CARE FOR THE MATERNAL, CHILD AND

ADOLESCENT
BSN YEAR 2 FIRST SEMESTER - WEEK # 7
INTRAPARTUM

TABLE OF CONTENTS 3. BARTHOLOMEW’S RULE OF FOURS

• Measure AOG by determining the position of the fundus in
• Classification of Pregnancy
the abdominal cavity
• Prenatal Assessment • 12 weeks: slightly above the symphysis pubis
• Methods of Estimating AOG • 20 weeks: level of umbilicus
• Methods of Estimating EDD/EDC • 28 weeks: halfway the umbilicus & the xiphoid process
• Past Obstetric History • 36 weeks: level of the xiphoid process
• Theories of Labor Onset • 40 weeks: slightly below the xiphoid process
• Components of Labor
• Stages of Labor
• Partograph

CLASSIFICATION OF PREGNANCY
BORN ALIVE
• Gravida - A person who is or has been pregnant
• Primigravida - A person who is pregnant for the first time
• Primipara - A person who has given birth to one child past
age of viability
• Multigravida - A person who has given birth past the age
of viability previously
• Grand multipara - A person who has carried five or more
pregnancies to viability
• Multipara - A person who has carried two or more
pregnancies to viability
• Nulligravida - A person who has never been and is not METHODS OF ESTIMATING EDD/EDC
currently pregnant
• TPAL- -Term, Premature,births, Abortions, and Living
children NAEGELE’S RULE
• January to March: Count back 3 calendar months from first
PRENATAL ASSESSMENT day of LMP then add 7 days

A. Extensive health history • April to December: Count back 3 calendar months from first
B. Physical Exam (P.E) and Pelvic Examination day of LMP then add 7 days and 1 year
C. Laboratory Assessment

FRENATAL VISIT DATE OF QUICKENING

Schedule of Visits:
• first 32 weeks: once/month • PRIMIGRAVIDA:
• 32-36 weeks: 2x a month (every 2 weeks) - Date of Q + 4 months & 20 days = EDC
• 36 to 40 weeks : 4x a month (every week) • MULTIGRAVIDA:
Prompt reporting of (+) danger signals of pregnancy – for - Date of Q + 5 months & 4 days = EDC
Evaluation
METHODS OF ESTIMATING AOG

1. DETERMINING WEEKS OF AOG

• Current date of consultation minus date of LMP
• The formulated answer is then divided by 7
• The quotient is the number of weeks
• The remainder is the number of days
•
2. MCDONALD’S RULE
• used in the second & third trimester
• First take the fundic height by measuring the distance from
the notch of the symphysis pubis to the fundus
• FH / 4 = AOG IN MONTHS

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USING THE GESTATION CALCULATION WHEEL OB SCORING (GP TPALM)

• G 4 P 2 T 2 P 0 A 2 L 2 M 0 (G4P2 20220)
= 4 pregnancies, 2 births, 2 term births, 0 preterm births, 2
abortions, 2 living children, 0 multiple pregnancies
• G 3 P 3 T 2 P 1 A 0 L 4 M 1 (G3P3 21041)
= 3 pregnancies, 3 births, 2 term births, 1 preterm birth, 0
abortion, 4 living children, 1 multiple pregnancy

THEORIES OF LABOR ONSET

Labor normally begins between 37 and 42 weeks of pregnancy,

when a fetus is sufficiently mature to adapt to extra uterine life,
yet not too large to cause mechanical difficulty with birth. In
some instances, labor begins before a fetus is mature (preterm
birth). In others, labor is delayed until the fetus and the placenta
“First day of LMP” arrow is placed on that date, as the other have both passed beyond the optimal point for birth (post term
arrow, labeled, “Expected Delivery Date” shows the expected birth).
date of delivery A number of factors are known to be responsible for the initiation
of spontaneous labor, although much is still unknown. Factors
PAST OBSTETRIC HISTORY such as withdrawal of progesterone, an increase of
prostaglandins, and other complex biochemical markers have
Components of OB SCORING shown to be at work.
• Gravidity/Gravida (G) A number of theories, including a combination of factors
• Parity/Para (P) originating from both the woman and fetus, have been proposed
• Preceding pregnancies & prenatal outcomes (TPALM) to explain why progesterone withdrawal begins. Some of the
• Pregnancy History theories include:
• The uterine muscle stretches from the increasing size of the
GRAVIDITY / GRAVIDA fetus, which results in release of prostaglandins.
• Number of pregnancies regardless of duration & outcomes, • The fetus presses on the cervix, which stimulates the
including present pregnancy release of oxytocin from the posterior pituitary.
o PRIMIGRAVIDA • Oxytocin stimulation works together with prostaglandins to
- woman who had one pregnancy initiate contractions.
o NULLIGRAVIDA: • Changes in the ratio of estrogen to progesterone occurs,
- woman who is not & never has been pregnant increasing estrogen in relation to progesterone, which is
o MULTIGRAVIDA interpreted as progesterone withdrawal.
- woman who had 2 or more pregnancies • The placenta reaches a set age, which triggers
PARITY / PARA contractions.
• Rising fetal cortisol levels reduce progesterone formation
and increase prostaglandin formation.
• Number of pregnancies carried to the period of viability (20
• The fetal membrane begins to produce prostaglandins,
weeks or greater) whether born dead or alive at birth
which stimulate contractions
• Multiple pregnancies are counted as ONE
• Usually listed as:
▪ Term (37-42 weeks Gestational Age) THE COMPONENTS OF LABOR
▪ Preterm (20-36 6/7 weeks Gestational Age) A successful labor depends on four integrated concepts, often
▪ Post term (more than 42 weeks Gestational Age) referred to as the four Ps:
1. The passage (a woman’s pelvis) is of adequate size
o NULLIPARA and contour.
o PRIMIPARA
2. The passenger (the fetus) is of appropriate size and in
- A woman who has delivered once of a fetus or an advantageous position and presentation.
fetuses who reached the stage of viability. Any 3. The powers of labor (uterine factors) are adequate.
ABORTION is NOT included in the counting of 4. The psyche, or a woman’s psychological state which
parity may either encourage or inhibit labor. This can be
o MULTIPARA
based on her past life experiences as well as her
- A woman who has completed two or more present psychological state. Developing embryo and
pregnancies to the stage of viability. placental structures throughout pregnancy
PRECEDING PREGNANCIES AND PRENATAL
OUTCOMES (TPALM)

T = Number of fullterm births

P = Number of preterm births
A = Number of Abortions/Miscarriages
L = Number of currently living children
M = Number of multiple pregnancies

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THE PASSAGE
● The passage refers to the route a fetus must travel from the
uterus through the cervix and vagina to the external
perineum 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.

THE PASSENGER
The passenger is the fetus. The body part of the fetus that has
the widest diameter is the head, so this is the part least likely to
be able to pass through the pelvic ring. Whether a fetal skull can • MOLDING
pass depends on both its structure (bones, fontanels, and suture o Change in the shape of the fetal skull to "mold" &
lines) and its alignment with the pelvis. fit through the birth canal
o Overlapping of skull bones along the suture lines,
which causes a change in the shape of the fetal
FETAL SKULL
skull to one long and narrow, a shape that
facilitates passage through the rigid pelvis.
• The cranium, the uppermost portion of the skull, is o Molding is caused by the force of uterine
composed of eight bones. The four superior bones—the contractions as the vertex of the head is pressed
frontal (actually two fused bones), the two parietal, and the against the not yet dilated cervix. The overlapping
occipital—are the bones important in childbirth. that occurs in the sagittal suture line and,
• FONTANELS generally, the coronal suture line can be easily
o Space between the bones of the skull allow for palpated on the newborn skull.
molding o There is little molding when the brow is the
o Often referred to as a baby's "soft spots" presenting part because frontal bones are fused.
o No skull molding occurs when a fetus is breech
o Anterior (larger) because the buttocks, not the head, present first.
- Diamond-shaped Babies born by cesarean birth when there is no
- Closes in 12–18 months pre-procedure labor also typically have nomolding.
o Posterior
- Triangle shaped FETAL ATTITUDE
- Closes in 8–12 weeks
• Attitude describes the degree of flexion a fetus assumes
Memory Trick: The post office always closes early
during labor or the relation of the fetal parts to each other
• A fetus in good attitude is in complete flexion: The spinal
column is bowed forward, the head is flexed forward so
much that the chin touches the sternum, the arms are flexed
and folded on the chest, the thighs are flexed onto the
abdomen, and the calves are pressed against the posterior
aspect of the thighs.
• A fetus is in moderate flexion if the chin is not touching the
chest but is in an alert or “military position”. This position
causes the next widest anteroposterior diameter, the
occipitofrontal diameter, to present to the birth canal. A fair
number of fetuses assume a military position early in labor
o A fetus in partial extension presents the “brow” of the
head to the birth canal
o If a fetus is in complete extension, the back is arched
and the neck is extended, presenting the

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occipitomental diameter of the head to the birth canal.

This unusual position usually presents too wide a skull
diameter to the birth canal for vaginal birth. Such a
position may occur in an otherwise healthy fetus or may
be an indication there is less than the usual amount of
amniotic fluid present (oligohydramnios), which is not
allowing the fetus adequate movement space.

2. Breech Presentation
- A breech presentation means either the
buttocks or the feet are the first body
parts that will contact the cervix.
- Breech presentations occur in
approximately 4% of births and are
affected by fetal attitude the same as
vertex presentations

FETAL LIE
• Lie is the relationship between the long (cephalocaudal)
axis of the fetal body and thelong (cephalocaudal) axis of a
woman’s body—in other words, whether the fetus is lying in
a horizontal (transverse) or a vertical (longitudinal) position.

FETAL PRESENTATION
• Refers to the part of the fetus that enters the pelvic inlet first
through the birth canal during labor
1. Cephalic Presentation
o the most frequent type of presentation, occurring
as often as 96% of the time.
o With this type of presentation, the fetal head is the
body part that first contacts the cervix.

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FETAL POSITION o If the presenting part is below the ischial spines,

• Fetal position is the relationship of the presenting part to a the distance is stated as plus stations (+1 to +4
specific quadrant and side of a woman’s pelvis. cm).
o • At a +3 or +4 station, the presenting part is at the
• The maternal pelvis is divided into four quadrants according
perineum and can be seen if the vulva is
to the mother’s right and left: (a) right anterior, (b) left
separated (i.e., it is crowning)
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 • ENGAGEMENT
quadrants. o Engagement refers to the settling of the presenting
o In a vertex presentation, the occiput (O) is the chosen part of a fetus far enough into the pelvis that it rests
point. at the level of the ischial spines, the midpoint of
o In a face presentation, it is the chin (mentum [M]). the pelvis. Descent to this point means the widest
o In a breech presentation, it is the sacrum (Sa). part of the fetus (the presenting skull diameter in a
o In a shoulder presentation, it is the scapula or the cephalic presentation, or the intertrochanteric
acromion process (A). diameter in a breech presentation) has passed
through the pelvis or the pelvic inlet has been
• Position is indicated by an abbreviation of three letters.
proven adequate for birth.
o The middle letter denotes the fetal landmark (O for
o A presenting part that is not engaged is said to be
occiput, M for mentum, Sa for sacrum, and A for
“floating.”
acromion process).
o One that is descending but has not yet reached
o The first letter defines whether the landmark is pointing
the ischial spines may be referred to as “dipping.”
to the mother’s right (R) or left (L).
o The last letter defines whether the landmark points
anteriorly (A), posteriorly (P), or transversely (T).

THE POWERS OF LABOR

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

• FETAL STATION
o Station refers to the relationship of the presenting
part of the fetus to the level of the ischial spines
o When the presenting fetal part is at the level of the
ischial spines, it is at a 0 station (synonymous with
engagement).
o If the presenting part is above the spines, the
distance is measured and described as minus
stations, which range from −1 to −4 cm.

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they should not bear down with their abdominal muscles to push thin-walled, supple, and passive so the fetus can
until the cervix is fully dilated. be pushed out of the uterus easily.
UTERINE CONTRACTIONS o The contour of the overall uterus also changes
During pregnancy, the uterus begins to contract and from a round, ovoid structure to an elongated one
relax periodically as if it is rehearsing for labor (Braxton Hicks with a vertical diameter markedly greater than the
contractions, or false labor). These contractions are usually horizontal diameter.
mild but can be so strong that a woman mistakes them for true - This lengthening straightens the body of
labor. the fetus, bringing it into better alignment
with the cervix and pelvis. The elongation
of the uterus can cause pressure against
the diaphragm and causes the often
expressed sensation that a uterus is
“taking control” of a woman’s body.

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
o shortening and thinning of the cervical canal. All
during pregnancy, the canal is approximately 1 to
• ORIGINS 2 cm long. During labor, the longitudinal traction
o labor contractions begin at a “pacemaker” point from the contracting uterus shortens the cervix so
located in the uterine myometrium near one of the much that the cervix virtually disappears.
uterotubal junctions. Each contraction begins at • DILATION
that point and then sweeps down over the uterus o Dilatation refers to the enlargement or widening of
as a wave. After a short rest period, another the cervical canal from an opening a few
contraction is initiated and the downward sweep millimeters wide to one large enough
begins again. (approximately 10 cm) to permit passage of a fetus
o In early labor, the uterotubal pacemaker may not
operate in a synchronous manner. This makes
contractions sometimes strong, sometimes weak,
and somewhat irregular. This mild incoordination
of early labor improves after a few hours as the
pacemaker becomes more attuned to calcium
concentrations in the myometrium and begins to
function effectively.
• PHASES
o A contraction consists of three phases:
▪ Increment - when the intensity of the
contraction increases
▪ Acme - when the contraction is at its
strongest
▪ Decrement - when the intensity
decreases

Effacement and dilation of the cervix. (A) The beginning of labor.

(B) Effacement is beginning; dilation is not apparent yet. (C)
The frequency of contractions is the time from the beginning of Effacement is almost complete. (D) After complete effacement,
one contraction to the beginning of the next. It consists of two dilation proceeds rapidly
parts: (A) the duration of the contraction and (B) the period of
relaxation. The broken line indicates an indeterminate period
THE PSYCHE
because the relaxation time (B) is usually of longer duration than
the actual contraction (A).
• The fourth “P,” or a woman’s psychological outlook, refers
• CONTOUR CHANGES to the psychological state or feelings a woman brings into
o The uterus gradually differentiates itself into two labor. For many women, this is a feeling of apprehension or
distinct functioning areas: an upper portion, which fright. For almost everyone, it includes a sense of
thickens, and a lower segment, which becomes excitement or awe.

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• Anxiety can increase pain perception & the need for more TRANSITION PHASE
medications (analgesia & anesthesia). During the transition phase, contractions reach their
• Everyone has a unique birthing process based on their peak of intensity, occurring every 2 to 3 minutes with a duration
social support, past experience, and knowledge. You as the of 60 to 70 seconds, and a maximum cervical dilatation of 8 to
nurse are there to support her in any way she needs. It's 10 cm occurs. If it has not previously occurred, show will occur
important to take into account these factors when caring for as the last of the mucus plug from the cervix is released. If the
a mother in labor and during the postpartum period. membranes have not previously ruptured, they will usually
rupture at full dilatation (10 cm). By the end of this phase, both
full dilatation (10 cm) and complete cervical effacement
PRE-EMINENT SIGNS OF LABOR (obliteration of the cervix) have occurred.
During this phase, a woman may experience intense
• Ripening Of The Cervix discomfort that is so strong, it might be accompanied by nausea
o “Butter softness” of the cervix and vomiting. She may also experience a feeling of loss of
• Decrease In Weight control, anxiety, panic, and/or irritability. Because of the intensity
o 1.5-3.0 lbs. prior to labor and duration of the contractions, it may seem as though labor
• Bloody Show has taken charge of her.
o Pinkish vaginal discharge (leukorrhea, operculum
and blood combined)
• Rupture Of Membranes SECOND STAGE
o Nursing intervention: check FHT. Check
temperature every 2 hrs because mother is more
The second stage of labor is the time span from full
prone to infection after membranes
dilatation and cervical effacement to birth of the infant. A woman
typically feels contractions change from the characteristic
DURATION OF LABOR crescendo–decrescendo pattern to an uncontrollable urge to
push or bear down with each contraction as if to move her
• Primipara bowels. She may experience momentary nausea or vomiting
o 14 hours but not more than 20 hours because pressure is no longer exerted on her stomach as the
• Multipara fetus descends into the pelvis. She pushes with such force that
o 8 hours but not more than 14 hours she perspires and the blood vessels in her neck become
distended.
STAGES OF LABOR
The fetus begins descent and, as the fetal head
Labor is traditionally divided into three stages: touches the internal perineum to begin internal rotation, her
• The first stage of dilatation, which begins with the perineum begins to bulge and appear tense. The anus may
initiation of true labor contractions and ends when the cervix become everted, and stool may be expelled. As the fetal head
is fully dilated pushes against the vaginal introitus, this opens and the fetal
• The second stage, extending from the time of full dilatation scalp appears at the opening to the vagina and enlarges from
until the infant is born the size of a dime, to a quarter, then a half-dollar. This is termed
• The third or placental stage, lasting from the time the crowning.
infant is born until after the delivery of the placenta
• The first 1 to 4 hours after birth of the placenta is sometimes THIRD STAGE
termed the “fourth stage” to emphasize the importance of
close maternal observation needed at this time.
The third stage of labor, the placental stage, begins
with the birth of the infant and ends with the delivery of the
placenta. Two separate phases are involved: placental
FIRST STAGE separation and placental expulsion. After the birth of the infant,
The first stage, which takes about 12 hours to the uterus can be palpated as a firm, round mass just below the
complete, is divided into three segments: a latent, an active, and level of the umbilicus. After a few minutes of rest, uterine
a transition phase contractions begin
again, and the organ assumes a discoid shape. It retains this
LATENT PHASE new shape until the placenta has separated, approximately 5
minutes after the birth of the infant.
The latent or early phase begins at the onset of
regularly perceived uterine contractions and ends when rapid
cervical dilatation begins. Contractions during this phase are
mild and short, lasting 20 to 40 seconds. Cervical effacement
occurs, and the cervix dilates minimally.

ACTIVE PHASE
During the active phase of labor, cervical dilatation
occurs more rapidly. Contractions grow stronger, lasting 40 to
60 seconds, and occur approximately every 3 to 5 minutes.
Show (increased vaginal secretions) and perhaps spontaneous
rupture of the membranes may occur during this time.

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PARTOGRAPH
It is a useful tool for monitoring the progress of labor. It guides
birth attendant to identify women whose labor is delayed and
therefore decide appropriate action.

Monitor during labor...

• Progress of labor
o Cervical dilatation
o Contraction pattern
• Maternal well being
o Pulse, temperature, blood pressure
o Urine voided
• Fetal well being
o Fetal heart rate and pattern
o Color of amniotic fluid

PLOTTING THE PROGRESS OF LABOR

• Plot only the CERVICAL DILATATION using symbol “X”
• Start when woman is in ACTIVE LABOR (4 cm or more) &
is contracting adequately (3-4 contractions in 10 mins)

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• If woman is admitted in LATENT PHASE for the next 8

hours (labor is prolonged), transfer her to the hospital.

SAMPLE CASE:

Marites, G1P0 was admitted at 6 pm.

BP=120/80, PR-84/min, T=36.5. FHT=150/min, cervix 5 cm

dilated, (+) BOW. She had 2-3 uterine contractions in 10 min.

After 4 hours, IE showed 7 cm dilated cervix. Vital signs and

FHT were the same.

At 12 am, another IE done showed 8 cm dilated cervix, negative

BOW, clear AF. FHT= 140/min. Another IE after 2 hours was the
same. FHT=144/min, Vital signs same
Progress of labor is normal if plotting stays on or to the left of
the alert line (green part).

If plotting passes alert line…

• Reassess woman & consider criteria for referral.
• Alert transport services.
• Encourage woman to empty the bladder.
• Encourage upright position & walking if woman wishes.
• Monitor intensively.
• DO NOT WAIT TO CROSS ACTION LINE!
• Refer immediately

If plotting reaches the action line…

Refer urgently to hospital unless birth is imminent.

OTHER FINDINGS TO NOTE & RECORD DURING INTERNAL

EXAMINATION
• Status of membranes, write “I” if intact
• “C” if clear
• “M” if meconium stained
• “A” if absent
• “B” if bloody

Monitor every 4 hours & record the findings:

o blood pressure, pulse rate &
o temperature
o urine voided (yes or no)
o number of contractions in 10 minute period
o fetal heart rate in 1 full minute
• If woman is admitted in LATENT PHASE of labor (less than
4 cm dilated) – record only other findings (BP, FHT, etc.)

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