WEEK 7: INTRAPARTAL CARE (LECTURE)

NCMA 217 - CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENT)

2ND YEAR - BS NURSING (MIDTERMS) Padayon, SN.

THEORIES OF LABOR ONSET urine production can lead to a weight loss

● Labor normally begins when a fetus is sufficiently between 1 and 3 pounds.
mature to cope with extrauterine life yet not too ○ Braxston Hicks Contraction - woman
large to cause mechanical difficulty with birth. usually notices extremely strong Braxton
Several theories including a combination of factors Hicks contractions.
originating from both the woman and fetus have ■ Ripening of the cervix - At term,
been proposed to explain why progesterone the cervix becomes still softer
withdrawal begins: (described as “butter-soft”), and it
○ Uterine muscle stretching, which results tips forward. Cervical ripening this
in release of prostaglandins (reason why way is an internal announcement
u feel pain) that labor is very close at hand.
○ Pressure on the cervix, which stimulates
the release of oxytocin from the posterior SIGNS OF TRUE LABOR
pituitary. ● Signs of true labor involve uterine and cervical
○ Oxytocin stimulation, which works together changes.
with prostaglandins to initiate contractions. ○ Uterine Contraction - The surest sign that
○ Change in the ratio of estrogen to labor has begun is productive uterine
progesterone (increasing estrogen in contractions. Because contractions are
relation to progesterone, which is involuntary and come without warning,
interpreted as progesterone withdrawal) their intensity can be frightening in early
○ Placental age, which triggers contractions labor. Helping a woman appreciate that
at a set point. she can predict when her next one will
○ Rising fetal cortisol levels, which reduces occur and therefore can control the degree
progesterone formation and increases of discomfort she feels by using
prostaglandin formation breathing exercises offers her a sense of
○ Fetal membrane production of well-being.
prostaglandin, which stimulates ○ Show - As the cervix softens and ripens,
contraction. the mucus plug that filled the cervical canal
during pregnancy (operculum) is expelled.
SIGNS OF LABOR The exposed cervical capillaries seep
● PRELIMINARY SIGNS OF LABOR - Before labor, blood as a result of pressure exerted by
a woman often experiences subtle signs that signal the fetus. This blood, mixed with mucus,
labor is imminent. It is important to review these takes on a pink tinge and is referred to as
with women during the last trimester of pregnancy “show” or “bloody show.” Women need
so they can more easily recognize beginning signs. to be aware of this event so that they do
○ Lightening - In primiparas, lightening, or not think they are bleeding abnormally.
descent of the fetal presenting part into the ○ Rupture of Membranes - Labor may
pelvis, occurs approximately 10 to 14 days begin with rupture of the membranes,
before labor begins. This fetal descent experienced either as a sudden gush or as
changes a woman’s abdominal contour, scanty, slow seeping of clear fluid from the
because it positions the uterus lower and vagina. Early rupture of the membranes
more anterior in the abdomen. Lightening can be advantageous as it can cause the
gives a woman relief from the fetal head to settle snugly into the pelvis,
diaphragmatic pressure and shortness of shortens labor. Two risks associated with
breath that she has been experiencing and ruptured membranes are intrauterine
“lightens'' her load. infection and prolapse of the umbilical
○ Increase in Level of Activity - This cord, which could cut off the oxygen
increase in activity is related to an increase supply to the fetus (Lewis et al., 2007). In
in epinephrine release initiated by a most instances, if labor has not
decrease in progesterone produced by the spontaneously occurred by 24 hours after
placenta. This additional epinephrine membrane rupture and the pregnancy is at
prepares a woman’s body for the work of term, labor will be induced to help reduce
labor ahead. these risks.
○ Slight loss of weight - As progesterone
level falls, body fluid is more easily COMPONENTS OF LABOR
excreted from the body. This increase in ● A successful labor depends on four integrated
concepts:
 a. A woman’s pelvis (the passage) is of engagement). If the presenting part is above the
adequate size and contour. spines, the distance is measured and described as
b. The passenger (the fetus) is of minus stations, which range from 1 to 4 cm. If the
appropriate size and in an advantageous presenting part is below the ischial spines, the
position and presentation. distance is stated as plus stations (+1 to +4). At a
c. The powers of labor (uterine factors) are +3 or +4 station, the presenting part is at the
adequate. (The powers of labor are perineum and can be seen if the vulva is separated
(i.e., it is crowning).
strongly influenced by the woman’s
position during labor.)
d. A woman’s psychological outlook is
preserved, so that afterward labor can be
viewed as a positive experience.

1. PASSAGE
a. The passage refers to the route a fetus
must travel from the uterus through the
cervix and vagina to the external
● Fetal Attitude - Attitude describes the degree of
perineum. Two pelvic measurements are
flexion a fetus assumes during labor or the relation
important to determine the adequacy of the
of the fetal parts to each other. A fetus in good
pelvic size: the diagonal conjugate (the
attitude is in complete flexion: the spinal column is
anteroposterior diameter of the inlet) and
bowed forward, the head is flexed forward so much
the transverse diameter of the outlet. At
that the chin touches the sternum, the arms are
the pelvic inlet, the anteroposterior
flexed and folded on the chest, the thighs are
diameter is the narrowest diameter; at the
flexed onto the abdomen, and the calves are
outlet, the transverse diameter is the
pressed against the posterior aspect of the thighs.
narrowest.

● This normal “fetal position” is advantageous for

birth because it helps a fetus present the smallest
anteroposterior diameter of the skull to the pelvis
and also because it puts the whole body into an
2. PASSENGER ovoid shape, occupying the smallest space
a. The passenger is the fetus. The body part possible.
of the fetus that has the widest diameter is ● A fetus is in moderate flexion if the chin is not
the head, so this is the part least likely to touching the chest but is in an alert or “military
be able to pass through the pelvic ring. position”.
Whether a fetal skull can pass depends on ● A fetus in partial extension presents the “brow” of
both its structure (bones, fontanelles, and the head to the birth canal.
suture lines) and its alignment with the ● Descent - means that the widest part of the fetus
pelvis. (the biparietal diameter in a cephalic presentation;
● Molding is a change in the shape of the fetal skull the intertrochanteric diameter in a breech
produced by the force of uterine contractions presentation) has passed through the pelvis inlet or
pressing the vertex of the head against the the pelvic inlet has been proved adequate for birth.
not-yet-dilated cervix. ● Fetal Lie - Lie is the relationship between the long
● Engagement – refers to the settling of the (cephalocaudal) axis of the fetal body and the long
presenting part of a fetus far enough into the pelvis (cephalocaudal) axis of a woman’s body; in other
to be at the level of the ischial spines, a midpoint of words, whether the fetus is lying in a horizontal
the pelvis. (transverse) or a vertical (longitudinal) position.
● Station - refers to the relationship of the presenting
part of a fetus to the level of the ischial spines.
When the presenting fetal part is at the level of the
ischial spines, it is at a 0 station (synonymous with
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 TYPES OF FETAL PRESENTATION
● Fetal presentation denotes the body part that will
first contact the cervix or be born first. This is
determined by a combination of fetal lie and the
degree of fetal flexion (attitude).

1. Cephalic Presentation - A cephalic presentation is

the most frequent type of presentation, occurring as
often as 95% of the time. With this type of
presentation, the fetal head is the body part that
will first contact the cervix. The four types of
cephalic presentation (vertex, brow, face, and
mentum). FETAL POSITION
● Position is the relationship of the presenting part to
a specific quadrant of a woman’s pelvis. For
convenience, 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.

POSSIBLE FETAL POSITION

Vertex Breech Face Shoulder
Presentatio Presentatio Presentatio Presentatio
n n (sacrum) n n (acromion
(occiput) (Mentum) process)

LOA, left LSaA, left LMA, left LAA, left

occiput sacroanteri mentoanteri scapula
anterior or LSaP, or LMP, left anterior LAP,
left mentoposter
LOP, left left
2. Breech Presentation - A breech presentation sacroposteri ior LMT, left
occipitopost or LSaT, mentum scapula
means that either the buttocks or the feet are the erior LOT, posterior
left sacrum transverse
first body parts that will contact the cervix. Breech left transverse RMA, right RAA, right
presentations occur in approximately 3% of births RSaA, right mentoanteri scapula
occipitotrans
and are affected by fetal attitude. A good attitude sacroanteri or RMP, anterior
verse ROA,
brings the fetal knees up against the fetal or RSaP, right RAP, right
right occiput
right mentoposter scapula
abdomen; a poor attitude means that the knees are anterior
sacroposteri ior RMT, posterior
extended. Breech presentations can be difficult ROP, right
occiput or RSaT, right
births, with the presenting point influencing the
posterior right mentum
degree of difficulty. Three types of breech ROT, right sacrum transverse
presentation (complete, frank, and footling) are occiput transverse
possible. transverse
3. Shoulder Presentation - In a transverse lie, a
fetus lies horizontally in the pelvis so that the
longest fetal axis is perpendicular to that of the
mother. The presenting part is usually one of the
shoulders (acromion process), an iliac crest, a
hand, or an elbow.

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 transverse one) in line with the wide
transverse diameter of the inlet.
● Extension
○ As the occiput is born, the back of the
neck stops beneath the pubic arch and
acts as a pivot for the rest of the head.
The head extends, and the foremost parts
of the head, the face and chin, are born.
● External Rotation
○ In external rotation, almost immediately
after the head of the infant is born, the
MECHANISM OF LABOR (CARDINAL MOVEMENTS) head rotates (from the anteroposterior
position it is assumed to enter the outlet)
● Passage of a fetus through the birth canal involves
back to the diagonal or transverse position
several different position changes to keep the
of the early part of labor. This brings the
smallest diameter of the fetal head (in cephalic
aftercoming shoulders into an
presentations) always presenting to the smallest
anteroposterior position, which is best for
diameter of the pelvis. These position changes are
entering the outlet. The anterior shoulder is
termed the cardinal movements of labor: descent,
born first, assisted perhaps by downward
flexion, internal rotation, extension, external
flexion of the infant’s head.
rotation, and expulsion.
● Expulsion
● Descent
○ Once the shoulders are born, the rest of
○ Descent is the downward movement of the
the baby is born easily and smoothly
biparietal diameter of the fetal head to
because of its smaller size. This
within the pelvic inlet. Full descent occurs
movement, called expulsion, is the end of
when the fetal head extrudes beyond the
the pelvic division of labor
dilated cervix and touches the posterior
vaginal floor. Descent occurs because of
POWERS OF LABOR
pressure on the fetus by the uterine
fundus. The pressure of the fetal head on ● The second important requirements for a successful
the sacral nerves at the pelvic floor causes labor are effective powers of labor. This is the
the mother to experience a pushing force supplied by the fundus of the uterus,
sensation. Full descent may be aided by implemented by uterine contractions, a natural
abdominal muscle contraction as the process that causes cervical dilatation and then
woman pushes. expulsion of the fetus from the uterus. After full
● Flexion dilatation of the cervix, the primary power is
○ As descent occurs and the fetal head supplemented by use of the abdominal muscles. It
reaches the pelvic floor, the head bends is important for women to understand they should
forward onto the chest, making the not bear down with their abdominal muscles until
smallest anteroposterior diameter (the the cervix is fully dilated. Doing so impedes the
suboccipitobregmatic diameter) present to primary force and could cause fetal and cervical
the birth canal. Flexion is also aided by damage
abdominal muscle contraction during ● Uterine Contraction - The mark of effective
pushing. uterine contractions is rhythmicity and progressive
● Internal Rotation lengthening and intensity.
○ During descent, the head enters the pelvis ● Phases - A contraction consists of three phases:
with the fetal anteroposterior head the increment, when the intensity of the
diameter (suboccipitobregmatic, contraction increases; the acme, when the
occipitomental, or occipitofrontal, contraction is at its strongest; and the decrement,
depending on the amount of flexion) in a when the intensity decreases
diagonal or transverse position. The head
flexes as it touches the pelvic floor, and
the occiput rotates to bring the head into
the best relationship to the outlet of the
pelvis (the anteroposterior diameter is
now in the anteroposterior plane of the
pelvis). This movement brings the
shoulders, coming next, into the optimal
position to enter the inlet, putting the
widest diameter of the shoulders (a

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 ● Cervical Changes – Even more marked than the
changes in the body of the uterus are two changes
that occur in the cervix: effacement and dilatation.
● Effacement - it is shortening and thinning of the
cervical canal. Normally, the canal is approximately
1 to 2 cm long. With effacement, the canal virtually
disappears.
● Dilatation refers to the enlargement or widening of
the cervical canal from an opening a few
millimeters wide to one large enough
(approximately 10 cm) to permit passage of a
fetus.

PSYCHE
● The fourth “P,” or a woman’s psychological outlook,
refers to the psychological state or feelings that 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.

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