Module 4

INTRAPARTUM

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 Intra partum: Labor and delivery

Labor - an involuntary physiologic process whereby the

contents of the gravid uterus are expelled through
the birth canal into the external environment.

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 Theories of Why Labor Begins:

• Uterine Muscle Stretching

• Pressure on the cervix
• Oxytocin stimulation works together with
prostaglandins
• Changes in the ratio of estrogen to progesterone
• Placental age
• Rising fetal cortisol levels
• Fetal membrane production of prostaglandin

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 PREPARATION FOR LABOR:
BEGINNING SIGNS AND SYMPTOMS OF LABOR
Sign or Cause
Symptom
Lightening Sinking of the fetal head into the true pelvis
Slight loss of As progesterone level falls, more fluid is excreted, slightly
weight lowering body weight
Excess energy Burst of adrenaline to provide energy for labor
Backache Beginning but unrecognized uterine contractions
Ripening of the Prostaglandins soften the cervix to allow for shortening and
cervix dilatation
Rupture of Membranes have ruptured with release of amniotic fluid
membranes
Show Internal cervical mucus plug has been released
Uterine True beginning of labor
contractions
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 PREPARATION FOR LABOR:
PRELIMINARY SIGNS OF LABOR
Lightening or descent of the fetal presenting part
(usually the fetal head) into the pelvis
• Primiparas - occurs approximately 10 to 14 days
before labor begins.
• Multiparas - it is not as dramatic and usually
occurs on the day of labor or even after labor has
begun.
• As the fetus sinks lower into the pelvis, a woman
may experience:
- shooting leg pains from the increased pressure on
a sciatic nerve
- increased amounts of vaginal discharge
- urinary frequency from pressure on her bladder
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 PREPARATION FOR LABOR:
PRELIMINARY SIGNS OF LABOR
Slight Loss of Weight
• progesterone level falls, body fluid is more easily
excreted from the body, lead to a weight loss
between 1 and 3 lb
Increase in Energy
• boost in epinephrine release, initiated by a
decrease in progesterone production by the
placenta.
Backache
• an intermittent backache stronger than usual may
be the first symptom a woman notices

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 PREPARATION FOR LABOR:
PRELIMINARY SIGNS OF LABOR
Ripening of the Cervix
• internal sign seen only on pelvic examination.
• throughout pregnancy, the cervix feels softer than
usual to palpation, similar to the consistency of an
earlobe (Goodell’s sign).
• at term, the cervix becomes still softer (described
as “butter soft”), and it tips forward.
• Cervical ripening this way is an internal
announcement that labor is very close at hand.

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 PREPARATION FOR LABOR:

PRELIMINARY SIGNS OF LABOR

Rupture of the Membranes
• a sudden gush or as a scanty, slow seeping of clear
fluid from the vagina.
• early rupture of the membranes can actually be
advantageous as it can cause the fetal head to
settle snugly into the pelvis, aiding cervical
dilation and shortening labor.
• risks are associated with ruptured membranes:
▪ intrauterine infection
▪ prolapse of the umbilical cord
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 PREPARATION FOR LABOR:
PRELIMINARY SIGNS OF LABOR
Show
• as the cervix softens and ripens, the mucus plug
that filled the cervical canal during pregnancy is
expelled.
• the exposed cervical capillaries seep blood as a
result of pressure exerted by the fetus
• this blood, mixed with mucus, takes on a pink
tinge and is referred to as “show” or “bloody
show.”

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 PREPARATION FOR LABOR:
PRELIMINARY SIGNS OF LABOR
Uterine Contractions
• true labor contractions usually begin in the back
and sweep forward across the abdomen
• increase in frequency and intensity over a period
of hours
• involuntary and come without warning

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 Signs of True Labor
▪ Starts to be irregular then becomes regular and
predictable.
▪ Pain starts at the lower back and sweeps around
the abdomen
▪ Pain continues on ambulation and at any level of
activity
▪ Progressive duration, frequency and intensity
▪ Progressive cervical effacement and dilatation

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 Signs of False Labor
▪ Irregular and unpredictable
▪ Confine at the lower abdomen and groin
▪ Disappear with ambulation and sleep
▪ No progressive increase of duration, frequency,
and intensity of uterine contraction.
▪ No progress of cervical effacement and dilatation

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 THE COMPONENTS OF LABOR:
There are four integrated concepts that are involved in
the success of labor and delivery, often referred to as
the Components or 4 P’s of Labor:
1. Passage
2. Passenger
3. Power
4. Psyche

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 THE COMPONENTS OF LABOR:
PASSAGE
– refers to the route a fetus must travel from the
uterus through the cervix and vagina to the external
perineum

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 THE COMPONENTS OF LABOR:
TYPES OF PELVIS

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 THE COMPONENTS OF LABOR:
Anatomy of the Bony Pelvis:
Pelvis - serves to support and protect the
reproductive organs. A bony ring formed by four
united bones:
▪Two innominate bones
▪Coccyx
▪Sacrum

oEach Innominate bone is divided into three:

•Ilium
•Ischium
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•Pubis
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 THE COMPONENTS OF LABOR:

Anatomy of the Bony Pelvis:

Pubis
• Coccyx - is below the sacrum, composed of very
small bones, fuse together. Between the coccyx
and the sacrum is the joint called (sacrococcygeal
joint).
• Sacrum - forms the upper posterior portion of the
pelvic ring.
• Sacral Prominence - a joint connected with the
lower lumbar vertebrae which is the landmark to
identify when securing pelvic measurements

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 THE COMPONENTS OF LABOR:

Anatomy of the Bony Pelvis:

The Pelvis is Further Divided:
A. False pelvis - the superior half.
B. True pelvis - the inferior half.
•Inlet - it is where the fetus must first pass to
be born vaginally.
•Outlet - the inferior portion, bounded at the
back by the coccyx, on the sides by ischial
tuberosity, and in front by the inferior aspect
of the symphysis pubis.

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 Views of the pelvic inlet and outlet: (A) the pelvic inlet, (B) the pelvic outlet.
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 THE COMPONENTS OF LABOR:

Anatomy of the Bony Pelvis:

Cavity - is the space between the inlet and the outlet.
It is not straight but curve.
Physiologic reasons for the design:
• The curve slows and control the speed of birth.
• The snugness of the cavity compresses the chest
of the fetus, as the fetus passes through.

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 THE COMPONENTS OF LABOR:
Anatomy of the Bony Pelvis:
Linea Terminales - an imaginary line divides the true
and the false pelvis.

Diameter of the Inlet:

True Conjugate - 10.5- 11 cm.

Diameter of the Outlet:

Diagonal Conjugate - 12.5 cm

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 THE COMPONENTS OF LABOR:
Anatomy of the Bony Pelvis:

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 THE COMPONENTS OF LABOR:
PASSENGER - refers to the fetus
Structure of the fetal Skull:
•Cranium - the uppermost portion of the fetal
skull, is composed of 8 bones
•Four Superior bones:
•Frontal - two fused bone anteriorly.
•Two Parietal
•One Occipital
•Other Inferior Bones: Sphenoid, Ethmoid, two
temporal bones.
•Sinciput - the area over the frontal bone
•Occiput - the area over the occipital bone
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 THE COMPONENTS OF LABOR:
•Suture Lines - this is where the bones of the
skull meet.
•Sagittal suture - a membranous inter-space that
joins the parietal bones
•Coronal suture - the line of junction of the frontal
bone and the two parietal bones.
•Lambdoid suture - the line of junction of the
occipital bone and the two parietal bones.

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 THE COMPONENTS OF LABOR:
Fontanelles - the membranes that are found at
the junction of the main suture line.
•Anterior fontanelle - also called “Bregma”, lies
in the junction of the coronal and sagittal
sutures and in diamond shape. It measures
3-4 cm. (anterior-posterior), and 2-3 cm
(transverse) in diameter.
•Posterior fontanelle - lies at the junction of the
lambdoid and sagittal sutures. It measures 2
cm. across the widest part.

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 THE COMPONENTS OF LABOR:

The fetal skull: (A) the lateral view, (B) the vertex view.
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 THE COMPONENTS OF LABOR:
Advantages of the Fontanelles:
•compress during birth to aid in molding of the
fetal head
•helps to establish the position of the fetal head
and whether it is in a favorable position for birth.
Diameters of the Fetal Skull:
•Biparietal diameter / transverse diameter -
smallest diameter; 9.25 cm.
•Suboccipitobregmatic diameter - smallest
anteroposterior diameter; app. 9.5 cm
•Occipitofrontal diameter - approximately 12 cm.
•Occipitomental diameter - widest anteroposterior
diameter; approximately 13.5 cm
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 THE COMPONENTS OF LABOR:
Which anteroposterior diameter that presents to the
birth canal is determined not only by rotation but
also by the degree of flexion of the fetal head
•Complete Flexion - allows the smallest
anteroposterior diameter of the head to enter the
pelvis.
•Moderate flexion - causes a larger diameter to
enter.
•Poor flexion - forces the largest diameter against
the pelvic brim so the head is too large to enter
the pelvis.

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 (A) Complete flexion allows the smallest
anteroposterior diameter of the head to enter the
pelvis. (B) Moderate flexion causes a larger diameter
to enter. (C) Poor flexion forces the largest diameter
against the pelvic brim so the head is too large to
enter the pelvis.
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 THE COMPONENTS OF LABOR:
Molding
– is 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
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 THE COMPONENTS OF LABOR:
Fetal Presentation and Position
Fetal Attitude
– describes the degree of flexion a fetus assumes
during labor or the relation of the fetal parts to
each other

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 THE COMPONENTS OF LABOR:
The fetus in full flexion
presents the smallest
anteroposterior diameter
(suboccipitobregmatic) of
the skull to the inlet in
this good attitude

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 THE COMPONENTS OF LABOR:
The fetus is not as well
flexed (military attitude)
and presents the
occipitofrontal diameter
to the inlet (sinciput
presentation).

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 THE COMPONENTS OF LABOR:
The fetus in partial
extension (brow
presentation).

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 THE COMPONENTS OF LABOR:
The fetus in complete
extension presents a
wide (occipitomental)
diameter (face
presentation).

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 THE COMPONENTS OF LABOR:
Fetal Lie - the relationship of the long
(cephalocaudal) axis of the fetus to the long
(cephalocaudal) axis of the woman’s body.
▪ Horizontal / Transverse Position
▪ Longitudinal / Vertical Position
Classification:
▪ Cephalic - head is the presenting part (Vertex
or Occiput, Brow and Face or mentum)
▪ Breech - buttocks or feet are presented.
[Complete, Frank, Footling (single or double)]

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 THE COMPONENTS OF LABOR:
Fetal Presentation
- denotes the body part that will first contact the
cervix or be born first
- determined by the combination of fetal lie and the
degree of fetal flexion (attitude).
▪Cephalic Presentation
- the most frequent type of presentation, occurring
as often as 96% of the time
- fetal head is the body part that first contacts the
cervix
- Types: vertex, brow, face, and mentum
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 THE COMPONENTS OF LABOR:
TYPES OF CEPHALIC PRESENTATIONS

Type Lie Attitude Description

Vertex Longitudinal Good (full The head is sharply flexed, making the parietal
flexion) bones or the space between the fontanelles (the
vertex) the presenting part. This is the most
common presentation and allows the
suboccipitobregmatic diameter to present to the
cervix.
Brow Longitudinal Moderate Because the head is only moderately flexed, the
(military) brow or sinciput becomes the presenting part.
Face Longitudinal Poor The fetus has extended the head to make the face
the presenting part. From this position, extreme
edema and distortion of the face may occur.
Mentum Longitudinal Very poor The fetus has completely hyperextended the head
to present the chin, causing the presenting
diameter (the occipitomental) to be so wide that
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 THE COMPONENTS OF LABOR:
▪Breech Presentation
- the buttocks or the feet are the first body parts
that will contact the cervix
- occur in approximately 4% of births
- are affected by fetal attitude the same as vertex
presentations
- a good attitude brings the fetal knees up
against the fetal abdomen.
- a poor attitude means the knees and legs are
extended.
- types: complete, frank, and footling

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 THE COMPONENTS OF LABOR:
TYPES OF BREECH PRESENTATIONS

Type Lie Attitude Description

Complete Longitudinal Good (full The fetus has the thighs tightly flexed
flexion) on the abdomen; both the buttocks
and the tightly flexed feet present to
the cervix.

Frank Longitudinal Moderate Attitude is moderate because the hips

are flexed, but the knees are extended
to rest on the chest. The buttocks alone
present to the cervix.

Footling Longitudinal Poor Neither the thighs nor lower legs are
flexed. If one foot presents, it is a
single-footling breech; if both present,
it is a double-footling breech.
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 THE COMPONENTS OF LABOR:
TYPES OF BREECH PRESENTATIONS

COMPLETE FOOTLING
FRANK
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 THE COMPONENTS OF LABOR:
▪Shoulder Presentation
- “transverse”
- presenting part:
•one of the shoulders
(acromion process)
•an iliac crest
•a hand, or an elbow
- usual contour of the
mother’s abdomen at
term may appear fuller
side to side rather than
top to bottom.
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 THE COMPONENTS OF LABOR:
▪Shoulder Presentation
- causes:
- pelvic contractions
- placenta previa
- relaxed abdominal
walls from grand
multiparity, which
allow the unsupported
uterus to fall forward
- type of delivery: CS

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 THE COMPONENTS OF LABOR:
Fetal Positions - the relationship of the presenting part
to the specific quadrant and side of a woman’s pelvis.
L - left; R - right
A - Anterior; P - posterior
Landmarks:
O - Occiput (Vertex) - LOA, ROA, LOP, ROP
M - Mentum (Face) - LMA, LMP, RMA, RMP
Sa - Sacrum (Breech Presentation)
A - Scapula (acromion process) - (Shoulder)

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 THE COMPONENTS OF LABOR:
Fetal Positions
Examples:
If the occiput of a fetus points to the left anterior
quadrant in a vertex position
left occipitoanterior (LOA) position
If the occiput points to the right posterior quadrant
right occipitoposterior (ROP)

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 Vertex Presentation Shoulder Presentation Shoulder Presentation
(Occiput) (Acromion Process) (Acromion Process)

LOA, left occipitoanterior LSaA, left sacroanterior LAA, left scapuloanterior

LOP, left occipitoposterior LSaP, left sacroposterior LAP, left scapuloposterior

LOT, left LSaT, left sacrotransverse RAA, right scapuloanterior

occipitotransverse

ROA, right RSaA, right sacroanterior RAP, right

occipitoanterior scapuloposterior

ROP, right RSaP, right sacroposterior

occipitoposterior

ROT, right RSaT, right

occipitotransverse sacrotransverse
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 THE COMPONENTS OF LABOR:
Station
- the relationship of the presenting part of the fetus
to the level of the ischial spines.
▪ Station 0 - the presenting part is at the level of
the ischial spine.
▪ above the ischial spine - stated as (-) stations
▪ below the ischial spine - stated as (+) stations
▪ at a +3 or +4 station, the presenting part is at the
perineum and can be seen if the vulva is
separated (crowning).

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 THE COMPONENTS OF LABOR:
Station

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 THE COMPONENTS OF LABOR:
Station

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 THE COMPONENTS OF LABOR:
Mechanisms (Cardinal Movements) of Labor
• Engagement
• Descent
• Flexion
• Internal Rotation
• Extension
• External Rotation
• Expulsion

Every Day Fine Infants Enter Eager & Excited

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 THE COMPONENTS OF LABOR:
Engagement
- refers to the settling of the presenting part of a fetus far
enough into the pelvis that it rests at the level of the ischial
spines, the midpoint of the pelvis.
- In a primipara, nonengagement of the head at the
beginning of labor suggests that a possible complication
such as an abnormal presentation or position, abnormality
of the fetal head, or cephalopelvic disproportion exists.
- In multiparas, engagement may or may not be present at
the beginning of labor.
• A presenting part that is not engaged is said to be
“floating.”
• One that is descending but has not yet reached the ischial
spines may be referred to as “dipping.”
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Descent
- is the downward movement of the biparietal diameter of the fetal head within the
pelvic inlet.
- full descent occurs when the fetal head protrudes beyond the dilated cervix and
touches the posterior vaginal floor
Flexion
- the head bends forward onto the chest, causing the smallest anteroposterior
diameter (the suboccipitobregmatic diameter) to present to the birth canal.
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Internal Rotation
- During descent, the biparietal diameter of the fetal skull is aligned to fit through
the anteroposterior diameter of the mother’s pelvis.
- As the head flexes at the end of descent, the occiput rotates so the head is brought
into the best relationship to the outlet of the pelvis, or the anteroposterior
diameter is now in the anteroposterior plane of the pelvis.
- This movement brings the shoulders, coming next, into the optimal position to
enter the inlet, or puts the widest diameter of the shoulders (a transverse one) in
line with the wide transverse diameter of the inlet.
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Extension
- as the occiput of the fetal head is born, the back of the neck stops beneath the
pubic arch and acts as a pivot for the rest of the head.
- the head extends, and the foremost parts of the head, the face and chin, are born.
External Rotation
- in external rotation, almost immediately after the head of the infant is born, the
head rotates a final time (from the anteroposterior position it assumed to enter the
outlet)
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Expulsion
- once the shoulders are born, the rest of the baby is
born easily and smoothly because of its smaller size.
- this movement, called expulsion, is the end of the
pelvic division of labor.
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 THE COMPONENTS OF LABOR:

https://www.youtube.com/watch?v=duPxBXN4qMg
https://youtu.be/dYu-0rOnLpA
https://youtu.be/7lwgnWYzGWY
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 THE COMPONENTS OF LABOR:
POWER
- it is accomplish by the fundus of the uterus by
contraction.
- it is considered as the primary power of labor and
is supplemented by the use of abdominal muscles
after full dilatation.
Origin of Uterine Contraction:
- begin at a pacemaker located at the myometrium
- sweeps down over the uterus as a wave
- after a short rest period, another contraction is
initiated and the downward sweep begins again.
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 THE COMPONENTS OF LABOR:

65

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 DIFFERENTIATING BETWEEN TRUE AND FALSE LABOR CONTRACTIONS

False Contractions True Contractions

Begin and remain irregular Begin irregularly but become
regular and predictable
Felt first abdominally and Felt first in lower back and
remain confined to the sweep around to the abdomen
abdomen and groin in a wave
Often disappear with Continue no matter what the
ambulation or sleep woman’s level of activity
Do not increase in duration, Increase in duration, frequency,
frequency, or intensity and intensity
Do not achieve cervical Achieve cervical dilatation
dilatation
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 THE COMPONENTS OF LABOR:
Phases of Contraction:
▪Increment
▪Acme
▪Decrement
Contour Changes: as labor contractions progress and
become regular and strong, the uterus gradually
differentiates itself into two distinct functioning areas:
▪upper segment becomes thicker and active as labor
progresses preparing to expel the fetus.
▪lower segment becomes thin-walled, supple and
passive so the fetus can be pushed out of the uterus
easily
▪the contour of the uterus changes from round, ovoid
structure to an elongated one
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 THE COMPONENTS OF LABOR:
Cervical Changes
Effacement - shortening and thinning of the cervical
canal
Dilatation - enlargement or widening of the cervical
canal

▪Primiparas - effacement is accomplished before

dilatation begins
▪Multiparas - dilatation may proceed before
effacement is complete

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 THE COMPONENTS OF LABOR:

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 THE COMPONENTS OF LABOR:
PSYCHE
- or a woman’s psychological outlook
- refers to the psychological state or feelings a
woman brings into labor.
- feeling of apprehension or fright, sense of
excitement or awe

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 The Stages of Labor
FIRST STAGE / STAGE OF DILATATION - begins with the
initiation of true labor contractions and ends when
the cervix is fully dilated
▪Latent Phase - or early phase begins at the onset
of regularly perceived uterine contractions and
ends when rapid cervical dilatation begins.
▪Active Phase - contractions grow stronger, lasting
40 to 60 seconds, and occur approximately every
3 to 5 minutes.
▪Transition Phase - contractions reach their peak of
intensity, occurring every 2 to 3 minutes with a
duration of 60 to 70 seconds

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 The Stages of Labor

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 The Stages of Labor
SECOND STAGE / STAGE OF FETAL EXPULSION - time
span from full dilatation and cervical effacement to
birth of the infant
Crowning - the fetal head pushes against the vaginal
introitus, this opens and the fetal scalp appears at
the opening to the vagina and enlarges from the size
of a dime, to a quarter, then a half-dollar.

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 The Stages of Labor
THIRD STAGE / PLACENTAL STAGE - begins with the birth
of the infant and ends with the delivery of the placenta.
Two Phases:
▪Placental Separation
• Signs of Placental Separation:
- There is lengthening of the umbilical cord.
- A sudden gush of vaginal blood occurs.
- The placenta is visible at the vaginal opening.
- The uterus contracts and feels firm again.
• Types of presentation:
- Schultze - shiny and glistening from the fetal membranes
- Duncan - raw, red, and irregular, with the ridges or
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cotyledons that separate blood collection spaces evident
 The Stages of Labor

Shiny
Schultze
Schultze

Dirty
Duncan
Duncan
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 The Stages of Labor
▪Placental Expulsion
•Measures:
• by the natural bearing-down effort of the mother
• by gentle pressure on the contracted uterine fundus
by the primary healthcare provider.
(Credé maneuver)

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 Duration of Labor
Primipara - average is 14 hours
▪First stage - 12 hours and 30 min.
▪Second stage - 1 hour and 20 min.
▪Third stage - 10 min.
Multipara - average is 8 hours
▪First Stage - 7 hours and 20 min.
▪Second Stage - 30 min.
▪Third Stage - 10 min.
Clinical Findings Before Labor/ Preliminary Signs:
- Lightening
- Braxton Hicks Contraction
- Softening of the cervix (Ripening)
- Increase in the level of activity
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 MATERNAL DANGER SIGNS OF LABOR
▪ High or Low Blood Pressure
▪ Abnormal Pulse - ↑ 100bpm (hemorrhage)
▪ Inadequate or Prolonged Contractions
▪ Abnormal Lower Abdominal Contour
▪ Increasing Apprehension - can be a sign of oxygen
deprivation or internal hemorrhage

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 FETAL DANGER SIGNS OF LABOR
▪ High or Low Fetal Heart Rate - possible fetal
distress
▪ >160 beats/min (fetal tachycardia)
▪ <110 beats/min (fetal bradycardia)
▪ Meconium Staining
▪ Hyperactivity
▪ Low Oxygen Saturation - 40% to 70%.

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 General Nursing Care During the Intrapartal Period

A. Assessment (on admission)

B. EINC Recommended Protocol
C. Planning and Implementation
▪ First Stage
▪ Second Stage
▪ Third Stage
▪ Fourth Stage

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 Essential Intrapartum Care
Recommended Practices During Labor:
1. Admission to labor when the parturient is already
in the active phase
2. Continuous maternal support specifically with
labor companions
3. Mobility and upright position during first stage of
labor.
4. Allow food and drink
5. Routine use of Partograph
6. Limit total number of IE to five or less.

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 Interventions that are not Recommended During Labor

1. Perineal shaving
2. Enema during first stage of labor
3. Vaginal douching
4. Amniotomy
5. Oxytocin Augmentation
6. Intravenous Fluids
7. Routine NPO

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 Practices Recommended During Delivery
1. Upright position during delivery
2. Selective (Non- routine episiotomy)
3. Use prophylactic oxytocin for the 3rd stage of
labor (palpate first the lower abdomen)
4. Delayed cord clamping (1 to 3 min after birth)
5. Controlled cord traction with counter traction to
deliver the placenta
6. Uterine massage after placental delivery

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 Active management of Third Stage of labor (AMSTL)
1. Administration of uterotonic within 1 min. after
the delivery of the baby.
2. Controlled traction with countertraction on the
uterus.
3. Uterine massage

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 Practices not recommended during delivery
1. Coaching the mother to push

2. Perineal massage in the second stage

3. Fundal pressure during the second stage

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 Maternal & Fetal Assessment During Labor
THE IMMEDIATE ASSESSMENT OF A WOMAN IN
FIRST STAGE OF LABOR
▪The Initial Interview and Physical Examination
▪Leopold’s Maneuver
▪Vaginal Examination
▪Sonography
▪Assessing Rupture of Membranes
▪Assessment of Pelvic Adequacy
▪Vital Signs – q4h, q30-60 min, q2h
▪Laboratory Analysis
▪The Assessment of Uterine Contractions
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 Maternal & Fetal Assessment During Labor
THE INITIAL FETAL ASSESSMENT
▪Auscultation of Fetal Heart Sounds

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 Maternal & Fetal Assessment During labor

(A) Left occipitoanterior

(LOA),
(B) right occipitoanterior
(ROA),
(C) left occipitoposterior
(LOP),
(D) right occipitoposterior,
(E) (E) left sacroanterior
(LSaA).
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 Measuring Progress in Labor
•recorded in a labor record (a Partogram) devised by
the World Health Organization, or a like form
•records the: vital signs, FHR, cervical dilation,
descent of the fetal head, urine tests, and any drugs
administered
•after each cervical examination, cervical dilatation
and fetal descent (which may be referred to as
“molding”) are plotted on the graph.
•“alert” line - marks when 4 hours has passed.
•four hours beyond that, an “action” line advises a
primary care provider that cervical dilation is taking
longer than usual and that an intervention may be
necessary to make the labor safe and effective.
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 THE MATERNAL PHYSIOLOGIC EFFECTS AND PSYCHOLOGICAL RESPONSES

▪ The Response to Pain

▪ The Response to Fatigue
▪ The Response to Fear

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 FETAL RESPONSES TO LABOR
▪ Neurologic System - ↑ ICP
▪ Cardiovascular System - the amount of nutrients,
including oxygen, exchanged during this time is
greatly reduced
▪ Integumentary System - minimal petechiae or
ecchymotic areas; edema of the presenting part
(caput succedaneum)
▪ Musculoskeletal System - full flexion with the head
bent forward (most advantageous position for
birth).
▪ Respiratory System - aid in the maturation of
surfactant production by alveoli in the fetal lung.
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 The Care of a Woman During the First Stage of Labor
Six major concepts that make labor and birth as natural
as possible include the following:
• Labor should begin on its own, not be artificially
induced.
• Women should be able to move about freely
throughout labor, not be confined to bed.
• Women should receive continuous support from a
caring support person during labor.
• No interventions such as intravenous fluid should be
used routinely.
• Women should be allowed to assume a nonsupine
position such as upright and side lying for birth.
• Mother and baby should be housed together after the
birth, with unlimited opportunity for breastfeeding
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 The Care of a Woman During the First Stage of Labor

▪ Help Empower Women

▪ Promote Change of
Positions
▪ Respect Contraction
Time
▪ Help With Fetal
Alignment
▪ Promote Voiding and
Provide Bladder Care.

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 The Care of a Woman During the Second Stage of Labor

▪Preparing the place of birth

▪Positioning for birth
▪Lithotomy vs Sim’s / Dorsal Recumbent
▪The Water Birth
▪ increased buoyancy they feel from the water helps them
change positions easily; a sitting posture helps with fetal
descent
▪Promoting Effective Second-Stage Pushing
▪Pushing is usually best done from a semi-Fowler’s
position with legs raised against the abdomen,
squatting, or on all fours rather than lying flat to allow
gravity to aid the effort
▪Make sure the woman pushes with contractions and
rests between them.
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 The Care of a Woman During the Second Stage of Labor

▪Perineal Cleaning and Massage

▪to keep it supple and prevent tearing
▪to remove vaginal or rectal secretions and prepare the
cleanest environment for the birth of the baby
▪The Birth
▪Ritgen Maneuver
▪Cutting and Clamping the Cord
▪Introducing the Infant

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 The Care of a Woman During the Third and Fourth Stages of Labor

▪The delivery of the Placenta

▪Up to 30 minutes
▪Oxytocin IM or IV - uterine contraction
▪Methergine - ↑ uterine contaction / guard against
hemorrhage
▪The Perineal Inspection
▪Check for perineal tears
▪The Immediate Postpartum Assessment and Nursing
Care
▪Clean the perineum, check for bleeding
▪Monitor VS q 15 mins for the 1st hour
▪Warm the mother (chills, excess epi production during
labor, associate with fever - infection)
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