NCM 107: Care of Well Clients Algen Morada Gayap ⎸1

INTRAPARTUM
PROCESS OF LABOR AND DELIVERY

LABOR
● series of events by which uterine contractions and abdominal pressure expels the fetus, placenta and membranes out of
the uterus and through the birth canal
DILATION
● enlargement of the cervical os from orifice a few millimeters in size to an aperture to large enough to permit the passage of
fetus
EFFACEMENT
● progressive thinning and shortening of cervix
- cervical dilation and effacement: during
labor, the multigravida’s cervix remains
thicker than the nulliparous

SHOW
● a mucoid discharge from the cervix that is present after mucous plug/cervical plug (operculum) has been discharged.
- when membranes ruptured, the show and amniotic fluid will be discharged.

THEORIES OF LABOR ONSET

PROGESTERONE WITHDRAWAL THEORY

● Decrease in progesterone facilitates prostaglandin synthesis —--> increases uterine contractility
- Labor occurs because of the response of the mother’s body from the decreasing levels of progesterone.
- Level of progesterone decreases as the pregnancy near its term
- Progesterone → hormone of pregnancy and it maintain pregnancy (no progesterone=no pregnancy)
OXYTOCIN STIMULATION THEORY
● Oxytocin increases the permeability of sodium in the myometrium —-> raises the intercellular calcium that is needed
for muscle contraction
FETAL ADRENAL RESPONSE THEORY
● Certain hormones produced by the adrenal glands (cortisol) —-> initiate labor contractions
UTERINE STRETCH THEORY
● Any hollow organ distended to any extreme extent will attempt to empty itself.
- by means of contracting
PROSTAGLANDIN THEORY
● When pregnancy reaches term, membranes produces arachidonic acid then converted by decidua to prostaglandin
- Prostaglandin: soften the cervix and cause muscle contraction in the uterus
THEORY OF AGING PLACENTA
● As the placenta “ages”, it becomes less efficient
- As placenta aging, it can not produce enough progesterone to maintain the pregnancy that results to
withdrawal

COMMON SIGNS OF LABOR

A. PRELIMINARY/PRODROMAL SIGNS
● not true signs but this may give a clue if mother has an active labor
● Labor may still occur without these preliminary/prodromal signs

1. lightening
● “fetal descent” occurs 10-14 days before onset of labor
2. increase in level of activity
3. Braxton-Hicks contractions
● contraction of the uterus all throughout the pregnancy
● tightening in your abdomen that come and goes
4. slight weight loss
● caused by loss of water in mother’s body
5. ripening of the cervix
● “butter-soft” cervix can be examined through IE (Internal Examination)
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● pre-pregnant: nose, pregnant: earlobe, labor:buttersoft —-->(These as what it feels like inside the cervix)

SIGNS OF TRUE LABOR

a. uterine contractions
b. bloody show
c. rupture of membranes

Criteria False Labor True Labor

Contraction - Irregular - Irregular to regular
- Often disappear with ambulation and sleep - Continuous even use of comfort measures
- Do not increase in duration, intensity or frequency - Progression in duration, frequency and intensity
Pain/Discomfort - Felt in abdomen and groin - Begins at the lower back and sweeps around to
lower abdomen
- Relieved by ambulation - Not relieved by ambulation
Cervical dilation - No significant changes - Progressive effacement and dilation

COMPONENTS OF LABOR
(Factors Affecting Labor and Delivery)

5P’s of LABOR : Passageway - Passenger - Powers - Psyche -Positions

I. PASSAGEWAY
● route a fetus must travel from the uterus to the cervix and vagina to the external perineum
● bony pelvis

Ischial spine: form a horizontal pelvic "floor” and support the abdominopelvic organs and resist intra-abdominal pressure that is
exerted from above, and second, as levator ani, to control the anal sphincter.
Sacral promontory: a bulge serves as a landmark to help determine the size of the pelvic cavity
Pelvis: structure of pelvis may used to determine a corpse whether its male or female

TYPE OF PELVIS
a. Gynecoid – wide and round
b. Anthropoid – narrow and deep ( upright oblong/oval)
c. Android – heart-shaped (pelvis shape of male)
d. Platypelloid – flat (transverse oblong/oval)

FEMALE PELVIS SHAPES: GAAP

Gynecoid 50% - Anthropoid 25% - Android 20% - Platypelloid 5%

DIVISION OF PELVIS OF A MOTHER

a. False pelvis – above the pelvic brim and plays no part in childbearing; supports the internal organs and the upper part of
the body
b. True Pelvis – found below the pelvic brim

THREE PARTS OF TRUE PELVIS

a. inlet (11.5cm - 13.5cm)
● located between the true pelvis below and the false pelvis above
● INLET MEASUREMENTS
- Diagonal conjugate (11.5 cm) from the sacral promontory to higher part of pubis
- Transverse conjugate (13.5 cm) from the sacral promontory to lower part of pubis
b. pelvic canal (10.5cm)
● located between the pelvic inlet and pelvic outlet
● Narrowest diameter where fetus bypass – because of ischial spine
c. outlet (9.5cm - 11.5 cm)
● located in the lower margin of true pelvis
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Station
● describes the position of the presenting part of fetus in relation to the level of the ischial spine
- Baby’s head is above the ischial spine measure as negative
- Baby’s head is even or below the ischial spine measure as positive

PRESENTING PART is AT THE LEVEL OF ISCHIAL SPINE 0 STATION (ENGAGED)

PRESENTING PART is ABOVE ISCHIAL SPINE -1 to -4 STATIONS (NEGATIVE)

PRESENTING PART is BELOW ISCHIAL SPINE +1 to +4 STATIONS (POSITIVE)

PRESENTING PART is CROWNING +3 or +4 STATIONS(CROWNED)

II. PASSENGER

A. FETAL HEAD
● Fontanels/Fontanelles (membrane-filled spaces)
i. Anterior fontanel
- diamond-shaped
- junction of coronal and sagittal sutures
- 3x2 to 4x3 cm
- closes at 13-18 months of age
ii. Posterior fontanel
- triangular-shaped
- lies between the lambdoidal and sagittal sutures
- 1x2 cm
- closes at 2-3 months of age
iii. Sphenoid fontanel
- closes at 6 months of age
iv. Mastoid fontanel
- close 6-18 months of age

● Sinciput
- area over the frontal bone/brow
● Vertex
- area between the two fontanelles (anterior and posterior)
● Occiput
- area over the occipital bone
● Mentum
- chin
● Suture Lines
- allow cranial bones to move and overlap, to
diminish the size of the skull to pass through
the birth canal
- MOLDING: overlapping of the bones which
permits adaptation to the various diameters of
the maternal pelvis
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B. FETAL LIE
● relationship of the long axis of the fetus to the long axis of the mother

i. Longitudinal lie
- 99%
- long axis of the fetus is parallel to the long axis of the mother
- fetal head or buttocks enters pelvis first
ii. Transverse lie
- -1%
- long axis of the fetus is at right angle to maternal long axis

C. FETAL ATTITUDE
● degree of flexion a fetus assumes during labor or the relation
of the fetal parts to each other

i. Complete flexion
ii. Moderate flexion
iii. Partial extension (Poor extension)
iv. Complete extension

D. FETAL PRESENTATION
● fetal part that enters the pelvis first
● determined by combination of fetal lie and attitude

i. Cephalic presentation
- 95%
- fetal head is the part that will first contact the cervix
- vertex, brow, face, mentum
ii. Breech presentation
- 3%
- either the feet or buttocks will first contact the cervix
iii. Shoulder presentation
- 0.2%
- fetus is in transverse lie
- presenting part is either a shoulder, an iliac crest, a hand or
an elbow
- High risk: preterm birth, high parity (mortality),
PROM (premature rupture of membranes),
hydramnios: too much amniotic fluid builds up during pregnancy,
placenta previa: placenta completely or partially covers the opening of the uterus

E. FETAL POSITION
● describes the relationship of the presenting part to a specific quadrant of the maternal pelvis

Fetal position expressed in three-letter abbreviation describing the:

* Maternal side — which side of mother does baby facing
R: right
L: left

* Presenting part — O: occiput

M: mentum
Sa: sacrum
A: acromion

* maternal abdominal quadrant — A: anterior

P: posterior
T: transverse
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MECHANISM OF LABOR
(Cardinal Movements)

DEF Ir ExErEx
Descent -Engagement -Flexion
Internal rotation
Extension-External rotation-Expulsion

DESCENT: downward movement of the biparietal diameter

of the fetal head within the pelvic inlet

ENGAGEMENT: settling of the fetal head into the true

pelvis

FLEXION: settling of the presenting part of the fetus far

enough into the pelvis to be at the level of the
ischial spine; Station 0

INTERNAL ROTATION: flexion of the head as it meets

resistance from the soft tissues
of the pelvis; head bends forward
to present the smallest anteroposterior diameter to the birth canal

EXTENSION: occurs as a result of negotiations of the fetal head to the curve of the pelvis

EXTERNAL ROTATION: rotation of the head, immediately after it is born, back to the diagonal or transverse position; brings the
shoulder into an anteroposterior position;

EXPULSION: complete birth of the body

III. POWERS (Powers of Labor)

1.Uterine Contractions (Primarypowers)

2.Bearing-down Efforts (Secondarypowers)

UTERINE CONTRACTIONS
a. Frequency: time from beginning of one contraction to the beginning of the next.
b. Regularity: refers to the discernible pattern of contractions.
c. Intensity: refers to the strength of contractions. Maybe determined by the “depressability”of the uterus during a contraction.
- Mild contractions: slightly tense fundus,is easy to indent with fingertips.
- Moderate Contractions: firm fundus that is difficult to indent with fingertips.
- Strong contractions: rigid board-like fundus that is almost impossible to indent with fingertips.
d. Duration: refers to the length of contraction

IV. PSYCHE
● Psychological state or feelings that a woman brings into labor

POSITION OF THE MOTHER

• Upright position •“All fours” position • Lateral recumbent position • Semirecumbent position • Sitting upright • Sitting, leaning
forward with support • Semi-sitting, tailor sitting and squatting position • Side lying position • Kneeling and leaning forward with
support position • Kneeling position • Lithotomy position
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3 STAGES OF LABOR & DELIVERY

A. FIRST STAGE “DILATING STAGE”
● From the onset of labor until the full dilation of the cervix
- last 12-13 hours in primipara and 8 hours for multipara. Nullipara:1.2cm/hr and Multipara:1.5 cm/hr
- Longest stage

Three phases: Nursing Interventions

Latent phase 0-3 cm a. Administer perineal prep/enema if ordered.

b. Assess vital signs, FHR, contractions, bloody show, cervical changes, and descent of fetus.
c. Maintain bed rest if indicated.
d. Reinforce/teach breathing techniques
e. Support laboring woman and couple
f. Have client attempt to void every 1-2 hours.
g. Apply external fetal monitoring if indicated or ordered.

Active phase 4-7 cm a. Continue to observe labor progress

b. Reinforce or teach breathing techniques as needed
c. Position client to maximum comfort
d. Support client/couple
e. Administer analgesia if ordered or indicated
f. If analgesia is give, monitor fetal and maternal vital signs
g. Provide ice chips or clear fluid
h. Keep the client/couple informed as the labor progresses.
- With posterior position, apply sacral counter pressure

Transition phase 8-10 cm a. Continue observation of labor progress and maternal/fetal vital signs
b. Give mother positive support
c. Accept behavioral changes of mother
d. Promote appropriate breathing patterns
e. If hyperventilation is present have mother re-breathe expelled CO2
f. Discourages pushing efforts until cervix is completely dilated
g. Observe signs of delivery.

B. SECOND STAGE “DELIVERY/EXPULSIVE STAGE”

● full dilation of cervix to birth of baby
- Last for an hour for primipara and 20 minutes for multiparas
- May observe: perspiration, the blood vessels in neck may become distended, signs of imminent delivery, mother feels
as if to move her bowel, intense and unstoppable need to push, increased bloody show, bulging perineum crowning

Nursing Interventions:
a. Carefully position mother on DR table or birthing chair
b. Help mother use handles or legs to pull as she bears down
c. Clean vulva and perineum for delivery
d. Continue observation of maternal/fetal vital signs
e. Encourage mother in sustained pushes
f. Support father’s participation if in delivery area
g. Catheterize mother’s bladder if indicated
h. Keep mother informed with the delivery progress
i. Remove secretions of baby’s mouth first and then nose
- first breathe should be through mouth for the newborn
j. Keep the baby warm
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Ritgen Maneuver - applying pressure in the perineum area to prevent laceration towards the anus.

Episiotomy - surgical incision of the perineum as the fetal head crowns.

Rationale for Episiotomy:

a. Reduces perineal trauma
b. Clean cut is easier to repair and heals better
c. Baby’s head is not subjected to lengthy pushing and subsequent pressure
d. Stretching of perineal muscles is minimized
Interventions:
a. Apply ice pack to the perineal area for the first 12 hours
b. Apply warm sitz bath after 12 hours
c. Observe signs of infection or hematoma
d. Instruct client about perineal hygiene

C. THIRD STAGE “PLACENTAL STAGE”

● Begins from expulsion of the baby to placental expulsion
- Duration: 5-10 minutes

SIGNS OF PLACENTAL SEPARATION

1. LENGTHENING OF UMBILICAL CORD
2. SUDDEN GUSH OF BLOOD
3. CHANGE IN SHAPE OF UTERUS
4. APPEARANCE OF PLACENTA AT VAGINAL OPENING

*duncan mechanism
*schultz mechanism
*NORMAL BLOOD LOSS IS 300-500 ML

Nursing Interventions:

a. Check completeness of placental membranes e. Observe lochia for color and amount
b. Determines APGAR SCORE f. Inspect perineum
- highest possible score is 10 g. Assist with maternal hygiene as needed
- the highest score usually is 9 because of the h. Offer fluids as indicated
presence of acrocyanosis caused by inefficient i. Promote beginning relationship with baby and parents
supply of oxygen needed by the newborn. through touch and privacy
Lungs are adjusting but after 5 minutes regular j. Administer medications as ordered
breathing will establish.
c. Palpate fundus immediately after delivery of placenta
d. Palpate fundus at least every 15 minutes for 1-2 hours

D. FOURTH STAGE “RECOVERY/REHABILITATION STAGE”

● From the expulsion of placenta until immediately after recovery
- Usually 1-4 hours

Nursing Interventions:
a. Palpate fundus every 15 minutes for the first 1-2 hours, massage gently if not firm
b. Check mother’s vital signs every 15 minutes
c. Inspect perineum if swollen
d. Encourage mother to void
e. Encourage early bonding through breastfeeding
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0 1 2
Appearance blue, bluish gray, body pink pink all over
color pale all over but extremities blue

Pulse absent < 100 bpm > 100 bpm

heart rate
Grimace absent facial movements/grimace cough or sneeze, cry and
by stimulation with stimulation withdrawal of foot with
stimulation
Activity limp or floppy Limbs flexed active
muscle tone
Respiration absent Irregular, weak cry good strong cry
breathing

The Apgar scores are recorded at one and five minutes. This is because if a baby’s scores are low at one minute, a
medical staff will likely intervene, or increased interventions already started. At five minutes, the baby has ideally
improved. If the score is very low after five minutes, the medical staff may reassess the score after 10 minutes. Doctors
expect that some babies may have lower Apgar scores. These include:
- premature babies
- babies born via cesarean delivery
- babies who had complicated deliveries

A score of 7 to 10 after five minutes is “reassuring.”

A score of 4 to 6 is “moderately abnormal.”
A score of 0 to 3 is concerning
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COMMON DISCOMFORTS OF THE WOMAN DURING LABOR AND DELIVERY

• Fatigue • Pain • Loose bowel movement • Diaphoresis

DANGER SIGNS DURING LABOR & DELIVERY

FETAL DANGER SIGNS MATERNAL DANGER SIGNS

•high or low FHR (normal:120-160 bpm) •Rising or falling BP

•meconium staining - 140/90 mmHg or ↑ in SBP of 30 mmHg and DBP of
•hyperactivity 15 mmHg may indicate Pregnancy Induced
Hypertension
FACTORS RELATED TO REDUCTION OF PLACENTAL BLOOD - Falling BP could be a sign of intrauterine
FLOW: hemorrhage
• Contraction frequency of < 2 minutes •Abnormal pulse
• Contraction interval of < 60 seconds • Inadequate or prolonged contraction
• Contraction duration of > 90 seconds • Inadequate contraction
• Uterine exhaustion (inertia) – Criteria for CS if not
corrected
• Prolonged contraction
- Contractions >90 seconds

INCREASING APPREHENSION: Could be a sign of oxygen deprivation or internal hemorrhage. Could you tell
me what is worrying you?”
FETAL MONITORING: Fetal status must be monitored during labor. The main parameters are fetal heart rate (HR)
and fetal HR variability.
VARIABILITY: Beat to beat changes in FHR. Indicates normal neurologic function in relation to heart rate and fetal
reserve.

PATTERNS OF FHR CHANGES

ACCELERATION: INCREASES EARLY DECELERATION: LATE DECELERATION: DUE VARIABLE DECELERATION:

IN FHR GRADUAL DECREASE IN FHR TO UTEROPLACENTAL USUALLY DUE TO CORD
THAT BEGINS EARLY IN INSUFFICIENCY COMPRESSION FROM
TERM: > 15 BPM AND LASTS CONTRACTION AND ONSET MATERNAL POSITION,
> 15 SECONDS FROM PEAKS IN < 30 SECONDS. ONSET OF DECREASING FHR PROLAPSED CORD, CORD
ONSET TO RETURN IS LATE IN THE LOOPS
TO BASELINE RETURNS TO BASELINE BY CONTRACTION
THE END OF THE DECREASE IN FHR BELOW
PROLONGED CONTRACTION RETURNS TO BASELINE AFTER BASELINE IS >15 BPM,
ACCELERATIONS: LAST AT THE END OF CONTRACTION LASTING >60 SECONDS AND
LEAST 2 MINUTES BUT < 10 TREATMENT: NONE; BENIGN < 2 MINUTES
MINUTES PATTERN TREATMENT: AIMED AT
INCREASING USUALLY ABRUPT
TREATMENT: NONE; UTEROPLACENTAL
REASSURING PERFUSION TREATMENT: MATERNAL
PATTERN POSITIONING, CHECK FOR
• CHANGE MATERNAL PROLAPSED CORD,
POSITION OXYGENATE
• CORRECT HYPOTENSION
• DISCONTINUE OXYTOCIN
• ADMINISTER OXYGEN
• CONSIDER TOCOLYTICS
• PROVIDE SUPPORT AND
DECREASE ANXIETY
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IT IS BETTER TO BE EARLY, THAN TO BE LATE!

GENERAL CARE OF CLIENTS EXPERIENCING LABOR & DELIVERY PROCESS

WHEN TO GOTO THE HOSPITAL OR BIRTH CENTER

● Contractions: nullipara—5 minutes apart for 1 hour, multipara—10 minutes apart for 1 hour
● Rupture of membrane
● Bleeding
● Maternal and fetal danger signs

NURSING RESPONSIBILITIES
● Therapeutic Relationship
● Assessment of maternal and fetal condition
● Explain the procedure of normal birth (or CS)
● Secure consent

PROVIDE COMFORT MEASURES

● Soft, indirect lighting
● Cool, damp washcloths over the woman’s forehead
● Enough ventilation
● Personal and bedding hygiene
● Mouth care

PROVIDE COMFORT MEASURES

● Ice chips or frozen juice bars,and hard candy on sticks to reduce dry mouth
● Mouth rinsing with water if fluid intake is contraindicated
● Apply moist washcloth over the lips
● Empty bladder every 2-4 hours;catheterize as needed
● Frequent change in position
● Information progress labor