Intrapartum 1

NRG 203 l LECTURE | Jane Pathay

 Changes in the ratio of estrogen to progesterone
occurs, increasing estrogen in relation to
Intrapartum Period Intrapartal Care
progesterone, which is interpreted as
Extends from the Refers to the medical and
progesterone withdrawal.
beginning of contractions nursing care given to the
that cause cervical dilation pregnant woman and her  The placenta reaches a set age, which triggers
to the first 1-4 hours after family during labor and contractions.
delivery of the newborn delivery.  Rising fetal cortisol levels reduce progesterone
and placenta formation and increase prostaglandin formation.
 The fetal membrane begins to produce
LABOR prostaglandins, which stimulate contractions
(Bienstock, Fox, & Wallach, 2015).
Physiologic and mechanical process in which the baby,  Any hollow organ stretched,will always
placenta and fetal membranes are propelled through the contract and expel its content (contraction
pelvis and expelled from the birth canal.
action); when the organ is full it will empty.
 Performed by means of some apparatus, not  Oxytocin stimulates the uterine muscles to
manually. contract and also increases production of
 Duration of labor: prostaglandins, which increase the
Primi – 14 hrs and not more than 20 hrs contractions further.
Multi – 8 hrs and not > 14hrs  Progesterone has a relaxing effect on the
uterus
 By 260 days, the placenta began to age
Theories of Why Labor Begins  Life span of placenta 42 wks, at 36 wks
generates = thus leading to contraction =
Normally begins between 37 and 42 weeks of
thus onset of labor
pregnancy, when a fetus is sufficiently mature to adapt
to extrauterine life, yet not too large to cause mechanical  The role of prostaglandins answers the often
difficulty with birth. asked question: does coitus help induce
labor? Semen does contain prostaglandins,
Factors: which can be helpful in softening, also
known as ―ripening,‖ of the cervix; if a cervix
 Withdrawal of progesterone , an increase of
is ready to ripen, semen prostaglandins
prostaglandins, and other complex biochemical
markers have shown to be at work (Irani & could possibly stimulate the beginning of
Foster, 2015). contractions.

Differences between
True and false labor
 Actual cause unknown
 In some instances, labor begins before a False Contractions True Contractions
fetus is mature (preterm birth).  Begin and remain  Begin irregularly but
 In others, labor is delayed until the fetus and irregular become regular and
the placenta have both passed beyond the predictable
optimal point for birth (postterm birth).  Felt first abdominally
and remain confined to  Felt first in lower back
the abdomen and and sweep around to
Theories
groin the abdomen in a
 The uterine muscle stretches from the wave
 Often disappear with
increasing size of the fetus, which results in
ambulation and sleep  Continue no matter
release of prostaglandins. what the woman’s
 The fetus presses on the cervix, which  Do not increase in level of activity
stimulates the release of oxytocin from the duration, frequency or
posterior pituitary. intensity  Increase in duration,
 Oxytocin stimulation works together with frequency and
prostaglandins to initiate contractions.  Do not achieve intensity
 cervical dilatation
 Achieve cervical
dilatation
 supports the weight of internal organs in the upper
part of the body.
 bony structure of the hip area.
 baby must pass through the pelvis during labor and
delivery

inlet
The Components of Labor

1. The passage (a woman’s pelvis) is of adequate

size and contour.
2. The passenger (the fetus) is of appropriate size
and in an advantageous position and
presentation.
3. The powers of labor (uterine factors) are
adequate.
4. Placenta Site of implantation and whether it
covers part of the cervical os. PELVIS
5. The psyche, or a woman’s psychological state
which may either encourage or inhibit labor. This
can be based on her past life experiences as
well as her present psychological state.
FOUR MAIN TYPES OF PELVIS
GYNECOID – round,wide, deeper, most suitable for
pregnancy
ANDROID – heart-shaped male pelvis; ant. Part is
pointed, post. Part shallow
ANTHROPOID- oval shape-like; AP diameter is wider;
transverse is narrow
1. PASSAGE PLATYPELLOID- flat AP diameter narrow; transverse
 Refers to the route a fetus must travel from the wider
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. Keep this in mind
when discussing with parents why 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 (and that is

rarely true). Avoiding this type of negative
thought helps promote good parent–child
bonding.

Passage

THE SOFT TISSUES OF THE PASSAGE INCLUDE: 2. PASSENGER

 LOWER UTERINE SEGMENT FETUS.
 CERVIX
 VAGINAL CANAL  The body part of the fetus that has the widest
diameter is the head, so this is the part least
Pelvis likely to be able to pass through the pelvic ring.
  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 pass depends on
both its structure (bones, fontanelles, and
suture lines) and its alignment with the
pelvis.
PASSENGER
A. Structure of the Fetal Skull
B. Diameters of the Fetal Skull
C. Molding
D. Fetal Presentation and Position
A. Structure of the Fetal Skull
The cranium, the uppermost portion of the skull, is
composed of eight bones.
The four superior bones— are the bones important in
childbirth
 the frontal (actually two fused bones),
 the two parietal, and
 the occipital.
The other four bones of the skull (sphenoid, ethmoid,
and two temporal bones) lie at the base of the cranium
and so are of little significance in childbirth because they
are never presenting parts
B. Structure of the Fetal Skull:
 Fontanelle spaces compress during birth to aid in
molding of the fetal head.
 Their presence can be assessed manually through
the cervix after the cervix has dilated during labor.
Palpating for fontanelle spaces during a pelvic
examination helps to establish the position of the
fetal head and whether it is in a favorable position
for birth.
B. 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.
 The AP dm of the pelvis, a space approximately
11 cm wide, is the narrowest diameter at the
pelvic inlet, and so the best presentation for birth
is when the fetus presents a biparietal diameter
(the narrowest fetal head diameter) to this
C. Molding
 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.
 caused by the force of uterine contractions as the
vertex of the head is pressed against the not yet
dilated cervix.
 The overlapping that occurs in the sagittal
suture line and, generally, the coronal suture
line can be easily palpated on the newborn
skull.
 Parents can be reassured that molding only
lasts a day or two and will not be a
permanent condition.
 No skull molding occurs when a fetus is
breech and born by cesarean birth
 The posterior fontanelle usually closes by
age 1 or 2 months
 The anterior fontanelle usually closes
sometime bet. 9-18 months
D. Fetal Presentation and Position
Other factors that play a part in whether a fetus is
properly aligned in the pelvis and is in the best position
to be born are
 fetal attitude,
 fetal lie,
 fetal presentation
 fetal position.
Fetal Attitude
the degree of flexion a fetus assumes during labor or
the relation of the fetal parts to each other
Types:
1. Good
2. Moderate
3. Partial
  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
 moderate flexion if the chin is not touching the
chest but is in an alert or ―military position
 complete extension, the back is arched and the
neck is extended, presenting the occipitomental
diameter of the head to the birth canal (a face
presentation;

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Fetal Lie

the relationship between the long (cephalocaudal) axis

of the fetal body and the long (cephalocaudal) axis of a A. Cephalic Presentation
woman’s body—in other words, whether the fetus is
lying in a horizontal (transverse) or a vertical
 the most frequent type of presentation, occurring as
(longitudinal) position.
often as 96% of the time.
 Longitudinal lies are further classified as  With this type of presentation, the fetal head is the
a) cephalic, which means the fetal head will be the body part that first contacts the cervix.
first part to contact the cervix
The four types:
b) breech, with a foot or the buttocks as the first
portion to contact the cervix. 1. Vertex
 Approximately 96% of fetuses assume a longitudinal 2. Brow
lie 3. Face
4. mentum
Fetal Lie

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 – Frequent type; 96%

 Breech - either the buttocks or the feet are the
first body parts that will contact the cervix; 4%
 Shoulder- In a transverse lie, a fetus lies
horizontally in the pelvis so the longest fetal axis
is perpendicular to that of the mother. b. the front of the skull from the forehead to the crown.

During labor, the area of the fetal skull that contacts the
cervix often becomes edematous from the continued
pressure against it. This edema is called a caput
succedaneum.

36

caput succedaneum

 swelling (lump or bump) of the scalp in a newborn. It

is most often brought on by pressure from the uterus
or vaginal wall during a head-first (vertex) delivery.
 typically resolves without the need for intervention
within 2 to 6 weeks following delivery.

B. Breech Presentation

 means either the buttocks or the feet are the first C. Shoulder Presentation
body parts that will contact the cervix.  In a transverse lie, a fetus lies horizontally in the
 occur in approximately 4% of births and are affected pelvis so the longest fetal axis is perpendicular to
by fetal attitude: that of the mother.
 A good attitude brings the fetal knees up against  The presenting part is usually one of the shoulders
the fetal abdomen. (acromion process), an iliac crest, a hand, or an
 A poor attitude means the knees and legs are elbow.
extended. Breech presentation  The usual contour of the mother’s abdomen at term
 can cause a difficult birth, with the presenting point may appear fuller side to side rather than top to
influencing the degree of difficulty. bottom.
 Three types of breech presentation:  Fewer than 1% of fetuses lie transversely.
1. complete  Causes:
2. frank  pelvic contractions
3. footling  placenta previa
 Multiparity
 must be born by
 cesarean birth

 pelvic contractions, in which the horizontal

space is greater than the vertical space
 presence of a placenta previa (the placenta is
located low in the uterus, obscuring some of the
vertical space
 relaxed abdominal walls from grand multiparity,
which allow the unsupported uterus to fall
forward

Fetal Position

 the relationship of the presenting part to a specific

quadrant and side of a woman’s pelvis.
 For convenience, the maternal pelvis is divided into
four quadrants according to the mother’s right and
left:
  right anterior Engagement
 left anterior
 right posterior  refers to the settling of the presenting part of a fetus
 left posterior far enough into the pelvis that it rests at the level of
the ischial spines, the midpoint of the pelvis.
 The degree of engagement is established by a
vaginal and cervical examination.
Four parts of a fetus are typically chosen as landmarks  A presenting part that is not engaged is said to
to describe the relationship of the presenting part to one be ―floating.‖
of the pelvic quadrants.  One that is descending but has not yet reached
the ischial spines may be referred to as
 In a vertex presentation, the occiput (O) is the ―dipping.‖
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).

 Position is indicated by an abbreviation of three

letters.
 The middle letter denotes the fetal landmark (O, M,
Sa, and A).
 The first letter defines whether the landmark is
pointing to the mother’s right (R) or left (L).  Can be identified through LM
 The last letter defines whether the landmark points
anteriorly (A), posteriorly (P), or transversely (T). Station
 Example: ROA
- Station refers to the relationship of the presenting part
of the fetus to the level of the ischial spines

Mechanisms (Cardinal Movements) of Labor

 Effective passage of a fetus through the birth canal

 Position is important because it can influence both involves not only position and presentation but also
the process and efficiency of labor. a number of different position changes in order to
 Typically, a fetus is born fastest from an ROA or keep the smallest diameter of the fetal head (in
LOA position. cephalic presentations) always presenting to the
smallest diameter of the pelvis.
 These position changes are termed the cardinal
movements of labor: descent, flexion, internal
rotation, extension, external rotation, and expulsion
 E Engagement
D Descent
F Flexion
IR Internal Rotation
E Extension
ER External Rotation
E Expulsion

EXTERNAL ROTATION
DESCENT
Rotation of the head back to the diagonal or transverse
Downward movement of the biparietal diameter of the
position of the early part of the labor
fetal head to within the pelvic inlet

EXPULSION
FLEXION

Caused by the pressure from the pelvic floor causes the

fetal head to bend forward onto the chest. Once the shoulders are born, the rest of the baby is born
easily and smoothly because of its smaller size.

INTERNAL ROTATION

Rotation of the occiput before reaching the outlet of the 3.POWER

pelvis
The third important requirement for a successful labor is
effective powers of labor.

THE POWERS OF LABOR

 This is the force supplied by the fundus of the uterus

EXTENSION
The head acts as a pivot for the rest of the head, thus
the head extends, and the foremost parts of the head,
the face and chin, are born
and implemented by uterine contractions, which
causes cervical dilatation and then expulsion of the
fetus from the uterus.
 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.
Uterine Contractions

 effective uterine contractions have rhythmicity, a

progressive increase in length and intensity, and
accompany dilatation of the cervix

 Strong uterine contractions compress uterine blood
vessels, preventing a continuous hemorrhage at
childbirth.
 tocodynamometer (TOCO), which is based on the
pressure force produced by the contorting abdomen
during uterine contractions. The contractions are
measured by a pressure transducer placed on the
patient's abdomen.
 Uncoordinated contractions may slow labor and
can lead to failure to progress and fetal distress
because they may not
 allow for adequate placental filling. All of these
possibilities make evaluating the rate, intensity,
and pattern of uterine contractions an important
nursing responsibility.
Characteristics of Contractions

Duration start to end of same

 During pregnancy, the uterus begins to contract contraction
and relax periodically as if it is rehearsing for Interval end of one to start of the
labor (Braxton Hicks contractions, or false next contraction
labor). The mark of Braxton Hicks contractions is Frequency start of one to start of next
that they are usually irregular and are painful but contraction
do not cause cervical dilation. In contrast, Intensity consistency of fundus at
effective uterine contractions have rhythmicity, a acme
progressive
 increase in length and intensity, and accompany
dilatation of the cervix.  The contraction intensity is 30 to 40 mmHg
 The intensity of Braxton Hicks contractions
varies between approximately 5-25 mm Hg (a
Phases: measure of pressure). For comparison, during
true labor the intensity of a contraction is
1. Increment - the intensity of the contraction increases between 40-60 mm Hg in the beginning of the
active phase
2. Acme - the contraction is at its strongest

3. Decrement - the intensity decreases

Cervical Changes

Effacement - is shortening and thinning of the cervical

canal.

 All during pregnancy, the canal is approximately 1 to

2 cm long.
 During labor, the longitudinal traction from the
contracting uterus shortens the cervix so much that
the cervix 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
 As dilatation begins, there is an increase in the
amount of vaginal secretions (show) because minute
capillaries in the cervix rupture and the last of the
mucus plug that has sealed the cervix since early
pregnancy is released.
4. PLACENTA
PLACENTA
 The placenta (Latin for ―pancake,‖ which is
descriptive of its size and appearance at term) grows
from a few identifiable trophoblastic cells at the
beginning of pregnancy to an organ 15 to 20 cm in
diameter and 2 to 3 cm in depth, covering about half
the surface area of the internal uterus at term
(Huppertz & Kingdom, 2012).
Placental Circulation
 12th day of pregnancy – maternal blood begins to
collect in the intervillous space of uterine
endometrium
 3rd week – O2 and other nutrients osmose from
maternal blood through cell layers of chorionic villi
into the villi capillaries -> nutrients are transported to
the embryo
Placental transfer:
 Almost all drugs are able to cross into the fetal
circulation
 Health teaching:
 it is important that a woman take no nonessential
drugs (including alcohol and nicotine) during
pregnancy (Ordean, Kahan, Graves, et al., 2015)
 alcohol perfuses across the placenta and may cause
fetal alcohol spectrum disorder (e.g., unusual facial
features, low-set ears, and cognitive challenge).
Because it’s difficult to tell what quantity is ―safe,‖
pregnant women are advised to drink no alcohol
during pregnancy to avoid these disorders (Rogers
& Worley, 2012).
 To provide enough blood for exchange, the rate of
uteroplacental blood flow in pregnancy increases
from about 50 ml/min at 10 weeks to 500 to 600
ml/min at term.
 The woman’s heart rate, total cardiac output, and
blood volume all increase to supply blood to the
placenta (Pipkin, 2012).
 Uterine perfusion and placental circulation are
most efficient when the mother lies on her left side,
as this position lifts the uterus away from the inferior
vena cava, preventing blood from becoming trapped
in the woman’s lower extremities.
 At term, the placental circulatory network has grown
so extensively that a placenta weighs 400 to 600 g
(1 lb), one-sixth the weight of the newborn.
 If a placenta is smaller than this, it suggests
circulation to the fetus may have been
compromised and/or
 inadequate. A placenta bigger than this also
may indicate circulation to the fetus was
threatened because it suggests the placenta
was forced to spread out in an unusual manner
to maintain a sufficient blood supply. The fetus
of a woman with diabetes may also develop a
larger than usual placenta from excess fluid
collected between cells.
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5. PSYCHE

Endocrine Function

 Besides serving as the source of oxygen and THE PSYCHE

nutrients for the fetus, the syncytial (outer) layer of
the chorionic villi develops into a separate and  Psychological state or feelings a woman brings into
important hormone-producing system. labor. For many women, this is a feeling of
apprehension or fright. For almost everyone, it
 Finding no serum hCG after birth can be used includes a sense of excitement or awe.
as proof that placental tissue is no longer
present.

Placental Proteins

 In addition to hormones, the placenta also produces

a number of plasma proteins.
 The function of these has not been well
documented, but they may contribute to decreasing
the immunologic impact of the growing placenta and
help prevent hypertension of pregnancy (Song, Li, &
An, 2015).

Placental Grading for Maturity

Placentas can be graded by ultrasound based on the

particular amount of calcium deposits present in the
base. Placentas are graded as:

• 0: between 12 and 24 weeks

• 1: 30 to 32 weeks

• 2: 36 weeks

• 3: 38 weeks (Because fetal lungs are apt to be mature

by 38 weeks, a grade 3 placenta suggests the fetus is
mature.)