Intrapartum: Normal Labor and

Birth Processes

1
Outlines
Definition of normal labor
Factors affecting labor
Clinical picture of labor
Stages of Labour
First stage of labour
Second stage of labour
Third stage of labour
Fourth stage of labour
Nursing diagnosis
Active Management of Labour & nursing Role
Objectives:
At the end of the session, the students will be able to:
1. Describe the onset of labor and the role of passenger,
passage, and powers in labor.
2. Assess a family in labor, identifying the woman’s
readiness, stage, and progression.
3. Formulate nursing diagnoses related to the physiologic
and psychological aspects of labor and birth.
4. Plan nursing interventions to meet the needs and promote
optimal outcomes for a woman and her family during labor
and birth.
5. Implement nursing care for a family during labor such as
teaching about the stages of labor.
6. Integrate knowledge of nursing care in labor with nursing
process to achieve quality maternal and child health nursing
care.
Normal Labor & Delivery
 process of spontaneous expulsion of a
single, full term, viable fetus presented by
the vertex, left occipito-anterior (LOA)
position, through the birth canal within a
reasonable time (12 hours), without
interference (except episiotomy) and
without complications to the mother or the
fetus.
Factors affecting the process of labor
1. Passengers: Fetus
2. Passages: type of pelvis, pelvic floor,
uterus, cervix, vagina
3. Powers
4. Position (maternal)
5. Psychological
 1. Passenger
• refer to the fetus and its ability to move through the
passageway.
• Based on the following:
a. Size of the fetal head and capability of the head to mold to the
passageway.
– Molding: change in shape of the fetal skull produced by
the uterine contractions pressing the vertex against the
non-yet dilated cervix.
– Fontanels: Intersection of sutures, allows for molding,
helps identify position of head
• Anterior : Diamond shaped; Approx2-3 cm; Ossifies in 12-18
months.
• Posterior: Triangle shaped; Closes in 8 weeks (2
month)
Fetal Presentation:
the part of the fetus that enters the maternal pelvis,
or be born first.
• Cephalic ( Vertex):head is the body part that
first contact the cervix (95%)
• 4 types:
Fetal Presentation:

– Breech: Buttocks or feet are the first parts to

contact the cervix (3%)
– 3 types: Complete; Frank; Footling
Fetal Presentation:
• Shoulder in transverse lie, the fetus is lying horizontally
in the pelvis (acromion process is the presenting part)

Fetal Lie:
• Relationship between long axis of the fetus to the long
axis of mother example, longitudinal, transverse lie.
Attitude:
• the degree of flexion of the fetus or the relation
of fetal parts to each other.
– Complete flexion = Spinal column is bowed forward,
and head flexed forward (chin touches the sternum)
(good attitude)
– Moderate flexion: Chin not touching the chest
(military position )
– Partial Extension (Brow): Back is arched, and neck
is extended
Fetal Position:
• Relationship of the presenting
part to a specific quadrant of
woman's pelvis.
• indicated by an abbreviation of
3 letters:
– 1st letter- landmark is pointing
to mother's right (R) or left (L).
– Middle letter denotes the fetal
landmark (O for occiput, M for
mentum or chin, S for sacrum &
A for acromion process).
– Last letter landmark points
anteriorly (A), posteriorly (P), or
transversely (T).
 Factors affecting labor cont.
Station:
• Relationship of the
fetus presenting part to
the mother ischial
spine
– Floating: is above the
spines.
– Engaged: is the level of the
spines.
– Crowning: the presenting
part is at the perineum and
can be seen if the vulva is
separated.
2. Passageway:
• refers to the adequacy of the pelvis and birth
canal in allowing fetal descent; factors include:
a. Type of pelvis (eg. gynecoid, android, anthropoid, or
platypelloid)
b. Structure of pelvis (eg. true versus false
pelvis)
c. Pelvic inlet diameters
d. Pelvic outlet diameters
e. Ability of the uterine segment to distend, the
cervix to dilate, and the vaginal canal and
introitus to distend
3. Power: Primary: Uterine contraction
 responsible for the dilation(opening) and
effacement(thinning) of the cervix in the first stage of
labor.
 Uterine contractions are rhythmic and intermittent
 Frequency:
 between the start of one contraction to the start of the next one.
 Interval:
 between the end of one contraction to the beginning of the next
one.
 Duration:
 between the start of one contraction to its end.
 Intensity:
 power or strength of the contraction (mild, moderate, strong)
3. Power: Primary: Uterine contraction
 3 phases of contraction:
 Increment (intensity of contraction increases)
 Acme(contraction is at its strongest)
 Decrement (intensity decreases)
3. Power: Secondary:
 power of the abdominal muscles and diaphragm, in
the from of bearing down effort, which is partly
voluntary and partly involuntary, or reflex.

4. Position: (maternal)
 most common position for birth has been a
lithotomy position

5. Psyche:
 client's psychological state, available support
systems. preparation for childbirth, experiences, and
coping strategies.
Premonitory Signs
 Braxton Hicks Contraction
 Irregular, mild uterine contractions that occur throughout
pregnancy and stronger in 3rd trimester.
 Lightening
 Fetus descends toward pelvic inlet most noticeable in
nulliparas and occurs about 2 to 3 weeks before natural
onset of labor
 Increased vaginal mucous secretions
 Increase clear and nonirritating vaginal secretions

 Cervical Ripening and Bloody shows

 Cervix softens because of hormone relaxin

 Bloody show- mixture of cervical mucus and pink or brown

blood from ruptured capillaries in cervix and precedes
labor and increases cervical dilatation.
Stages of Labour
1. First Stage (Dilating stages):
• begins with the initiation of true labor contractions and
ends when the cervix is fully dilated
2. Second Stage (Expulsive stage):
• extending from the time of full dilatation until the infant is
born
3.Third Stage (Placental stage):
• time infant is born until the placenta is delivered
4. Fourth Stage:
• first 4 hours after the birth of placenta
First Stage of Labour
begins with the onset of regular contractions, which cause
progressive cervical dilation and effacement.
It ends when the cervix completely effaced and dilated.
a. Latent phase.
begins with the onset of regular contractions, and
effacement and dilation of the cervix to 3 .
It lasts an average of 6. 4-8 hours for nulliparas and 4-6
hours for multiparas. Contractions become increasingly
stronger and more frequent.
b. Active phase.
Dilation continues from 4 cm to 7cm. Contractions become
stronger, more frequent, longer, and more painful.
c. Transition phase.
cervix dilates from 8 to 10 cm. The intensity, frequency and
duration of contractions peak, and there is an irresistible
urge to push.
First Stage of Labour: Nursing Diagnosis
• Pain related to the process of labor or contractions.
• Knowledge deficit: lack of information related to expected physical
changes, symptoms of labor, and options available to the childbearing
woman.
• Anxiety related to childbirth, pelvic examinations, or obstetric
interventions.
• Fear related to parenting.
• Fluid volume excess related to intake during labor.
• Fluid volume deficit r/t inadequate fluid intake
• Altered nutrition: less than body requirements related to decreased
intake during labor.
• Health seeking behavior R/T management of discomfort of labor
• Situational low self steam R/T inability to use prepared childbirth
method or body exposure
• Communication impaired r/t inability to understand medical
terminology or English
First Stage
Active of Labour:ofNursing
Management Labour Care
& nursing Role
1. History taking.
2. Examination: General – Abdominal – Pelvic
3. Investigations: Blood Group & Rh typing – Hb% –Urine for
albumin & sugar – Ultrasound
4. Active Procedures:
– Evacuation of the rectum
– Evacuation of the bladder
– Preparation of the vulva
– Nutrition
– Posture
– Analgesia
– Partograph
– Monitoring of labor (CTG)
First Stage: Nursing Intervention
Admission of the Woman & Assessment: (quick history):
• Uterine Contraction:
– Ask the woman when true contractions began, how often are they coming and
how long they last.
• Show:
– Ask the woman if she had a blood stained mucous discharge
• Membranes:
– Ask the woman if she had a gush of fluid? If she is not sure, use litmus papers &
smell it to exclude urine.
• Sleep, rest & food:
– Ask the woman if she has had enough rest & sleep, and if she has had food
within 6 hours?
• Ask the woman about her previous labour history and her present
pregnancy.
• Bladder & Bowel:
– Ask the woman if she has passed urine or stool.
First Stage: Nursing Intervention

• Orientation to environment, expected assessments and

procedures.
– Keep informed; Establish rapport; Express confidence; Provide support
• Encourage ambulation unless contraindicated
• Provide comfort measures, Frequent position changes
• Administration of prescribed analgesia
• Encourage urine voiding 2 hourly
• Monitor progress of labour and fetal well being
• Provide fluids to prevent dehydration
• Teach and reinforce Relaxation Techniques, Massage,
visualization and breathing patterns
• Document care given and report status/progress
Signs of Maternal & Fetal Distress
Signs of Maternal Distress:
• Increased pulse rates
• Elevated temperature
• Decreased blood pressure.
• Sweating and pale face.
• Signs of dehydration.
• Dark vomitus.
• Ketone bodies in urine.
• Irritability and restlessness.
• Anxious expressions.
Signs of Fetal Distress:
• Excessive fetal movements.
• Excessive molding of fetal
head.
• Excessive formation of caput
succedaneum.
• FHR increasing or decreasing
or becoming irregular.
• Passage of meconium of
cephalic presentation.
Nursing Management to Distress
• Encouraging the mother to change position when
lying down, specifically on a left lateral side-lying
position
• The woman has to be well hydrated
• The woman has to be monitored for adequate
oxygen supply.
• Stop oxytocin if it is being administered.
Second Stage of Labour
• Begins with complete dilation of the cervix and
ends with delivery of fetus
• Start when the baby's head is visible at the
opening of the vagina, it is called "crowning."
• Duration of Second Stage
– Primigravida: 50 minutes ( may take btw 30min-2 hrs).
– Multiparous: 20 minutes or less
• Contractions
– Interval: 2 to 3 minutes; Duration: 50 to 90
Mechanisms of Delivery
• Engagement
– ischial spines
• Descent
– downward movement of the biparietal diameter of the fetal head to within the
pelvic inlet
• Flexion
– head bends forward onto the chest
• Internal rotation
– occiput rotates to bring the head into the best relationship to the outlet of the
pelvis
• Extension Restitution
– back of the neck stops beneath the pubic arch and acts as a pivot for the rest of
the head
• External rotation
– head rotates back to the diagonal or transverse position of the early part of the
labor
• Expulsion
– end of the pelvic division of labor
Second Stage: Nursing Diagnosis

• Fear related to birth process, pain, and

unknown outcome.
• Fatigue related to physical exertion during
labor and lack of sleep.
• Pain related to fetal descent, crowning,
and perineal stretching.
Second Stage: Highlight
1. Identification of its Beginning
2. Delivery room admission
3. Bearing down instruction
4. Delivery of the fetal head
5. Prevent perineal lacerations
by perineal support –
Episiotomy
6. Mucus aspiration
7. Inspect for cord around the
neck
8. Delivery of the shoulders
9. Delivery of the rest of the
body
10. Clamping of the cord
11. Care of the newborn
Second Stage: Nursing Management

Transfer to Delivery Room:

– Primigravida is transferred to the delivery
room when the cervix is fully dilated, and the
presenting part is seen (crowning).
– Multipara is transferred when the cervix is 7-8
cm (3-4 fingers).
Position of Woman in Labour:
– lithotomy position.
Second Stage: Nursing Management
• DR should be warm enough for the infant.
• All equipment needed for the infant’s care is
present including resuscitation trolley.
• Place the woman on the delivery table and
put her legs in the leg holder.
• The legs and thighs should dress with
sterile leggings. Sterile towels should be
laid over the abdomen and under buttocks
leaving only the vulva and perineum
exposed.
• Empty the bladder. Swab external genitalia
and apply a sterile pad.
• Keep the woman informed of her progress.
• Teach the woman how to bear down.
– She takes a deep breath, holds it, closes her lips,
and bears down.
Third Stage of Labour
• involves the separation and expulsion of the
placenta.
• It begins with the delivery of the infant and ends
with the delivery of the placenta.
Average duration: 8 minutes up to 30 mins
Signs of Placental Separation:
– Change in the shape of the uterus, firm contraction of
the uterus, the fundus rising in the abdomen
– A sudden gush of vaginal blood
– Lengthening of the umbilical cord
Third Stage: Nursing Role
Delivery of the Placenta
– Conservative Method (Crede’s method).
• Placenta delivered by controlled cord traction with
counter traction on the fundus during contraction,
gentle pressure on contracted uterine fundus)
– Active Method (Brandt-Andrew’s method).
– Oxytocin given
– Fundal massage after delivery of the placenta
Routine Examination
– Placenta & Membranes.
– Genital Tract. Carefully inspect vagina, perineum, and
labia for lacerations and tears. And Inspect vulva for
bleeding, edema, and hematoma.
Third Stage: Nursing Management

• Evacuate the bladder by a catheter if the

placenta is not separated within 20 minutes.
• Examine the placenta and membranes for
general appearance, completeness, cord
vessels , and weight.
• Estimate the average blood loss (200-500 ml).
• Clean and dry the vulva, buttocks and thighs and
then apply a sterile pad.
Fourth Stage: Nursing Management
• Remain beside the patient.
• Check and record the maternal vital signs every 15
minutes, or as necessary.
• Check the uterus to ensure that it is well contracted to
prevent bleeding.
• Observe the amount of lochia.
• Inspect the perineum for edema and hematoma.
• Encourage the woman to pass urine.
• Clean the woman, change her clothes, swab the
perineum
• Give the woman a drink or light snack if she is hungry.
• Show the mother her newborn infant.
Fourth Stage: Warning Sign

• Severe perineal pain suggestive for hematoma

formation.
• Rapid pulse increases hypotension.
• Severe headache hyperreflexia may precede
eclampsia.
• Distended bladder often visible will lead to
enhanced uterine bleeding, catheterization for
retention when necessary.
Information to be documented:

• Exact date and time of delivery.

• Mother's name.
• Sex of the infant.
• Condition of the infant (APGAR) after birth. Use
of oxygen and suction on the infant. Number of
vessels in the cord.
• Type of episiotomy, lacerations.
• Spontaneous or forceps delivery.
• Any other pertinent facts about the delivery.
Immediate Newborn Care

• Given to mother and place to radiant warmer

• 1st Priority=Airway
– Placed in modified trendelenburg
– Suctioned with bulb syringe/deep suctioning. Mouth then nose <5
seconds.
• 2nd priority=provide warmth
– Kept dry (head first)
• Apgar Score (1minute and 5 minutes)
– Heart rate; Respiration effort; Muscle tone; Reflex irritability; Color
– Scoring:
• 7 to 10 provide supportive care
• 4 to 6 indicates moderate depression
• < 4 requires aggressive resuscitation
Immediate Newborn Care
• Physical Assessment
– Gross inspection
• Vital signs
– Temp: >36.6 (rectally)
– Pulse: 120-160 bpm, may be irregular
– Respiration: 30-60, irregular, abdominal breathing; no retractions, nasal flaring,
grunting.
• Anthropometric Measurement
– Length, weight, head and chest circumference
• Vitamin K Administration (vastus lateralis 0.5 mg)
• Ophatlmia Neonatorum prophylaxis
• Newborn Identification
– ID bands
– Footprints/ mother’s fingerprint
• Initiation of attachment
41