Intrapartal Care

INTRAPARTAL CARE
DURING LABOR
Integrating Rubin’s Framework With Social Support Theory
Numerous studies and articles on labor support have focused on the potential for improved labor
and birth outcomes from supportive care during labor. Despite increased attention to labor
support research, surprisingly little has been written about the theoretical underpinnings for
intrapartum nursing care. This article explores Reva Rubin’s framework and social support theory
as a foundation for intrapartum nursing care. The most common features of social support
provided the structure into which Rubin’s descriptions of nursing care during labor and birth could
be evaluated. Social support theory fit remarkably well, both with Rubin’s views of the role of the
perinatal nurse and with Rubin’s observations of mothers’ needs and feelings during childbirth.

Both the social support literature and Rubin’s writings provide a theoretical foundation for
intrapartum nursing care. Rubin (1968b) described nursing as an interactive helping process and
suggested that intrapartum nurses should create in the laboring woman feelings of acceptance
and of being valued. Regarding the nurse as a support provider, Rubin clearly established both the
privilege and commitment that nurses have when they help women “through the valley of the
shadow that all women walk to have a child” (Rubin, 1975b, p. 1685). To provide nurturing and
empathetic care, nurses need a sense of respect and awe for the trials and endeavors of laboring
women. A final quote captures the embeddedness of social support theory within Rubin’s
framework: Nurses performed miracles of healing. . . . There is something very special about the
laying on of hands right where the hurt is. . . . Mothers left the hospital for home feeling cared for,
respected, and wanted in this world. (Rubin, 1975a, p. 1682)
Assessment
The key to a successful individualized care plan is the precise assessment and accurate obtaining
of data. The woman would be placed under observation during labor to monitor her progress and
ensure a safe delivery for her and the child.
Assess for the signs of true labor. The signs of true labor are contractions that begin
irregularly but progresses regularly and predictably, the pain is felt first at the lower back and
circles towards the abdomen, continues to progress no matter what the woman’s activity level
is, increases in duration, frequency, and intensity and cervical dilation is already present.
Assess for the appearance of show, which is blood mixed with mucus and would be present
once the operculum or mucus plug is expelled.
Assess for the rupture of membranes. This is the scanty or sudden gush of clear fluid from
the vagina.
Assess for the engagement of the fetal head. Engagement refers to the settling of the
presenting part into the pelvis at the level of the ischial spines.
Assess for the station. Station is the relationship of the presenting part to the level of the
ischial spines.
Assess for the effacement and dilatation of the cervix. Effacement is the shortening and
thinning of the cervical canal. In cervical dilatation, the enlargement or widening of the cervical
canal is assessed.
 Diagnosis
First stage of labor
This stage of labor is divided into three phases.
The latent phase starts during the onset of true labor contractions until cervical dilatation.
The active phase occurs when cervical dilatation is at 4 to 7 cm and contractions last from 40 to 60
seconds with 3 to 5 minutes interval.
The transition phase occurs when contractions reach their peak with intervals of 2 to 3 minutes
and dilatation of 8 to 10 cm.
Second stage of labor
This stage starts at full cervical dilatation until the birth of the infant.
The woman may experience an uncontrollable urge to push and bear down with every contraction.
Crowning or the appearance of the fetal head on the vaginal opening occurs.
Third stage of labor
The third stage begins with the birth of the infant until the delivery of the placenta.
The signs of placental expulsion are lengthening of the umbilical cord, sudden gush of vaginal
blood, changes in the shape of the uterus and its firm contraction, and the appearance of the
placenta at the vaginal opening.
 Plannin
With all the data gathered during assessment and through an accurate diagnosis, a care plan for the woman in

g
labor would be made to aid her through her progress.
Care of a woman in the first stage of labor
Labor should be allowed to start naturally, not artificially induced.
The woman must also be allowed to move freely throughout the labor. Artificial interventions should also be
prohibited.
Allow the woman to assume a non-supine position for delivery.
Upon delivery of the newborn, mother and child should be given unlimited opportunity for breastfeeding and
bonding.
Care of a woman in the second stage of labor
During the second stage of labor, the place of delivery of the woman must be prepared.
The position of birth wherein the woman is most comfortable must also be determined at this stage.
Another important part is the promotion of second stage effective pushing.
Perineal cleaning is also an integral part of the second stage.
Care of the woman in the third stage of labor
Placental delivery should be given focus at this stage. Once the placenta is delivered, oxytocin should be
administered intramuscularly to promote uterine contractions.
If there is episiotomy performed, perineal repair should be integrated into the care plan.
 Implementation
Some interventions are implemented to give comfort and safety for the mother during
and after the labor period. These are essential in promoting the strength that the
mother would need during delivery.
Encourage the client to void every 2 hours.
Observe and review the client’s breathing techniques.
Inform the client if c interventions are necessary.
Create a birth plan with the client so she could integrate her preferences in the care
plan.
Provide ice chips, hard candies, or fluids to relieve dry mouth.
Provide a comfortable environment to aid in the effective coping management of the
client.
Allow the client to walk and move around freely during labor.
Do not intervene with the client during a contraction to avoid disturbing her focus on
her technique.
Induction and Augmentation of Labor
Cervical Ripening
Cervical ripening must be complete during early labor.
If there is no cervical ripening, there would be no dilatation and coordination of uterine
contractions.
To determine whether the cervix is ripe, Bishop established criteria for scoring the
cervix.
If the woman’s score is 8 or greater, the cervix is already ready or birth and would
respond to induction.
One of the ways to ripen the cervix is known as “stripping the membranes”, or
separating the membranes from the lower uterine segment manually using a gloved
finger in the cervix.
Complications that may arise from this procedure include bleeding due to undetected
low-lying placenta, inadvertent rupture of membranes, and infection when the
membranes rupture.
Induction and Augmentation of Labor
Another method that is also considered is the use of hygroscopic suppositories or
suppositories of seaweed that swell upon contact with cervical secretions.
These suppositories gradually and gently urge dilatation.
They are held in place by gauze sponges saturated with povidone iodine or an
antifungal cream.
The number of sponges and dilators should be documented accordingly to avoid
leaving behind one of them inside the cervix.
A more common method of speeding cervical ripening is the application of a
prostaglandin gel to the interior surface of the cervix by a catheter or suppository, or to
the external surface by applying it to a diaphragm and then replacing it against the
cervix.
Additional doses may be applied every six hours, but two or three doses are usually
enough to achieve ripening.
Instruct the woman to remain in a side lying position to avoid leakage of the
medication.
Induction and Augmentation of Labor
Continuously monitor the FHR at least every 30 minutes after each
complication.
Side effects of this method include diarrhea, fever,hypertension, and
vomiting.
Oxytocin administration may also be started, but that would be 6 to 12 hours
after the last prostaglandin dose.
Use prostaglandin with caution in women with asthma, renal or
cardiovascular disease, or glaucoma.
Women who underwent cesarean birth in the past are contraindicated with
prostaglandin method.
Induction and Augmentation of Labor
Induction of Labor by Oxytocin
Administration of oxytocin can initiate contractions in a uterus in pregnancy term.
Oxytocin is administered intravenously so that when there is hyperstimulation, then it
could be quickly discontinued.
The effects happen immediately because the half-life of oxytocin is
approximately 3 minutes.
Oxytocin is usually mixed with Ringer’slactate, 10 units of oxytocin in 1000 mL
of Ringer’s lactate.
The infusion could also be administered piggyback to a maintenance IV
solution, so that if the infusion would be discontinued, the main IV line could still be
maintained.
The oxytocin solution must always be attached to the port nearest to the woman so
that little solution remains in the tubing if it is discontinued.
Use of an infusion pump is recommended to regulate the infusion rate and make sure
that the rate would not change even if the woman moves.
Induction and Augmentation of Labor
Do not increase the rate without any further instructions because it can cause tetanic
contractions.
Artificial rupture of membranes may be done when cervical dilatation reaches 4 cm to
further induce labor.
Be aware of peripheral vessel dilatation, a side effect of oxytocin administration, which
can cause hypotension.
Assess the woman’s pulse and blood pressure every 15 minutes to be certain of a safe
induction.
Monitor uterine contractions and FHR accordingly.
Contractions should occur no more often than every 2 minutes, should not be longer
than 70 seconds, and not stronger than 50 mmHg.
Stop the IV infusion if the contractions become more frequent or longer in duration
than the safe limits or if there are signs of fetal distress.
Induction and Augmentation of Labor
Excessive stimulation of the uterus by oxytocin may lead to tonic uterine contractions
with fetal death or rupture of the uterus.
In the event that hyperstimulation is not stopped even if the infusion has been
discontinued, a beta-adrenergic receptor drug or magnesium sulfate may be
prescribed to decrease myometrial activity.
A complication of oxytocin infusion is water intoxication because oxytocin has an
antidiuretic effect that results in decreased urine flow.
Symptoms of water intoxication are headache and vomiting.
Water intoxication in its most severe form can cause seizures, coma, and even death
because of the large shift in interstitial tissue fluid.
Monitor the intake and output appropriately and assess urine specific gravity to detect
fluid retention.
Limit the amount of IV fluid to 150 mL/hr by making sure that the main line is infusing
at a rate not greater than 2.5 mL/min.
Induction and Augmentation of Labor
Induced labor tends to have shorter first stage than the average unassisted
labor.
Assure the woman that uterine contractions in an induced labor are basically
normal so she can use her breathing techniques effectively.
However, h yperbilirubinemia and jaundicein a newborn are
possible because of induction of labor with oxytocin.
The infant should be observed closely for theseconditions during
the first few days of life.
Induction and Augmentation of Labor
Augmentation by Oxytocin
If labor contractions begin spontaneouslybut become weak,irregular,
and ineffective, augmentation of labor is required.
Precautions for oxytocin administration are the same as for primary induction of
labor.
The uterus may respond effectively to oxytocin used as augmentation.
The drug should be increased in small increments only and fetal heart sounds
should be monitored during the procedure.
 Evaluation
After the labor has passed, delivery would commence immediately. And when the
labor period for the woman has gone smoothly, a great chance for a safe and
healthy delivery is within reach.
Client should exhibit no signs of bladder distention and have the ability to void
every 2 hours.
Client has a good to tolerable level of pain.
Client can express her preferences during labor.
Client has the ability to understand the usual process of labor.
Client reports that her environment is comfortable and secure.
Client would be able to verbalize her feelings about her experiences during her
labor period.
INTRAPARTAL
CARE DURING
DELIVERY
Assessment
Assessment for delivery starts at the second stage of labor, which is the full cervical dilatation
until the birth of the baby. This would be a crucial time since the mother would need to deliver
her baby at this stage without any troubles and with her strength intact so she could push for a
normal vaginal delivery.
Assess the responses of the mother towards the intensity and duration of the contractions.
Assess the comfortability of the mother with her birthing position.
Assess her breathing techniques if they are effective or could add to the difficulty that the
mother might be experiencing.
Assess the ability of the support person to assist the mother during labor and birth.
Assess the fetal heart sounds to make sure that there is no occlusion in the cord that could
hinder fetal circulation.
Assess if the environment is comfortable for both the mother and the baby.

Diagnosis
The difficulties that the mother may encounter during delivery are endless. Not all deliveries have
gone smoothly, so every caregiver must be capable of whipping up a diagnosis and care plan
immediately to assist the mother towards a safe and meaningful delivery.
Pain related to intensity of uterine contractions
 Plannin
The place of birth must be prepared prior to delivery.
gthe room could start when the cervix has dilated to
For multigravidas, preparation of
9 to 10 cm.
For primiparas, preparation of the birth place should start when the head has
crowned to the size of a quarter.
The newborn care area must also be prepared within the same room and include
supplies for eye care, suction and resuscitation equipment, radiant heat warmer,
sterile towels, and identification of the newborn.
The mother should choose a position that will be most comfortable for her during
birth.
Alternative birthing positions today are the dorsal recumbent position, the lateral
Sim’s position, squatting, and semi-sitting.
A health care provider must be situated at the foot of the birthing table already so
that the infant would not fall off if birth happened precipitously.
 Implementation
Now that the care plan is already established, time to take someaction
and implement those interventions listed on your cheat sheet.

If the client has a birth plan, make sure all health care providers are aware of
her individual preferences.
Encourage the mother to void before delivery to reduce the discomfort.
Allow client to take ice chips or hard candies for relief of dry mouth.
Provide a comfortable environment for both the mother and the baby.
Allow the client to assume a birthing position of her choice as long as it is not
contraindicated.
Assist the client in venting out any emotions with regards to her
delivery experience.
 Evaluation
A care plan would not be complete if no evaluation was done to test
the effectiveness of your plan.
Client will be able to manage her discomfort using nonpharmacologic methods.
Client will be able to identify other pain relief measures.
Client has no signs of bladder distention and can void every 2 hours.
Client states that she has reduced or no mouth discomfort.
Client states that the environment is comfortable enough.
Client reports that the delivery is a tolerable and highly meaningful part of her
life.
T H A N K YOU!