipitoposterior (LOP). PMI is on the LLQ
 Right occipitoanterior (ROA) and Right occipitoposterior (ROP). PMIis on the RLQ
b. Cephalic( Face): the PMI is below the umbilicus and along the side of the fetal feet
c. Breech: the PMI is usually above the ambilicus and along the side of the sacrum , which is line with the
fetal back
 Left sacroanterior (LSA) and left sacroposterior (LSP). PMI --- LUQ
 Right sacroanterior (RSA) and Right sacroposterior (RSP). PMI ---RUQ
 Assess changes in FHR to identify the following.
 Early deceleration – slowing of the FHR early on the contraction. It is considered benign,
minor the contraction and has a characteristics V or U pattern.
 Late deceleration – an indication of fetal hypoxia due to uteroplacental insufficiency. It
usually begins at the peak of the contraction and ends after the contraction ends.
 Variable deceleration – a transient decrease in FHR before, during or after the contraction.
It indicates cord compression and has a characteristics V or U pattern.
 Bradycardia – an FHR less than 100 beats per minutes or a drop of 20 beats per minutes
below baseline. In indicates cord compression or placental separations
 Tachycardia – an FHR greater than 160 beats per minute. It indicates fetal distress if it
persists for more than 1 hour is accompanied by late deceleration.
 Loss of beat-to-beat variability – indicates fetal reaction to maternal drugs, fetal sleep, or
fetal demise.
 Signs of fetal distress
1.) FHR <120 & >160
2.) Mecomium stain amnion fluid
3.) Fetal thrushing – hyperactive fetus due to lack O2
o Provide emotional support
o Bathing is advisable to make mother feel comfortable if contraction is tolerable
o NPO
o Encourage to void q 2 – 3 hours
o Perform enema if necessary
o Do perineal prep – ue the no. 7 method, front to back
o Perineal shave – not a routine procedure;move along the direction of hair
o Encourage sim’s position
a. It favors rotation of the fetal head
b. Promotes relaxation between contractions
c. Prevents vena cava symdrome
o Not allowed to push unnecessarily during contractions of the first stage
a. It leads to unnecessary exhaustion
b. Repeated pounding of the fetus against the pelvic floor will lead to cervical edema ---interfere
with the dilatation and prolonging length of labor.
 o Advise abdominal breathing – to reduce tension and hyperventilation
o Administer analgesia as ordered
o Transport mother to delivery room once there is bulging of the perineum or when cervix is fully
dilated for primis. Multis are transported once cervical dilatation is 7-8 cm.

iii. Transitional phase:

 Dilates from 8 to 10 cm.
 Contractions are every 2 to 3 minutes, lasting 50 to 60 seconds and of moderate to strong intensity. Some
contractions may last up to (but not exceed) 90 seconds.
 Maternal behavior: with increased perspiration, nausea and vomiting, restlessness, panic, irritability, have
lost control of labor, tends to push during contractions, with circumoral pallor
 Time to perform Lamaze technique; pant-blow pattern of chest breathing
 Should push can cause caput succedaneum – a serous effusion or edema overlying the scalp periosteum on
an infant’s head.
 Characteri stics
o Sudden gush of amniotic fluid(if membranes are intact) as fetus is pushed into the birth canal
o Amniotomy is done (if BOW is not ruptured) to prevent fetus from aspirating the fluid as it makes its
different fetal position changes. Done only if station is still “minus” to prevent cord compression.
o Show becomes prominent
o Nausea and vomiting – decrease gastric motility and aborption
o In primis, baby I delivered within 20 contractions (40 minutes); in multis, after 10 contractions (20
minutes)
 Nursing Actions: Primarily comfort measures
o Sacral pressure; relieves discomfort from contractions
o Proper bearing down technique; push with contractions
o Controlled chest breathing during contractions
o Emotional support

2. SECOND STAGE (Stage of Expulsion)

 The second stage begins with complete dilation of the cervix and ends with delivery of the newborn.
 Durations may differ among primiparas (longer) and multiparas (shorter), but this stage should be completed
within 1 hour after complete dilation.
 Contractions are severe at 2 to 3 minute intervals, with duration of 50 to 90 seconds.
 Powers/Forces: invouluntary uterine contractions and contraction of the diaphragmatic and abdominal muscles.
 The newborns exists the birth canal with help from the following cardinal movements or MECHANISMS OF
LABOR:
 If the woman's pelvis is adequate, size and position of the fetus are adequate, and uterine contractions are
regular and of adequate intensity, the fetus will move through the birth canal.
 The position and rotational changes of the fetus as it moves down the birth canal will be affected by
resistance offered by the woman's bony pelvis, cervix, and surrounding tissues.
 The events of engagement, descent, flexion, internal rotation, extension, external rotation, and
expulsion (ED FIRE ERE) overlap in time.
1. Engagement
 Engagement- mechanism by which the biparietal diameter (BPD), the greatest transverse diameter
of the fetal head in occiput presentation, passes through the pelvic inlet
 occurs during the last few weeks of pregnancy or until after the commencement of labor
 Usually, the fetal head is in the transverse diameter or in one of the oblique diameters
 in the "floating" phenomenon, the head is not yet engaged and is freely movable above the
pelvic inlet
 Primigravidas occurs up to 2 weeks before onset of labor.
 Multigravidas usually occurs with onset of labor.

 Cardinal movements are the remaining movements which are the passive adjustments of position
the fetus makes as it descends through the pelvis during labor.
 ASYNCLITISM- the lateral deflection of the fetal head to a more anterior or posterior position in the
pelvis
 Anterior Asynclitism (naegele's Obliquity)- the sagittal suture approaches the sacral promontory;
the anterior parietal bones presents itself to the examining fingers
 Posterior Asynclitism (Litzmann's Obliquity or Ear presentation)- the sagittal suture lies close to
the symphysis and more of the posterior parietal bone will present
Note: Severe asynclitism may lead to CPD
2. Descent
  Descent- the first requisite for the birth of the infant
in nulliparas-engagement may take place before onset of labor; descent may not follow until the 2nd
stage of labor
multiparous- descent begins with engagement
 Occurs throughout labor and is the downward movement of the fetus; occurs simultaneously with
engagement.
 Accomplished by force of uterine contractions on fetal portion in fundus and pressure of the amniotic
fluid; during second stage of labor, bearing down increases intra-abdominal pressure, thus
augmenting effects of uterine contractions. In addition, the extension and straightening of the fetal
body assists with its descent.
 Station is the relationship of the level of the presenting part to the ischial spines. The degree of
descent is described as:
 Floating - fetal presenting part is not engaged in pelvic inlet
 Fixed - fetal presenting part has entered pelvis.
 Engagement - fetal presenting part (usually BPD of fetal head) has passed through pelvic inlet.
 Stations -1, -2, -3, or -4 occur when the presenting part is 1, 2, 3, or 4 cm above the level of the
ischial spine
 Station 0 occurs when the presenting part is at the level of the ischial spines.
3. Flexion
 Resistance to descent causes head to flex so the chin is close to the chest; this causes the smallest
fetal head diameter, the suboccipitobregmatic, to present through the canal.
 This puts the posterior fontanelle at almost the center of the cervix, making it easily palpable on
vaginal examination.
 Flexion begins at the pelvic inlet and continues until the fetal head (or presenting part) reaches the
pelvic floor.
4. Internal rotation
 In accommodating the birth canal, the fetal occiput rotates 45 or 90 degrees from its original
position toward the symphysis.
 The rotation is usually anteriorly, but if the pelvis cannot accommodate the occiput anteriorly due to
a narrow forepelvis, it will rotate posteriorly, resulting in an occipitoposterior (OP) position of the
fetus.
 This movement results from the shape of the fetal head, space available in the midpelvis, and
contour of the perineal muscles.
 it is accomplished when the head is already engaged
 The ischial spines project into the midpelvis, causing the fetal head to rotate anteriorly to
accommodate to the available space.
 Deviations from the normal internal rotation:
1. If rotation is incomplete, transverse arrest results
2. if the occiput rotates to the direct occiput position, persistent occiput posterior results
5. Extension
 Extension- it is the movement that brings the base of the occiput into direct contact with the inferior
margin of the symphysis
> if extension does not occur, the fetal head will impinge upon the posterior portion of the
perineum and would eventually tear the perineum upon delivery of the head
The two forces bringing about extension
1. Force exerted by uterus which acts more posteriorly
2. Force supplied by the resistant pelvic floor and the symphysis which acts more anteriorly
 As the fetal head descends further, it meets resistance from the perineal muscles and is forced to
extend. The fetal head becomes visible at the vulvovaginal ring; its largest diameter is encircled
(crowning), and the head then emerges from the vagina.
6. External rotation
 External rotation-it is the mechanism in which the delivered head undergoes restitution such that
the head returns to the original oblique posistion
 Initial phase is called restitution. It is simply the fetal head returning to its normal relationship with
the shoulders.
 After restitution, the second phase of external rotation occurs as the body rotates so that the
shoulders are in the anteroposterior diameter of the pelvis.
7. Expulsion
 Expulsion-the anterior shoulder appears under the symphysis and is delivered first, followed by the
delivery of the posterior shoulder. The rest of the body is quickly extruded
 After delivery of the infant's head and internal rotation of the shoulders, the anterior shoulder rests
beneath the symphysis pubis. The posterior shoulder is born, followed by the anterior shoulder and the
rest of the bod
  CHANGES IN THE SHAPE OF THE FETAL HEAD
 CAPUT SUCCEDANEUM-it is the swelling of the fetal scalp over the cervical os due to edema resulting
from prolonged labor before dilatation of the cervix
 It occurs more commonly when the head is in the lower portion of the birth canal and after
the resistance of a rigid vaginal outlet is encountered
 MOLDING- It refers to the certain degree of overlapping of the parietal bones ( with the anterior parietal
usually overlapping the posterior), leading to a diminution in the biparietal and suboccipitobregmatic
diameters of 0.5 to 1.0cm or even more in prolonged labors

 Nursing Care:
o Continue to offer psychological support
Praise
Reassurance
Encouragement
Inform mother of the progress
Support system
Touch
o Placed mother in lithotomy position – put legs same time up.
o During crowning instruct mother to pant--- if hyperventilation occurs --- let patient breathe into a paper
bag or cupped hands over the mouth to recover lost CO2.
o Assist in the Episiotomy (surgical incision in perineum) may be done to facilitate delivery and avoid
laceration of the perineum, reduced duration of second stage and enlarge outlet.
Types of episiotomy:
a. median – from middle portion of lower vaginal border directed towards the anus;less bleeding, less
pain easy to repair, fast to heal, possible to reach rectum ( urethroanal fistula)
b. Mediolateral – begun in the midline but directled laterally away from the anus, often done because it
prevents 4th degree laceration. More bleeding & pain, hard to repair, slow to heal
 Use local or pudendal anesthesia
o Apply the Modified Ritgen’ Manuever: place towel at perineum
a. To prevent laceration
b. Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if
coiled. Pull shoulder down & up.
c. Check time, identification of baby.

o IMMEDIATE CARE OF THE NEONATE

A. Promoting Airway Clearance and Transitioning of the Neonate

 Transitioning/close observation of the neonate is essential for at least 6 to 12 hours after birth.
 Wipe mucus from the face and mouth and nose.
 Clamp the umbilical cord approximately 1 inch (2.5 cm) from the abdominal wall with a cord clamp.
o Count the number of vessels in the cord; fewer than three vessels have been associated with
renal and cardiac anomalies or normal outcome.
 Evaluate the neonate's condition by the Apgar scoring system at 1 and 5 minutes after birth.

Apgar Scoring Chart

SIGN 0 1 2
Heart rate Absent Slow (<100) > 100
Respiratory effort Absent Slow, irregular Good, crying
Muscle tone Flaccid Some flexion of extremities Active motion
Reflex irritability No response cry Vigorous cry
Color Blue, pale Body pink, extremities blue Completely pink

o Neonates scoring 7 to 10 are free from immediate stress.

o Neonates scoring 4 to 6 are moderately depressed.
o Neonates scoring 0 to 3 are severely depressed.
o Apgar scores < 7 at 5 minutes are to be repeated every 5 minutes until 20 minutes have passed,
the infant is intubated, or two successive scores of > 7 occur.

B. Promoting Thermoregulation
 Dry the neonate immediately after delivery.Drying the infant cuts this heat loss in half.
  Cover the neonate's head with a cotton stocking cap to prevent heat loss.
 Wrap the neonate in warm blankets.
 Place the neonate under a radiant heat warmer, or place the neonate on the mother's abdomen
with skin-to-skin contact.
 Provide a warm, draft-free environment for the neonate.
 Take the neonate's axillary temperature; a normal temperature is between 97.5°F and 99° F (36.4°
and 37.2° C).

C. Preventing Injury and Infection

 Administer prophylactic treatment against ophthalmia neonatorum (gonorrheal or chlamydial).
 Administer a single parental prophylactic injection of vitamin K within 1 hour of birth.
 While in the delivery room (DR), place identical identification bracelets on the mother and the
neonate. The nurse in the DR should be responsible for preparing and securely fastening the bands
on the neonate.
>Complete all identification procedures before the infant is taken from the delivery room.
 Weigh and measure the infant shortly after birth.
>Normal neonate weight is 6 to 9 lb (2,700 to 4,000 g).
>Normal neonate length is 19 to 21 inches (48 to 53 cm).
 No later than 2 hours after birth, nursery/mother-baby personnel should evaluate the neonate's
status and assess risks.
 Administer hepatitis B vaccine according to institution policy.
 Administer BCG vaccine according to institution policy

B. THIRD STAGE (placental stage)

 This stage begins with delivery of the newborn and ends with delivery of the placenta. It occurs in two phases –
placental separation and placental expulsion.
 Powers: strong uterine contractions cause placental separation from the uterine wall; when placenta is fully
detached, maternal pushing can affect final delivery of the placenta.
 Contraction of the uterus controls uterine bleeding and aids placental separation and explanation.
 Generally, oxytocic drugs are administered to help the uterus contract.
 Signs of placental separation include:
 Calkin’s sign the uterus changes its shape (from discoid to globular) and consistency (soft to firm)
 Sudden gushing of blood
 Lengthening of the cord – most definitive sign
 Types of placental delivery
 Shultz mechanism “shiny” – begins to separate from center to edges causing inverted umbrella shape,
presenting the fetal side shiny,”clean bluish side. Most common, present in 80% of cases. Less bleeding.
 Duncan’s mechanism “dirty” – begin to separate form edges to center, umbrella-shaped delivered
sideways, presenting natural side – rough, beefy red or dirty
 Nursing care:
o Obeserve principle of placental delivery stage: watchful waiting
o Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER. Hurrying of placental delivery will
lead to inversion of uterus.
o Note the time of delivery of the placenta it should be delivered within 20 minutes after the delivery of
the baby.
o Inspect for completeness:
a. Complete cotyledons
b. Complete coed vessels
c. Complete membranes
o Feel the fundus for contraction or firmness. If “boggy,” “soft,” “non-palpable,” “non-contracted” means
uterine atony --- massage fundus gently and properly until firm. Ice cap maybe applied will further contract
the uterus.
o Inject oxytoxin (Methergin=0.2mg/ml or Syntocinon= 10U/ml, IM) after placental delivery, to maitain
uterine contractions
o Assess VS, Monitor BP for HPN (or give oxytocin IV)
o Check perineum for lacerations
a. First degree – involves the vaginal mucous membranes and perineal skin
b. Second degree – involves not only the vaginal mucous membranes and perineal skin but also the
muscles
 c. Third degree – involves not only the vaginal mucous membranes and perineal skin and muscles
including the external sphincter of the rectum
d. Fourth degree - involves not only the vaginal mucous membranes and perineal skin and muscles and
the external sphincter of the rectum but also the mucous membranes of the rectum
o Assist MD for episiorapy (repair of episiotomy); vaginal pack should be removed after 24-48 hours.
o Position mother flat on bed to prevent dizziness
o May complain of Chills-due dehydration or decreased BP, fatigue or cold temperature in DR. Provide
blanket; give clear liquid-tea, ginger ale, clear gelatin. Allow to sleep to regain energy.

C. FOURTH STAGE (Recovery and Bonding Stage)

 This stage lasts form 1 to 4 hours after birth.
 The mother and newborn recover from the physical process of birth.
 The maternal organs undergo initial readjustment to the nonpregnant state.
 The newborn body systems begin in the midline of the abdomen with the fundus midway between the umbilicus
and symphysis pubis.
 Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.
 Check placement of fundus at level of umbilicus.
 If fundus above umbilicus, deviation of fundus
 Empty bladder to prevent uterine atony
 Check lochia a vaginal discharge that consists of fatty epithelial cells, shreds of membrane, decidua, and blood

Parameter Rubra Serosa Alba

Color Red Brownish White
Amount Moderate Scanty Slight
Time Present 1 – 3 days 4 – 10 days lower limit 7 10 -14 days(upper limit
days) 21 days)

 Check the Perineum for

R – edness
E – dema
E – cchymosis
D – ischarges
A – pproximation of blood loss. Count pad & saturation
 Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc
 Check for bladder distention – displaces uterus to the side a factor for uterine atony.
 Bonding – interaction between mother and newborn – rooming in types
1.) Straight rooming in baby: 24hrs with mom.
2.) Partial rooming in: baby in morning , at night nursery