INTRAPARTAL PERIOD

1. Define labor (2)

 Labor is the series of events by which uterine contractions and abdominal
pressure expel a fetus and placenta from the uterus.
2. Theories of labor onset with explanation (15)
 Uterine stretch theory
 The uterine muscle stretches from the increasing size of the fetus,
which results in release of prostaglandins.
 Oxytocin theory
 The fetus presses on the cervix, which stimulates the release of
oxytocin from the posterior pituitary.
 Oxytocin stimulation works together with prostaglandins to initiate
contractions.
 Progesterone deprivation theory
 Changes in the ratio of estrogen to progesterone occurs, increasing
estrogen in relation to progesterone, which is interpreted as
progesterone withdrawal.
 Progesterone produced by the placenta relaxes uterine smooth
muscles by interfering with conduction of the impulses from one cell to
other cells.
 Decreased amount of progesterone inhibits relaxation effect on the
uterus.
 Prostaglandin initiation theory
 Rising fetal cortisol levels reduce progesterone formation and
increase prostaglandin formation.
 The fetal membrane begins to produce prostaglandins, which
stimulate contractions.
 Theory of the aging placenta
 The placenta reaches a set age, which triggers contractions.
3. Premonitory signs of labor (either definition or explanation) (18)
 Lightening
 Fundal height reaches xyphoid process
 Vaginal discharge – Show - pressure
 This happens when the baby's head "drops" down into the pelvis.
 Braxton Hick’s contractions
 These are false labor contractions, painless, irregular, abdominal and
relieved by walking, and are also known as practice contractions.
 Rupture of amniotic membranes
 Also known as water breaks. The amniotic sac ruptures, a feeling that
a fluid leak from the vagina in a trickle or a gush.
 Cervical changes
 Effacement - Softening/ripening of the cervix
 Dilation – Opening of the cervical os during labor.

 Bloody 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.
 Nestling behaviors
 This is meant to prepare the body for the “labor” ahead.

 Slight decrease is maternal weight.

 Loss of weight is about 2-3 lbs. One to two days before the onset of labor
because of the decrease in progesterone level and probably loss of
appetite.

4. Compare true labor and false labor, place in table format 3 columns: criteria, true labor,
false labor (15)

Criteria True labor False labor

Timing of Contractions Contractions come at Contractions are often
regular intervals and get irregular and do not get
closer together as time closer together.
goes on. (Contractions last
about 30 to 70 seconds.)
Pattern of Contractions Regular pattern No pattern
Intensity of Contractions Contractions get stronger Intensity of the
and stronger contractions does not
change
Pain with Contractions Discomfort or pressure Discomfort is usually felt in
starts in the back and the front, like menstrual
moves to the front. cramps.
Changes with Movement Contractions continue, Contractions might stop
 despite moving or when you walk or rest or
changing positions might even stop when you
change position.
Cervix Dilation Cervix dilates (opens) Cervix does not dilate

5. Physiologic alterations in labor (12)

System Physiologic alterations in labor
Cardiovascular system • Cardiac output increases 40%–50% from pre labor
levels.
• Blood loss at birth is 300–500 ml on average.
• Blood pressure may rise with pain response and, due
to work of the system during contractions, by an
average systolic rise of 15 mmHg per contraction.
Respiratory system • Increased respiratory rate to respond to increased
cardiovascular parameters
Temperature regulation • Temperature may increase up to (1°F).
• Diaphoresis occurs with accompanying evaporation
to cool and limit excessive warming.
Fluid balance • Insensible water loss increases during labor due to
diaphoresis and the increase in rate and depth of
respirations.
Urinary system • Pressure of the fetal head as it descends in the birth
canal against the anterior bladder reduces bladder
tone or the ability of the bladder to sense filling.
Musculoskeleta During pregnancy, relaxin is secreted from the ovaries
wqAAl causing the cartilage between joints to be more
system flexible. This allows the joints of the pelvis to be able to
open as much as 2 cm in labor to allow for fetal
passage.
Gastrointestinal • Blood shunts to life sustaining organs causing the GI
(GI) system system to become fairly inactive during labor.
• Digestive and emptying time of the stomach becomes
lengthened.
• Some women experience a loose bowel movement
as contractions grow strong.
Neurologic and Sensory • Increased pain
response • Increased respiratory rate
Psychological responses • Labor can lead to emotional distress because it is not
only painful and fatiguing but it also represents the
beginning of a major life change for a woman and her
partner.

6. Components of labor process 5 p’s:

a. Power (50)
 The third important requirement for a successful labor is effective powers
of labor.
  This is the force supplied by the fundus of the uterus and implemented by
uterine contractions, which causes cervical dilatation and then expulsion
of the fetus from the uterus.
 After full dilatation of the cervix, the primary power is supplemented by
use of a secondary power source, the abdominal muscles. It is important
for women to understand that they should not bear down with their
abdominal muscles to push until the cervix is fully dilated. Doing so
impedes the primary force and could cause fetal and cervical damage.
b. Passenger (fetus) (60)
 The passenger is the fetus.
 The body part of the fetus that has the widest diameter is the head, this is
the part least likely to be able to pass through the pelvic ring. Whether a
fetal skull can pass depends on both its structure (bones, fontanelles, and
suture lines) and its alignment with the pelvis.

Considerations:

Structure of the Fetal Skull

 The cranium, the uppermost portion of the skull, is composed of
eight bones. The four superior bones the frontal (two fused
bones), the parietal, and the occipital are the bones important in
childbirth.
Diameters of the Fetal Skull
 The shape of a fetal skull causes it to be wider in its
anteroposterior diameter than in its transverse diameter. To fit
through the inlet of the birth canal best, a fetus must present the
smaller diameter (the transverse diameter) of the head to the
smaller diameter of the maternal pelvis (the diagonal conjugate);
otherwise, progress can be halted, and vaginal birth may not be
possible.
Molding
 Molding is overlapping of skull bones along the suture lines, which
causes a change in the shape of the fetal skull to one long and
narrow, a shape that facilitates passage through the rigid pelvis.

c. Passageway (60)
 The passage refers to the route a fetus must travel from the uterus
through the cervix and vagina to the external perineum.
 If a disproportion between fetus and pelvis occurs, the pelvis is the
structure at fault.
 If the fetus is the cause of the disproportion, it is often not because the
fetal head is too large but because it is presenting to the birth canal at
less than its narrowest diameter.
  An infant may not be able to be born vaginally. It can be upsetting for
parents to learn that a child cannot be born vaginally because the
mother’s pelvis is too small. It can be much more upsetting to think their
infant’s head is too large because it implies something may be seriously
wrong with their baby.

d. Position of parturient (15)

Fetal Presentation and Position
 A fetus should be properly aligned in the pelvis and is in the best
position to be born are fetal attitude, fetal lie, fetal presentation,
and fetal position.

Fetal Presentation
 Fetal presentation denotes the body part that will first contact the
cervix or be born first and is determined by the combination of
fetal lie and the degree of fetal flexion (attitude).

Cephalic Presentation

Type Lie Attitude Description

Vertex Longitudina Good (full The head is sharply flexed, making the
l flexion) parietal bones or the space between the
fontanelles (the vertex) the presenting part.
This is the most common presentation and
allows the suboccipitobregmatic diameter
to present to the cervix.
Brow Longitudina Moderate Because the head is only moderately
l (military) flexed, the brow or sinciput becomes the
presenting part.
Face Longitudina Poor The fetus has extended the head to make
l the face the presenting part. From this
position, extreme edema and distortion of
the face may occur.
Mentu Longitudina Very poor The fetus has completely hyperextended
m l the head to present the chin, causing the
presenting diameter (the occipitomental) to
be so wide that vaginal birth may not be
possible.

Breech Presentation
A breech presentation means either the buttocks or the feet are the first body
parts that will contact the cervix.
Type Lie Attitude Description
Complet Longitudinal Good (full The fetus has the thighs tightly flexed on
e flexion) the abdomen, both the buttocks and the
tightly flexed feet present to the cervix.
Frank Longitudinal Moderate Attitude is moderate because the hips
 Moderate are flexed, but the knees are extended to
rest on the chest. The buttocks alone
present to the cervix.
Footling Longitudinal Poor Neither the thighs nor lower legs are
Poor flexed. If one foot presents, it is a single-
footling breech; if both present, it is a
double footling breech.

Fetal Position
 Fetal position is the relationship of the presenting part to a specific
quadrant and side of a woman’s pelvis.
The maternal pelvis is divided into four quadrants according to the mother’s right
and left: (a) right anterior, (b) left anterior, (c) right posterior, and (d) left posterior.

Four parts of a fetus are typically chosen as landmarks to describe the

relationship of the presenting part to one of the pelvic quadrants.
• In a vertex presentation, the occiput (O) is the chosen point.
• In a face presentation, it is the chin (mentum [M]).
• In a breech presentation, it is the sacrum (Sa).
• In a shoulder presentation, it is the scapula or the acromion process (A).

e. Psychological response of the mother (30)

 It refers to the psychological state or feelings a woman brings into labor.
 For many women, this is a feeling of apprehension or fright. For almost
everyone, it includes a sense of excitement or awe.
 Women who manage best in labor typically are those who have a strong
sense of self-esteem and a meaningful support person with them. These
factors allow women to feel in control of sensations and circumstances
they have never experienced before and which may not be what they
pictured (Hodnett, Gates, Hofmeyr, et al., 2013).
 Women without adequate support can have a labor experience so
frightening and stressful that they develop symptoms of posttraumatic
stress disorder (PTSD)