Chapter 8

Intrapartum Assessment and

Interventions
 OBJECTIVES
The learner will be able to
• Define key terms
• Describe the four stages of labor and the related
nursing and medical care
• Demonstrate understanding of supportive care of
the laboring woman
• Identify the five Ps of labor
• Describe the mechanism of spontaneous vaginal
delivery and related nursing care
 Intrapartum Period
• Begins with the onset of regular contractions and ends with the
delivery of the placenta
• Triggered by maternal factors and fetal factors
ONSET OF LABOR

• Usually begins between

38 & 42 weeks

• Mechanism is unknown
 LABOR PROCESS
• Premonitory signs of labor are
– Lightening: Descent of the fetus into the pelvis
– Baby is not on the diaphragm
– Braxton-Hicks Contractions: Irregular contractions that do not result in cervical change
– Cervical Ripening: Softening of the cervix, effacement (thinning)
– Surge in Energy: Nesting, cleaning
– Gastrointestinal Changes: Nausea, vomiting, diarrhea, weight loss
– May feel sick
– Backache: Lower back pain
– 28 weeks, not huge, but has back pain--- preterm labor
– Pressure: Lower pelvic and vaginal pressure
– Bloody show: Brownish/blood-tinged cervical mucous
– Spontaneous Rupture of Membranes (SROM): Leaking of amniotic fluid
FACTORS AFFECTING LABOR
(5 PS)

1.Powers (the contractions)

2.Passage (the pelvis)
3.Passenger (the fetus)
4.Psyche (the response of woman)
5.Position (maternal postures and
physical positions to facilitate
labor)
 Powers
(contractions)

• Uterine muscle= myometrium Uterus is divided into

the upper and lower segments
• Uterine contractions—primary *The upper segment is 2/3rds of the uterus
force to bring the fetus down and contracts to push the fetus down
into the pelvis and out
through the vaginal canal
• Contractions are also
responsible for the dilation
and effacement of the cervix
 ASSESSMENT OF
UTERINE CONTRACTIONS
Phases of uterine contractions

• Increment
• Acme
• Decrement

• Characteristics of contractions
• Frequency
• Duration
• Intensity
• Palpation
 EFFACEMENT

Effacement: shortening and thinning of cervix

Degree of effacement is measured as a percentage
(0% to 100%)
 DILATION
Dilation: opening and enlargement of cervix
Expressed in centimeters of diameter (1 to 10 cm)
 Powers
(Maternal Pushing Efforts)

• “Bearing down”
sensation
• Urge to push
• No urge to push?
• Pushing “too early”?
 Passage
(Pelvis)

• Importance of maternal pelvic structures

• Cephalopelvic disproportion (CPD)
• Suspect if presenting part does not engage in pelvis (0 station)
 PELVIC TYPES

50%. Adequate
• Gynecoid:
dimensions for birth. The
best.
• Android:Male type. 20%.
Inadequate outlet
dimensions for birth. C-
section may be required.
25%. Adequate
• Anthropoid:
dimensions for birth.
5%. Outlet may
• Platypelloid:
be inadequate (anterior-
posterior dimension). May
need c-section.
STATION
 PASSENGER
(FETUS)
• Fetal skull: The head is typically the largest part of the fetus to come
through the birth canal. Bones and membranous spaces allow it to
mold during the delivery process.
• Molding: The ability of the fetal head to change shape to
accommodate (fit through) the maternal pelvis.
• Head becomes more narrow and longer. Sutures can overlap. This is
normal and resolves 1-2 days after birth.
 FETAL HEAD
Fetal head: 4 bones with 3 membranous interspaces (sutures) that
allow bones to move & overlap to diminish size of skull

Fontanelles: at junctures of skull bones

 FETAL ATTITUDE
OR POSTURE
Flexion or extension of the fetal joints
*With proper fetal attitude, the head is in complete flexion in a vertex presentation
and passes more easily through the pelvis
 FETAL LIE
AND PRESENTATION
• Can be determined by Leopold's maneuvers or US
• Longitudinal lie: Vertical
• Presenting part:
• Cephalic (head),
• Vertex (occiput), Chin (mentum)
• Breech (buttocks or feet)
• Sacrum, Foot/feet
• Transverse lie: Horizontal
• Presenting part:
• Shoulder (acromion)
 LEOPOLD’S MANEUVERS

1. Fundal Grip
2. Umbilical Grip
3. Pawlik’s Grip
4. Pelvic Grip
CEPHALIC PRESENTATION
BREECH PRESENTATION

Assessment Findings:
•FHT heard high on the
abdomen
•Palpated on Leopold’s
Maneuver
•Vaginal exam
•Ultrasound
 BREECH PRESENTATION

•Head entrapment
•Cord prolapse
•Cord compression
•Delivery trauma (fracture
of spine or arm)
•Dysfunctional labor, less
effective cervical dilation
•Higher risk of anoxia from
prolapsed cord or traumatic
injury to the head.
 BREECH PRESENTATION
Change in ACOG Guidelines for recommendations
for mode of delivery for breech infant
Recommendations
The American College of Obstetricians and Gynecologists makes the following
recommendations:
•The decision regarding the mode of delivery should consider patient wishes
and the experience of the health care provider.
•Obstetrician–gynecologists and other obstetric care providers should offer
external cephalic version as an alternative to planned cesarean for a woman
who has a term singleton breech fetus, desires a planned vaginal delivery of a
vertex-presenting fetus, and has no contraindications. External cephalic version
should be attempted only in settings in which cesarean delivery services are
readily available.
•Planned vaginal delivery of a term singleton breech fetus may be reasonable
under hospital-specific protocol guidelines for eligibility and labor management.
•If a vaginal breech delivery is planned, a detailed informed consent should be
documented—including risks that perinatal or neonatal mortality or short-term
serious neonatal morbidity may be higher than if a cesarean delivery is
planned.
SHOULDER PRESENTATION
• Occurs when fetus is in
the transverse lie position
• Cannot be delivered
vaginally unless rotation
occurs (External Cephalic
Version)
 FETAL POSITION

The relationship of the presenting part to the pelvis

 PSYCHE
• The psychological and Most common factors that can prolong
psychosocial aspects that a labor
woman brings into the labor
process •Lack of analgesic control of excessive
• Factors that can affect pain
•Absence of support person or coach
psychological readiness for
•Immobility and restriction to bed
labor
•Lack of ability to carry out cultural
• Preparation/Childbirth traditions
Classes
• Support Person (s)
• Past Experiences
• Tasks of pregnancy
• Situation Control
• Culture and Birth Traditions
POSITION
ONSET OF LABOR
FALSE LABOR vs TRUE LABOR

False Labor True Labor

Benign and irregular Begin irregularly but become
contractions regular and predictable
Continue no matter what the
 Often disappear with
women’s level of activity
ambulation and sleep.
Increase in duration,
Do not increase in frequency, and intensity
duration, frequency or Progressive change in dilation
intensity and effacement
No significant change Bloody show
in dilation or Presenting part engages in
effacement pelvis
RUPTURE OF MEMBRANES

• Leaking of fluid
from vaginal canal

• Obtain sample for

analysis
 MECHANISMS OF LABOR

Cardinal Movements of Birth HEAD ROTATION DURING DESCENT

Mechanisms of labor. A, Descent. B, Flexion.

C, Internal rotation. D, Extension. E, External
rotation.
 Stages of Labor
Labor (parturition) is the process in which the fetus, placenta,
and membranes are expelled spontaneously from the uterus.

Stage 1 Stage 2 Stage 3 Stage 4

Latent Active Transition 10 cm delivery of delivery of
phase phase phase baby placenta
0-5 cm 6-8 cm 8-10 cm

Begins with onset of labor

and ends with complete
cervical dilation delivery of baby delivery of completed 4
placenta hours later
 PERFORMING A
VAGINAL EXAM

• Indications
• Timing
• Risks

• Charted as
• Dilation
• Effacement
• Station Examples:
3/60%/-3
8/90%/+1
 FIRST STAGE OF LABOR

Interval between onset of true labor until

complete cervical dilation. Divided into 3 phases
 Latent phase
• Early and slower part of labor
• Average of 9 hrs in primips
• Average of 5 hrs in multiparas
• Cervix 0–5 cm dilation, 0–40% effacement
• *Reason for change in definition (3-4 cm vs 5-6
cm)
• Irregular contraction every 5–10 min mild
intensity, lasting 30–45 sec
• Excitement and apprehension. Talkative
and breathing easily through contractions
• Discomfort described as feelings of strong
menstrual cramps
• Laboring at home in a familiar environment
• Ambulating, showering
 Active phase
• Average dilation 0.5 cm/hr for primips and 1.5 cm/hr for multiparas
• Dilation progresses 6–8 cm, 40–80% effacement
• Fetal descent continues
• Intense contraction every 2–5 min, lasting 40–60 sec
• Increase in pain
• Deep breathing techniques
• Position changes
• IV pain medication
• Epidural anesthesia
 Transition phase
• Dilation from 8 to 10 cm, 100% effacement

• Contractions intense, q 2 min lasting 60–90 sec

• Exhaustion, difficulty concentrating

• Bloody show

• N/V, backache, diaphoresis, and trembling

• Strong urge to bear down

 Second Stage of labor
• Complete cervical
dilatation until the birth
of the baby. “Pushing
Stage”

• Sudden burst of energy

• Shorter duration in
multiparous women than
with primiparous

• Intense contraction
every 2 min, lasting 60–
90 sec

• Increase in bloody show

• Perineum flattens, with

bulging rectum and
vagina
 IMMINENT BIRTH
• Crowning
• Burning sensation
• Intense pressure in
rectum
EPISIOTOMY
Midline or Mediolateral
LACERATIONS
DELIVERY OF THE FETUS
THIRD STAGE OF LABOR
 MANAGEMENT OF
THIRD STAGE OF LABOR

Medications
•Pitocin
•Methergine
•Hemabate
•Cytotec
 Fourth Stage of Labor

This stage begins after the delivery of the placenta and lasts
about 4 hours or until stabilization of the mother

•Mechanism of homeostasis occurs

•Repair of laceration or episiotomy
•Inspect placenta
•Evaluate bleeding
•Pain medication as needed
•Bonding with newborn
SKIN TO SKIN
 THE NEWBORN
• Newborn transition and initial care typically occur in the delivery room

• Obtain Apgar scores at 1 min and 5 min (and at 10 minutes if needed)

• Monitor temperature, heart rate, respiratory rate, skin color, level of

consciousness, tone, activity

• Newborn identification

• Medication administration
• Erythromycin
• Gonococal
• Vitamin K
APGAR SCORE
APGAR SCORE

If the Apgar score is less than

7 at 5 minutes, the Neonatal
Resuscitation Program
guidelines state that the
assessment should be repeated
every 5 minutes for up to 20
minutes (3). However,
an Apgar score assigned
during a resuscitation is not
equivalent to a score assigned
to a spontaneously breathing
 MANAGEMENT OF DISCOMFORT DURING LABOR
AND DELIVERY

Gate Control Theory of Pain

• Pain is transmitted from periphery along ascending nerve pathways
to the brain
• Application of counter-pressure, cutaneous stimulation and application
heat/cold can ‘close the gate’ to limit nerve transmission

Non-pharmacological Methods of Pain Control

• Childbirth Preparation Methods (Lamaze Class, Bradley Method)
• Relaxation and Deep Breathing Techniques
• Effleurage- hands around belly
• Thermal Stimulation
• Mental Stimulation (Distraction, Focal Points, Imagery, Music)
• Support person (s)
 PAIN MANAGEMENT IN LABOR

IV Pain Medication Nitrous Oxide

•Parenteral Opioids •Self-administered during labor by
• Stadol tube or face mask
•Takes effect in 50 sec and the effect
• Nubain is transient
*Opioids can cross the placenta and
have effects on the fetus leading to
possible neonatal respiratory depression
at time of delivery
 SPINAL AND EPIDURAL ANESTHESIA

Definition: Injection of local anesthesia to

block specific nerve pathways
Regional Anesthesia
Nursing Care
 POSTDURAL PUNCTURE
(SPINAL) HEADACHE
• Leakage of
cerebrospinal fluid

• Intensified in upright
position

• Auditory and visual

problems

• Autologous epidural
blood patch
• Discharge instructions
 DISADVANTAGES
OF EPIDURAL
• Limited mobility
• Prolonged Second
Stage
• Accidental injection
into blood vessel
• Sympathetic
blockage
• Urinary retention,
bladder distention
 Chapter 12
Postpartum Physiological Assessments and
Nursing Care
 OBJECTIVES
The learner will be able to

• Define key terms

• Describe the physiological changes that occur during
the postpartum period
• Identify the critical elements of assessment and
nursing care during the postpartum period
• Describe the critical elements of discharge teaching
 Postpartum period
• 6 week period after delivery until body returns to normal
• Rapid physiological changes- most take place within the first 2
weeks
POSTPARTUM ASSESSMENT
 Reproductive System
Uterus

• Uterus
• Physiological changes
• Involution
• Afterpains
• Assessments
• Expected findings
• Nursing actions
• Boggy uterus: fundal massage more Pitocin
• Oxytocin
• Patient education
LOCATION OF FUNDUS

Reasons for
deviation from
normal

Charted as how many

fingerbreadths above
or below umbilicus
(example 1 below U)
 FUNDAL CHECK
FUNDAL MASSAGE
 REPRODUCTIVE SYSTEM
Endometrium

• Endometrium
• Physiological changes
Comparison of Heavy,
• Lochia Moderate, and Scant Lochia
• Assessments
on Pads
• Expectant findings
• Nursing actions
• Excessive bleeding
• Clots
• Bigger than golfball, come in
• Patient education
 PERINEAL CARE
• Swelling, bruising,
lacerations, episiotomy
repair
• Nursing care:
• Assess for
approximation,
swelling, discharge, &
infection
• Relief for pain: ice pack
in first 24 hours, then
heat, local analgesic
spray, witch hazel pads
(Tucks), sitz bath, peri-
bottle for voiding, pain
medications
 BREASTS

• Physiological changes
• Primary engorgement 3 days postpartum
• Subsequent engorgement
• Production of colostrum
• Milk production
 CARDIOVASCULAR SYSTEM
• Physiological changes
• Average blood loss of 200-
500 mL
• WBC’s increase (up to
25,000), return to
baseline by 7 days
• Risk for thrombosis due to
increase in circulation of
clotting factors (PE)
• Cardiac output
• Orthostatic hypotension:
due to decreased vascular
resistance in the pelvis
• Postpartum chills: related
to vascular instability
 RESPIRATORY SYSTEM

• Physiological changes
• Return of chest wall compliance
• Reduced pressure on the diaphragm
• Risk for Pulmonary Embolism
• Assessments
• Vital signs
• Lung sounds
• Pulse Oximetry
 IMMUNE SYSTEM

• Physiological changes
• Temperature
• Mild elevations are normal in the first 24 hours after
birth (and ~Day 3 postpartum when milk comes in)
• Rubella
• RhoGAM
 URINARY SYSTEM

• Physiological changes
• Diuresis
• Bladder distention
• Cystitis
• Assessments
• Expected findings
• Nursing actions
 ENDOCRINE SYSTEM
• Physiological changes
• Nonlactating women
• Prolactin levels decline in first 3 weeks
• Lactating women
• Prolactin levels increase in response to infant’s suckling
• Diaphoresis
• Night sweats due to decreasing estrogen levels
 MUSCULAR AND NERVOUS
SYSTEMS
• Physiological changes
• Diastasis recti abdominis
• Effects of epidural
• Early Ambulation
• Nursing actions
• Comfort measures
 GASTROINTESTINAL
SYSTEM
• Physiological changes
• Constipation
• Hemorrhoids
• Appetite
• Weight loss
 DISCHARGE TEACHING

• Signs and symptoms of possible complications

• Health promotion
• Nutrition and fluids
• Activity and exercise
• Rest and comfort
• Contraception
• Sexual activity
• Prescribed medications
 Chapter 13
Transition to Parenthood
 OBJECTIVES

The learner will be able to

• Define key terms
• Describe the process of “becoming a mother”
• Identify factors that influence women and men in their role
transitions to parents
• Discuss bonding and attachment
• Identify factors that affect the family dynamics
• Describe nursing actions that support the couple during
their transition to parenthood
 OVERVIEW

• Developmental process
• Factors that enhance or hamper transition to parenthood
• Previous life experiences
• Couple’s relationship
• Financial concerns
• Educational level
• Support systems
• Desire to be parents
• Age of parents
MOTHERHOOD
 FATHERHOOD
• Preparation for fatherhood
• Meaning of fatherhood
• Factors influencing transition to fatherhood
• Varies based on interpretation of role
• Cultural variations
 ADOLESCENT PARENTS
• Adolescent parents are taking on
the responsibilities of parenting at
the same time they are working
through the developmental tasks
of being a teenager.
• Few life experiences to help
prepare
• Majority of teen parents live with
family members the first year
• Adolescent fathers who are
involved in the pregnancy have a
higher involvement in child’s life
after delivery
• Body image changes for teen
moms
 BONDING AND ATTACHMENT

• Bonding
• Unidirectional—parent → baby
• Bonding behaviors
• Attachment
• Bidirectional—parent ↔ baby
• Attachment behaviors
• Risk factors for delayed bonding and/or attachment
• Nursing actions
MOTHER & DAUGHTER
EN FACE POSITION
FATHERS EXHIBITING SIGNS
OF ENGROSSMENT
 COMMUNICATION BETWEEN
PARENT AND CHILD
• Bidirectional process
• Forms of communication
• Newborn’s ability to communicate
• Entrainment
• Assessing parent-infant interactions
• Expected findings
• Nursing actions
 FAMILY DYNAMICS
• Family
compositions
• Effects of new
member on the
family unit
• Coparenting
• Multiparas
• Concerns of
multiparas
when taking
on a new
child
• Sibling rivalry
• Nursing actions
 Postpartum Blues
vs Postpartum Depression
 POSTPARTUM
PSYCHOSIS
• Onset within first 8 weeks after childbirth
• Distinguishing signs: hallucinations, agitation, confusion, suicidal/homicidal
thoughts, delusions, sleep disturbances, loss of touch with reality
• Requires hospitalization & treatment
SELF CARE
HAPPY LUNAR NEW YEAR