Intrapartum

Early Signs of Labor

🞂Braxton Hicks Contractions
◦Irregular and mild
◦Become more noticeable and
painful
◦May become regular, decrease
spontaneously
◦No cervical change
Early Signs of Labor
🞂Lightening
◦Fetus descends towards pelvic inlet
◦Breathing becomes easier
◦Urinary frequency, leg cramps and
edema occur
◦Occurs approx. 2-3 weeks before
delivery
Early Signs of Labor
🞂Cervical changes
◦Ripening
●Softening of cervix
◦Collagen fibers break down
●Increased vaginal discharge
◦Increased water content,
weakening, softening of cervix
Early Signs of Labor
🞂Bloody show
◦Mucous plug released and
capillaries exposed causing
bleeding
◦Labor usually begins 24-48 hours
after show
◦Vaginal exams and/or intercourse
may cause blood-tinged discharge
Early Signs of Labor
🞂Rupture of Membranes
◦Spontaneous rupture of amniotic
fluid occurs in 12% of women prior
to labor
◦Spontaneous labor begins within 24
hours in 80% of women
◦If fetal head is not in the pelvis
there is increased risk for cord
prolapse
◦Increased risk of infection
Early Signs of Labor
🞂 Energy Burst
◦Occurs 24-48 hours prior to labor
◦“Nesting” instinct

🞂 Other signs
◦Weight loss of 1-3 lbs.
◦Increased backache and sacroiliac
pressure
◦Diarrhea, indigestion, or N/V
True vs. False Labor
True Labor False Labor
Cervical change No cervical change
Contractions get stronger, Contractions stay about
longer and closer together the same, then go away
Contractions regular Contractions irregular
Contractions increase Contractions go away
with walking with walking
Pain > with strength of No relationship b/t pain
abdominal tightening and abdominal tightening
Bloody show increases No bloody show
LDR admission
🞂 Review prenatal records: complications,
GBS, hepatitis B and HIV status
🞂 Start IV
🞂 Labs – CBC, Type and Cross, UA
🞂 Place external monitors
🞂 Complete admission assessment
🞂 If ROM, sterile speculum exam for ferning
🞂 RN vaginal exam if appropriate
Ferning
Cervical Changes
🞂Dilatation - enlargement of the
cervical os
◦From closed to 10 cm.
🞂Effacement - thinning and shortening
of the cervix
◦Usually stated as a percentage
◦More accurate if stated as a
measurement
Cervical changes
Cervical changes
Cervical Station
🞂 Station - relation of
the fetal skull to
the ischial spines
◦ 0 is at the ischial
spines (engaged)
◦ above -3 is
considered floating
or ballotable
◦ Crowning is +3 - +4
◦ Delivery is + 5
Friedman Curve
Stages of Labor and Birth
🞂 First Stage - onset of regular contractions
until cervix is completely dilated
◦ Latent Phase
◦ Active Phase
◦ Transitional Phase

◦ Multiparous women progress faster -

vaginal tone stretched and dilatation and
effacement occurs together
Latent Phase or
Dilation from 0-3 cms.
🞂 Time
8 hours for nulliparas or 1st baby
5 hours for multiparas or multiple
babies
Typically see:
- UC occur every 3 - 30 minutes
(frequency)
- Duration of contractions is 20-40 sec.
- Intensity- mild to moderate; 25-40 mmHg
◦ Station remains high
◦ Progressive effacement to 100%
◦ Mother excited, talkative, independent,
happy
Active Phase or
Dilation from 4-7 cm
🞂 Time
5 hours for nulliparas or 1st baby
2 hours for multiparas or multiple
babies
Typically see:
- UC occur every 2-5 minutes (frequency)
- Duration of contractions is 40-60 sec.
- Intensity- moderate to strong; 50-70 mmHg
◦ Station –fetus descends in the pelvis
◦ Effacement to 100%
◦ Mother feelings of helplessness, anxious,
fearful, fatigue, dependent
Transition Phase or
Dilation from 8-10 cm
🞂 Time
3.6 hours for nulliparas or 1st baby
Variable for multiparas or multiple
babies
Typically see:
- UC occur every 1-2 minutes (frequency)
- Duration of contractions is 60-90 sec.
- Intensity- strong; 70-90 mmHg
◦ Station – fetus continues to descend and turn
◦ Progressive effacement to 100%
◦ Mother tired, fearful, out of control, consumed
with pain; introverted; uncooperative; panic,
amnesic between
Nursing Role for Stage One
🞂 Quiet, calm environment
🞂 Activity: ice chips, cool
🞂 cloth, position change,
🞂 back rubs, effleurage,
🞂 void q 2 hours or
🞂 catheterize
🞂 Support: encourage or
🞂 provide; focus on breathing
🞂 talk through each
🞂 contraction; praise coping
Stages of Labor and Birth
🞂 Second Stage - duration of time from full
dilatation to delivery of the baby or the
pushing phase; descent of the baby
1-2 hours nullipara
0-45 minutes multipara
Typically see:
🞂 Signs: deep variable decels, rectal

pressure
(urge to bear down, have a BM) and
increase in bloody show
Stages of Labor
🞂 Second stage
◦ Crowning occurs when fetal head is
encircled by external opening of vagina
or + 4 station

◦ May feel acute, severe pain and burning

sensation as perineum distends
Stages of Labor
🞂 Second stage
◦ Active management of second stage – if patient
has epidural, allow fetus to descend further
before pushing begins – decreases pushing time
by allowing contractions to push fetus into pelvis
Nursing Role for Stage Two
🞂 Open glottis with slight exhale for 6-7
seconds, deep breath before and after
each push, usually 3 pushes per
contraction, wear face shield and gloves
when assisting patient
Stages of Labor and Birth
🞂 Third Stage - Time from the birth of the
fetus to the delivery of the placenta
◦Time 5-30 minutes
◦Placental separation signs
●Globular and firm uterus
●Rise of fundus in abdomen
●Lengthening of the umbilical cord
●Sudden gush of blood
◦Happy, relieved, tired
Nursing Role Stage Three
🞂Activity: Frequent vitals, risk for
hemorrhage/start pitocin, recover
🞂newborn,
🞂Physician: Repair of episiotomy or
laceration, estimated blood loss of
🞂<500 ml. for a vaginal (SVD) or
🞂<1000 ml. for a cesarean section
(C/S)
Stages of Labor and Birth
🞂Fourth Stage -Time from the delivery
of the placenta until the mother is
fully recovered (1-4 hours)

Typically see:
Shaking, chills, hunger, thirst and
fatigue
Nursing Role Fourth Stage
🞂Activity: ice pack, pericare, change
pads, return of sensation, provide
food and quiet, assist to void or
catheterize, pain management
🞂Breast Feeding: teach how to latch
on, breast/nipple care
Charting the BUBBLE
🞂 Fourth stage
◦ BUBBLE assessment
●B – breasts soft, non-tender, nipples intact
●U – umbilicus in relation to the position of the
fundus (firm vs. boggy, midline vs. displaced)
●B – bladder voiding without dysuria, quantity
●B – bowel sounds x4, abdomen soft, passing flatus,
last BM
●L – lochia rubra, scant vs. heavy, without odor or
clots
●E – episiotomy midline vs. mediolateral without
REED and edges approximated
Assessment
Lochia:
🞂 Rubra – red (consists entirely of blood), 3

days
🞂 Serosa – pink, watery (consists of

exudate,
erythrocytes, leukocytes, mucus),10
days

Mother shaking, chills, fatigue, hungry

Degree of lacerations
🞂Periurethral - “skid marks”
🞂First degree - Involves skin and
superficial structures
🞂Second degree - reaches into the
perineal muscles
🞂Third degree - extends into the anal
sphincter muscle
🞂Fourth degree - involves the anterior
rectal wall
Nursing Role During Labor

🞂Ice for first 24 hours and then heat

on perineum,
🞂Education: pericare, assess for signs
of infection, hemorrhage, UTI, and
orthostatic hypotension.
🞂High Risk Mothers: traumatic
delivery, over distended uterus,
multiple gestations, and multiparous
women
Components of the Birth Process

🞂 Passage
◦ Consists of the maternal pelvis and soft tissue
◦ Bony pelvis more important as it does not yield
during labor
●Divided into false pelvis (top) and true pelvis
(bottom)
●True pelvis is most important during childbirth
●Size includes diameter of inlet, pelvic cavity,
and outlet
Components of the Birth
Process
🞂Passage, cont.
◦Inlet
●Divides the false from true pelvis
●Widest diameter from side to side
◦Outlet
●Widest diameter from front to
back
◦Pelvic cavity
●Space between mid pelvis
Components of the Birth
Process
◦ Type of pelvis
●Gynecoid (most common)
●50%, round and adequate
●Anthropoid
●25%, 50% African American, narrow side to
side, wide front to back, oval, adequate
●Android
●20%, male-like, heart shaped, not adequate
●Platypelloid
●3%, flat front to back, wide side to side, not
adequate

◦ Soft tissue of cervix and vagina to distend

Types of Pelvic Shapes
Components of the Birth
Process
🞂 Passenger
◦ The fetus, membranes, and placenta

◦ Fetal head
●Enters the birth canal in cephalic presentation
96% of the time
●Least compressible, largest part of fetus
Components of the Birth Process
🞂 Passenger
◦ Fetal head, cont.
●3 major parts: face, base of skull, and vault of
cranium
●Face and cranial base: well-fused and fixed
●Base of cranium: composed of two temporal
bones
●Vault: 2 frontal bones, 2 parietal bones, 1
occipital bone
●The vault bones are not fused, allowing
adjustment in shape during delivery - molding
Components of the Birth
Process
🞂 Passenger
◦ Fetal head, cont.
●Sutures are membranous spaces between
bones
●Allow for molding of fetal head and identify
position of fetus
●Mitotic suture – between parietal bones
●Coronal suture – between frontal and parietal
bones
●Lambdoidal suture – between parietal and
occipital
Components of the Birth
Process
🞂 Passenger
◦ Fetal head, cont.
●Fontanelles – wider spaces at the
intersections of the sutures
●Anterior – diamond shaped. Closes at 18
months
●Posterior – triangular shaped. Closes at 8-12
weeks
Fetal Head
Variations in the Passenger
🞂 Attitude – relation of the fetal head, chest
and body
●Normal – flexion of the head to chest,
arms onto chest and legs on abdomen
●Abnormal – cause larger diameters of
fetal head to maternal pelvis,
contributing to difficult labor
●Degree flexed determines ease at
delivery
Fetal Attitude
Suboccipito Bregmatic Angle
Variations in the Passenger
🞂 Lie – Orientation of the long axis of the
fetus to the long axis of the woman

◦ Longitudinal – head or buttocks of the

fetus enters the pelvis first (parallel)
◦ Transverse – fetus is at a right angle to
the woman (perpendicular)
◦ Oblique – some angle between
Variations in the Passenger
🞂 Presentation – Fetal part that first enters the
pelvis
◦ Cephalic – fetal head presents (96%)
◦ Vertex – head completely flexed onto chest
●Smallest diameter of head presents to maternal pelvis
●Occiput is presenting part (O)
◦ Military – head is neither flexed or extended
●Top of head is presenting part
◦ Brow – head partially extended
●Largest diameter presents to maternal pelvis
●Sinciput is presenting
◦ Face – head hyperextended
■ Face is presenting part (mentum or chin) (M)
Variations in the Passenger
◦ Presentation, cont.
●Breech – (3%) Sacrum is landmark (S)
●Complete – fetal knees and hips flexed,
thighs on abdomen (buttocks and feet
presents)
●Frank – fetal hips flexed, knees extended
(buttocks presents)
●Footling – fetal hips and legs extended
(feet present)
●Shoulder – transverse lie (c/s necessary);
Scapula (Sc) or Acromiodorso process (Ad)
Variations in the Passenger
🞂 Position – location of presenting part in
relation to the four quadrants of maternal
pelvis
●Abbreviations used to describe position
●Right (R) or Left (L)
●Occiput (O), Mentum (M), Scapula (Sc),
Acromiodorso (Ad), or Sacrum (S)
●Anterior (A), Posterior (P), or Transverse (T)
Fetal Position Changes
Fetal Position
Leopold’s Maneuvers
🞂Used to determine position
🞂Systematic abdominal palpation
◦Fundal part
◦Locate back (fetal monitoring)
◦Engaged head
◦Degree of flexion
Cardinal movements of fetus
◦ Descent - head enters inlet in occiput
transverse
●Pelvic inlet widest from side to side
◦ Flexion - head descends and meets
resistance from soft tissue (chin to chest)
◦ Internal rotation - head rotates to fit
diameter of pelvic cavity
●Occiput rotates and sagittal sutures
align in AP pelvic diameter – fits widest
part of pelvis
Cardinal Movements, cont.
◦Extension - fetal head extends as it
passes under symphysis pubis
(extend neck; deliver head)

◦Restitution - shoulders of fetus

enter pelvis obliquely and remain as
head rotates to AP diameter.
Cardinal Movements, cont.
◦External rotation - shoulders rotate
to AP position in pelvis, head turns
farther to one side

◦Expulsion - Anterior shoulder meets

undersurface of symphysis and slips
under it (delivery of shoulders)
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The Four “P” s that can impact
labor
🞂Powers
◦Primarily uterine contractions
during 1st stage of labor – moves
fetus through maternal pelvis

◦Maternal pushing efforts is

secondary force during 2nd stage of
labor – continues to push fetus
through pelvis
Components of the Birth
Process
🞂Psyche
◦Crucial part of childbirth
◦Anxiety and fear decreases
woman’s ability to cope with pain in
labor
◦Individual and cultural values effect
woman’s view, behavior and
reaction to labor and delivery
◦Previous and present experiences
Components of the Birth
Process
🞂Assessment
◦Palpation - determine position,
fundal height, and size
◦Vaginal Exam - determine position
and cervical status
◦Fetal heart sounds - determine
position and well being
Question #1
🞂 Suzanne is calling you on labor and delivery.
She wants to know if she should come in
right away or if she is having false labor.
Name at least 4 questions you need to ask
her in order to make this decision.
Answer #1
🞂 ROM, bleeding; frequency and intensity of
contractions; stronger, longer, closer
together; diarrhea; pain in back and
radiates to the front
Question #2
🞂 The client’s vaginal exam reveals: 3/80%/-1
vertex, The woman is talkative and appears
excited. The nurse determines the client to
be in which stage and phase of labor.

◦ A. First stage, latent phase

◦ B. First stage, active phase
◦ C. Second stage, latent phase
◦ D. Third stage, transition phase
Answer #2
🞂 A – The first stage of labor is from the onset
of labor to complete dilation, and is divided
into latent (0-3), active (4-7) and transition
(8-10) phases. The second stage has no
phases and is from 10 to delivery of the
newborn. The third stage has no phases
and extends from delivery of the newborn
to delivery of the placenta.
Question #3
🞂 Name four warning signs during labor that
would prompt the nurse to call the
physician?
Answer #3
🞂 UC intensity > 75 mmHg, duration > 90
seconds, frequency < 2 min. apart
🞂 FHT rate > 160 or <110, loss of variability,
late decelerations, deep variable
decelerations
🞂 ROM with meconium or prolapsed cord
🞂 Temp > 100.4
🞂 Vaginal discharge with foul smell, bright red
or dark persistent bleeding
Question #4
🞂 The nurse performs a vaginal examination
and determines that the fetus is in a
sacrum anterior position. This means:

◦ A. The fetal sacrum is toward the maternal

symphysis pubis
◦ B. The fetal sacrum is toward the maternal
sacrum
◦ C. The fetal face is toward the maternal sacrum
◦ D. The fetal face is toward the maternal
symphysis pubis
Answer #4
🞂 A – the presenting part is given first when
describing fetal position. The second half of
the fetal position description refers to the
maternal pelvis. In this example, it is the
sacrum presenting and the fetal sacrum is
toward the maternal anterior pelvis.
Question #5
🞂 Which of the following nursing
observations would indicate a sign of
impending placental separation and
expulsion?

◦ A. Steady trickle of blood with an unchanged

cord length
◦ B. No bleeding with lengthening of the cord
◦ C. Small gush of blood with lengthening of the
cord
◦ D. Small gush of blood with an unchanged cord
length
Answer #5
🞂 C – As the uterus contracts and the placenta
begins to shear off the uterine wall and be
expelled, you will see a small gush of blood
resulting from the uterine contractions
emptying the uterus. In addition, the cord
will lengthen as the placenta is released
from the uterine wall and moves toward the
cervix prior to expulsion.
Question #6
🞂 The nurse determines a laboring patient is
anxious and recognizes that this may result
in:

◦ A. Rapid progression of labor

◦ B. Increased pain in labor
◦ C. No reliance on support person
◦ D. Need for episiotomy
Answer #6
🞂 B – Anxiety commonly increases the
perception of pain, and childbearing is no
exception to this. Decreasing anxiety
through education and support will facilitate
the birthing process.