INTRAPARTUM

PERIOD
Reproductive Health Nursing
(NURS 325)

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Learning Outcomes:
• Increased knowledge and understanding of the role
and responsibilities during the labor and delivery.
• Discuss serious intrapartum complications
• Identify signs and symptoms of labor and delivery.
• Develop the nursing care plan as a framework for
care for patient with complications during labor and
delivery.
• Demonstrate appropriate documentation and
reporting.

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LABOR and DELIVERY
OUTLINE:
• Intrapartum Assessment
• Fetal posture and positioning
• Passage, Passenger and Power
• Stages of Labor
• First Stage, Second Stage, Third Stage and
Fourth Stage.
• Labor Complications:
• Dystocia
• Lacerations,
• Instrumental Delivery
• Cesarean Section (C/S)

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INTRAPARTUM PERIOD

• The phases of pregnancy, labor, and birth are

normal physiologic processes.
• The intrapartum period includes labor and
delivery.
• During the intrapartum period, the stages of
labor as well as fetal posture and positioning
are monitored.
• A pregnant woman typically approaches the
birth process with possible concerns of
personal well-being, that of her unborn child,
and fear of labor pain.
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INTRAPARTUM PERIOD
INTRAPARTUM ASSESSMENT
• Nursing care in the intrapartum period depends on
which signs and symptoms are present at the onset of
labor and the client’s physiologic and psychosocial
responses to labor.
• Care may involve basic obstetric procedures and
methods of monitoring the client and fetus.
• To intervene effectively during the birthing process
(considered a normal process), the nurse must
understand not only the physiology of labor and
delivery but also the impact of sociocultural and
personal factors on the client’s childbearing
experience.
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INTRAPARTUM PERIOD
Fetal posture and positioning
• The posture and positioning of the fetus may be
monitored during labor and delivery.

Fetal habitus
• The term fetal habitus, or fetal attitude, is used to
describe the relationship of fetal parts.
• The relationship is usually one of flexion, that is, legs
flexed against the trunk, arms flexed across the
chest, and so on.
• Any extended part presents a potential problem for
labor and deliver.

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INTRAPARTUM PERIOD
Fetal habitus
• The fetal head is the most significant body part
because it’s the least malleable.
• Suture lines enable molding of the fetal head during
labor and delivery.
• They meet to form the anterior and posterior
fontanels; the location of the fontanels is helpful in
assessing fetal position.
• Suture lines also enable rapid growth during the
infant’s first year.

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Fetal Head Diameters

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INTRAPARTUM PERIOD
Fetal lie
• Fetal lie is the relationship of the long axis
(spine) of the fetus to the long axis of the
mother. That is, whether the fetus is lying in a
horizontal (transverse) or vertical (longitudinal)
position.
• Approximately 99% of fetuses assume a
longitudinal lie (long axis parallel to the long axis
of the mother).

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INTRAPARTUM PERIOD
Fetal presentation and presenting part
• Fetal presentation refers to the part of the fetus
closest to the internal os of the mother’s cervix, or
portion of the fetus that enters the pelvic passageway
first.

Various fetal presentation are possible.

• In a cephalic presentation, any part of the head can present,
including the occiput or vertex, brow, or face.
• In a transverse presentation, the back or shoulders present,
and vaginal delivery isn’t possible.
• In a breech presentation, the buttocks (frank breech), one
or both feet (footling breech), or both the buttocks and feet
(complete breech) are the presenting parts.

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Variations in presentation

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INTRAPARTUM PERIOD
Fetal position
Fetal position describe the relationship of the
presenting part of the fetus to the four quadrants of
the mother’s pelvic (front, back, and sides).

Right anterior RA LA Left anterior

Right posterior RP LP Left posterior

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Fetal Position

• The examiner can determine fetal position through

vaginal examination, location of fetal heart tones,
Leopold’s maneuvers, and ultrasonography or X-ray.

• During a vaginal examination, the examiner first

determines the presenting part (location of the
suture lines and fontanels) and then determines
whether the presenting part is directed toward the
right or left side of the mother and toward the
symphysis pubis (anterior) or the sacral area
(posterior).

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Fetal positions

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Fetal Position
• For example, in the left occipital anterior (LOA)
position, the presenting part is the occiput, and it’s
directed toward the left side of the pelvis and toward
the symphysis pubis. (The middle initial represents
the presenting part.)
• Occipital anterior is the preferred delivery position
because the fetal head can extend under the arch of
the symphysis pubis; LOA is the ideal position
because, with the fetus lying on the mother’s left
side, oxygen supply to the client and the fetus is
maximized.
• With occipital posterior, the occiput attempts to
extend into the sacral area.
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LABOR and DELIVERY
Fetal station
• Fetal station, also called degree of engagement, is
the location of the presenting part in relation to the
mother’s ischial spine.
• Fetal station can be determined by vaginal
examination.

Measuring fetal station

• Fetal station (also called degree of engagement) describes
where the presenting part lies in relation to the level of the
ischial spines.
• Measures in centimeters, fetal station advances from -5 cm
to 0 (ischial spine level) to +5 cm.
• The head is considered engaged when it reaches 0.
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Measuring fetal station

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LABOR and DELIVERY

• Labor: Coordinated sequence of involuntary,

intermittent uterine contractions
• Delivery: Actual event of birth

Preliminary signs that indicate the onset of labor

include:
 Lightening, or fetal descent into the pelvis, which
usually occurs 2 to 3 weeks before term in a
primiparous client and later or during labor in a
multiparous client
 Cervical changes, including softening, effacement,
and slight dilation several days before the initiation of
labor
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LABOR and DELIVERY
Preliminary signs that indicate the onset of labor
include:
 Braxton hicks contractions, which can occur
irregularly and intermittently throughout pregnancy
and may become uncomfortable and produce false
labor
 Bloody show as the mucous plug is expelled from the
cervix
 Membrane rupture, occurring before the onset of
labor in about 12% of clients and within 24 hours for
about 80% of clients
 Sudden burst of energy before the onset of labor,
commonly demonstrated by house cleaning activities
and called the nesting instinct. 19
LABOR and DELIVERY

• Four major factors (four P’s) interact during

normal childbirth; the four P’s are interrelated
and depend on each other for a safe delivery
and include
• Powers,
• Passageway,
• Passenger,
• Psyche

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LABOR and DELIVERY

• Powers: Uterine contractions

1. Forces acting to expel the fetus
2. Effacement: Shortening and thinning
of the cervix during the first stage of
labor
3. Dilation: Enlargement of cervical os
and cervical canal during the first stage
of labor
4. Pushing efforts of mother during the
second stage

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LABOR and DELIVERY
• Passageway: The mother’s rigid bony pelvis
and the soft tissues of the cervix, pelvic
floor, vagina, and introitus (external
opening to the vagina)

• Passenger: The fetus, membranes, and

placenta
• Psyche: A woman’s emotional structure that
can determine her entire response to labor
and influence physiological and psychological
functioning; the mother may experience
anxiety or fear.
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LABOR and DELIVERY
True labor: Contractions may manifest as back
pain in some women; contractions
often resemble menstrual cramps during early
labor

False labor: Also known as prodromal labor,

contractions are felt in the abdomen and groin
and may be more annoying than painful

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LABOR and DELIVERY
True Labor Pains False Labor Pains
Regular Irregular
Increases progressively Does not do so
in frequency, duration
and intensity
Pain in abdomen Pain is mainly in the
radiates to back abdomen
Progressive dilation No effect on cervix
and effacement of
cervix
Cannot be relieved by Can be relieved by
painkillers or sedatives painkillers or sedatives 24
LABOR and DELIVERY
Leopold’s Maneuvers
Methods of palpation to determine presentation
and position of the fetus and aid in location of fetal
heart sounds
• If the head is in the fundus, a hard, round,
movable object is felt. The buttocks feel soft and
have an irregular shape and are more difficult to
move.
• The fetus’s back, which is a smooth, hard surface,
should be felt on one side of the abdomen.
• Irregular knobs and lumps, which may be the
hands, feet, elbows, and knees, are felt on the
opposite side of the abdomen.
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Methods for Determining Fetal Presentation:
Leopold's maneuvers

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Evaluating the Fetus during Labor

Fetal Monitoring
1. The fetal monitor displays the fetal heart rate
(FHR).
2. The device monitors uterine activity.
3. The monitor assesses frequency, duration,
and intensity of contractions.
4. The monitor assesses FHR in relation to
maternal contractions.
5. Baseline FHR is measured between
contractions; the normal FHR at term is 110 to
160 beats/minute.
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Evaluating the Fetus during Labor

External fetal monitoring

1. External fetal monitoring is noninvasive and is
performed with a tocotransducer or Doppler
ultrasonic transducer.
2. Leopold’s maneuvers are performed to
determine on which side the fetal back is
located, and the ultrasound transducer is placed
over this area (fasten with a belt or stocking
tubing).

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Evaluating the Fetus during Labor

External fetal monitoring

3. The tocotransducer is placed over the fundus
of the uterus, where contractions feel
the strongest (fasten with a belt or stocking
tubing).
4. The client is allowed to assume a comfortable
position, avoiding vena cava compression
(maternal supine hypotensive syndrome).
5. The preferred position is to have the client lie
on her side to increase perfusion.

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Evaluating the Fetus during Labor

Internal fetal monitoring

1. Internal fetal monitoring is invasive and
requires rupturing of the membranes and
attaching an electrode to the presenting part of
the fetus.
2. The client must be dilated 2 to 3 cm to perform
internal monitoring.

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Evaluating the Fetus during Labor

Periodic patterns in FHR

1. Fetal bradycardia and tachycardia
a. Bradycardia: FHR is less than 110
beats/minute for 10 minutes or longer.
b. Tachycardia: FHR is more than 160
beats/minute for 10 minutes or longer.

If fetal bradycardia or tachycardia occurs, change the position

of the mother, administer oxygen, and assess the mother’s vital
signs. Notify the health care provider as soon as possible.

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Evaluating the Fetus during Labor
Variability
a. Fluctuations in baseline FHR
b. Absent or undetected variability is considered
nonreassuring.
c. Decreased variability can result from fetal hypoxemia,
acidosis, or certain medications.
d. A temporary decrease in variability can occur when
the fetus is in a sleep state (sleep states do not
usually last longer than 30 minutes).

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Evaluating the Fetus during Labor

Variability in Fetal Heart Rate

• Absent Variability: Undetected variability
• Minimal Variability: Greater than undetected
but not more than 5 beats/minute
• Moderate Variability: Fetal heart rate
fluctuations are 6 to 25 beats/minute
• Marked Variability: Fetal heart rate fluctuations
are greater than 25 beats/minute

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Evaluating the Fetus during Labor
Accelerations
a. Brief, temporary increases in FHR of at least 15
beats/minute more than baseline and lasting at least
15 seconds
b. Usually are a reassuring sign, reflecting a responsive,
nonacidotic fetus
c. Usually occur with fetal movement
d. May be nonperiodic (having no relation to
contractions) or periodic (with contractions)
e. May occur with uterine contractions, vaginal
examinations, or mild cord compression, or when the
fetus is in a breech presentation.

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Evaluating the Fetus during Labor

Decelerations of FHR
Decelerations of FHR can be a reassuring sign
but may also indicate complications.
• Early decelerations
• Late decelerations
• Variable decelerations

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Evaluating the Fetus during Labor
Decelerations of FHR: Early decelerations
• Early decelerations are caused by head
compression in the fetus.
• They’re smooth, uniformly shaped waveforms
that inversely mirror the corresponding
contractions. Early decelerations:
• Normally range from 120 to 160
beats/minute
• Are reassuring pattern not associated with
fetal difficulties
• Reassure the client that labor is progressing
as expected.
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37
Evaluating the Fetus during Labor
Later decelerations
Later decelerations are caused by uteroplacental
insufficiency. They are smooth, uniformly shaped
waveforms that inversely mirror the corresponding
contractions but are late in onset and may remain
after the contraction is over. Later decelerations:
 Are usually with the normal range with a high
baseline but may drop to below 100 beats/minute
when severe
 Are considered an ominous sign if they are persistent
and uncorrected; the pattern is associated with
decreased Apgar scores, fetal hypoxia, and acidosis
 May require emergency cesarean delivery if
persistent.
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39
Evaluating the Fetus during Labor
Variable decelerations
Variable decelerations of FHR occur in about half of
all labors and are due to umbilical cord
compression. They vary in onset, occurrence, and
waveform.
 Variable decelerations are characterized by a
heart rate that may (in severe cases) decelerate
below 70 beats/minute for more than 30 seconds
with a slow return to baseline
 Usually are transient and correctable
 Aren’t associated with low Apgar scores.

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LABOR AND DELIVERY
Stages of labor
• The labor process is divided into four stages,
ranging from the onset of true labor, through
delivery of the fetus and placenta, to the first hour
after delivery.
• Nursing care may be specific to stage of labor that
the client is experiencing.

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STAGES OF LABOR

First stage
• The first stage is measured from the onset of
true labor to complete dilation of the cervix.
• Stage 1 is the longest. A labor curve, often
called a Friedman curve, may be used to
identify whether a woman’s cervical dilation is
progressing at the expected rate
• This period lasts from 6 to 18 hours in a
primiparous client and from 2 to 10 hours in a
multiparous client.

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A labor curve, often called a Friedman curve
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STAGES OF LABOR
First stage
• There are three phrases of this dilation stage:
• During the LATENT PHASE, the cervix is dilated
0 to 3 cm (1-4cm), contractions are irregular,
and the client may experience anticipation,
excitement, or apprehension.
Interventions
a. Encourage mother and partner to participate in care.
b. Assist with comfort measures, changes of position,
and ambulation.
c. Keep mother and partner informed of progress.
d. Offer fluids and ice chips.
e. Encourage voiding every 1 to 2 hours.
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STAGES OF LABOR
First stage
• During the ACTIVE PHASE, the cervix is dilated 4 to
7 cm. contractions are about 3 to 8 minutes apart
and last 30 to 60 seconds with moderate to strong
intensity.
• During this phase, the client becomes serious
and concerned about the progress of labor; she
may ask for pain medication or use breathing
techniques.
• If the membranes haven’t ruptured
spontaneously, amniotomy may be performed.

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STAGES OF LABOR
First stage ACTIVE PHASE
Interventions
a. Encourage maintenance of effective breathing
patterns.
b. Provide a quiet environment.
c. Keep mother and partner informed of progress.
d. Promote comfort with back rubs, sacral pressure,
pillow support, and position changes.
e. Instruct partner in effleurage (light stroking of
abdomen).
f. Offer fluids and ice chips and ointment for dry lips.
g. Encourage voiding every 1 to 2 hours.

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STAGES OF LABOR
First stage
• During the TRANSITIONAL PHASE, the cervix is
dilated 8 to 10 cm. contractions are about 1 to 3
minutes apart and last 45 to 90 seconds with strong
intensity.
• During this phase, the client may lose control,
thrash in bed, groan, or cry out.
Interventions
a. Encourage rest between contractions.
b. Wake mother at beginning of contraction so she can
begin breathing pattern.
c. Keep mother and partner informed of progress.
d. Provide privacy.
e. Offer fluids and ice chips and ointment for dry lips. 49
STAGES OF LABOR
Second stage
• The second stage of labor extends from
complete dilation to delivery.
• This stage lasts an average of 40 minutes (20
contractions) for the primiparous client and
20 minutes (10 contractions) for the
multiparous client.
• It may last longer if the client has had
epidural anesthesia.
• The client may become exhausted and
dehydrated as she moves from coping with
contractions to actively pushing.
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STAGES OF LABOR
Second stage
• During this stage, the fetus is moved along
the birth canal by the mechanism of labor
listed below:
 The fetus’s head is considered to be
engaged when the biparietal diameter
passes the pelvic inlet.
 The movement of the presenting part
through the pelvis is called descent.
 During flexion, the head flexes so that
the chin moves closer to the chest

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STAGES OF LABOR

Second stage
 Internal rotation is the rotation of the
head in order to pass through the ischial
spine.
 Extension is when the head extends as it
passes under the symphysis pubis.
 External rotation involves the external
rotation of the head as the shoulders
rotate to the anteroposterior position in
the pelvis.

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Cardinal movements of Labor

• Engagement
• Descent
• Flexion
• Internal rotation
• Extension
• External rotation
(restitution)
• Expulsion (birth)

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Second stage: Interventions
• Perform assessments every 5 minutes.
• Monitor maternal vital signs.
• Monitor FHR via ultrasound Doppler,
fetoscope, or electronic fetal monitor.
• Assess FHR before, during, and after a
contraction, noting that the normal FHR is
110 to 160 beats/minute.
• Monitor uterine contractions by palpation or
tocodynamometer, determining frequency,
duration, and intensity.

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Second stage: Interventions
• Provide mother with encouragement and praise
and provide for rest between contractions.
• Keep mother and partner informed of progress.
• Maintain privacy.
• Provide ice chips and ointment for dry lips.
• Assist mother into a position that promotes
comfort and facilitates pushing efforts, such as
lithotomy, semisitting, kneeling, side-lying, or
squatting.
• Monitor for signs of approaching birth, such as
perineal bulging or visualization of the fetal head.
• Prepare for birth (expulsion of the fetus).
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STAGES OF LABOR

Third stage
• The third stage of labor extends from
delivery of the neonate to expulsion of the
placenta and lasts from 5 to 30 minutes.
• During this period, the client typically
focuses on the neonate’s condition.
• The client may experience discomfort from
uterine contractions before expelling the
placenta.

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Fetal Side Maternal Side

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STAGES OF LABOR
Third stage: Interventions
a. Assess maternal vital signs.
b. Assess uterine status.
c. Provide parents with an explanation regarding
expulsion of the placenta.
d. After expulsion of the placenta, uterine fundus
remains firm and is located 2 fingerbreadths below
the umbilicus.
e. Examine placenta for cotyledons and
membranes to verify that it is intact.
f. Assess mother for shivering and provide warmth.
g. Promote parental-neonatal attachment.
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STAGES OF LABOR
Fourth stage
• The fourth stage of labor is the first 4-hour after
delivery, when the primary activity is the promotion
of maternal-neonatal bonding.

Interventions
a. Perform maternal assessments every 15 minutes for 1
hour, every 30 minutes for 1 hour, and hourly for 2 hours
(or as per agency policy).
b. Provide warm blankets.
c. Apply ice packs to the perineum.
d. Massage the uterus if needed, and teach the mother
to massage the uterus.
e. Provide breast-feeding support as needed.
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Maternal Assessment
• Uterus
• Lochia
• Perineum
• Bladder
• Vital signs
• Pain
• Newborn-family attachment
• Breastfeeding initiated

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PAIN RELIEF DURING LABOR AND DELIVERY
Anesthesia
Local anesthesia
• Local anesthesia is used for blocking pain during
episiotomy.
• Local anesthesia is administered just before the
birth of the infant.
• The anesthetic has no effect on the fetus.

General anesthesia
• General anesthesia may be used for some surgical
interventions.
• The mother is not awake.

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Anesthesia
 Lumbar epidural anesthetic requires an injection of
medication into the epidural space in the lumbar
region, leaving the client awake and cooperative. An
epidural provides analgesic for the first and second
stages of labor and anesthetic for delivery without
adverse fetal effects. Hypotension is uncommon, but
its incidence increase if the client doesn’t receive a
proper fluid load before the procedure. Epidural
anesthesia may decrease the client’s urge to push.
 Spinal anesthesia involves an injection of medication
into the cerebrospinal fluid in the spinal canal.
Because of its rapid onset, spinal anesthesia is useful
for urgent cesarean deliveries.
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Non-Pharmacologic Pain Relief
 Effleurage, a light abdominal stroking with the
fingertips in a circular motion, is effective for mild to
moderate discomfort.
 Distraction can divert attention from mild discomfort
early in labor.
 Patterns of controlled chest breathing are used
primarily during the active and transitional phases of
labor.
 Relaxation techniques include positioning, focusing
and imagery, therapeutic touch and massage, music
therapy, and support of a birthing partner.
 Other methods include heat and cold application,
transcutaneous stimulation (TENS), hypnosis, and yoga
to help reduce pain and promote comfort.
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References
• Silvestri, L.A. (2014), “Saunders Comprehensive Review
for the NCLEX-RN Examination” Elsevier Publishing
• Nettina, S. (2010) “Lippincott Manual of Nursing
Practice.” 9th Edition. Wolters Kluwer Health. Lippincott
Williams & Wilkins.
• Springhouse Review for NCLEX-RN 6th edition. 2006.
Lippincott Williams and Wilkins.
• For images taken from https://www.google.com.sa
• Perry S, Hockenberry M, Lowdermilk D, Wilson D:
Maternal-child nursing care, ed 4, St. Louis, 2010,
Mosby.

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