Maternal and Child Health Nursing

CARE AND
MANAGEMENT OF THE
INTRAPARTAL WOMAN
Reymart B. Bolagao, RN, MAN, PhD
INTRAPARTUM
A. Extends from the beginning of
contractions that cause cervical dilation
up to the first 1 to 4 hours after delivery
of the newborn and placenta.

B. Refers to the medical and nursing care

given to the pregnant woman during
labor and delivery.
Admitting the Laboring Mother

Personal Data Physical Exams

1 4
3
2 5
Baseline Data Pelvic Exams

Obstetrical Data
Essential Knowledge of the intrapartum
Process

Theories of the Onset of Labor:

UTERINE STRETCH THEORY - any
hollow organ once stretched to is
maximum potential will always
contract and expel its content.
Essential Knowledge of the intrapartum
Process

Theories of the Onset of Labor:

PROSTAGLANDIN THEORY - due to the
stimulation of "arachidonic acid,
substance prostaglandin is produce that
causes contraction of the uterus thus
initiating labor.
Essential Knowledge of the intrapartum
Process

Theories of the Onset of Labor:

PROGESTERONE DEPRIVATION -
sudden drop in progesterone near
delivery stimulates labor .
Essential Knowledge of the intrapartum
Process

Theories of the Onset of Labor:

THEORY OF AGING PLACENTA - as the
placenta begins to degenerate by 36 weeks, the
body perceives it as a foreign body hence
makes its own defense to expel it by contraction
of the uterus.
Essential Knowledge of the intrapartum
Process

Theories of the Onset of Labor:

OXYTOCIN STIMULATION THEORY -

the production of the posterior pituitary
gland of this substance will cause uterine
contractions.
PASSENGER POWER

PSYCHE AND
PASSAGEWAY PERSON

4 PS IN LABOR & DELIVERY

PASSENGER (FETUS)

Fetal head: largest part of the

newborn's body - representing
1/4 of the newborn's length.
PASSENGER (FETUS)
Bones:
• Sphenoid
• Ethmoid
• Temporal
• Frontal or Sinciput
• Occipital or Occiput
• Parietal
PASSENGER (FETUS)
1. Anterior Fontanel (Bregma)
Diamond in shape, 3 x 4 centimeters in
size. Closes at 12-18 months.

2. Posterior Fontanel (Lambda)

Triangular in shape, 1x 1 centimeter in
size. Closes at 2-3 months.
PASSENGER (FETUS)
Important Measures of Fetal Head
-Transverse Diameter (TD)
• *Biparietal - 9.25 cm (largest transverse).
• *Bitemporal - 8.0 cm.
• *Bimastoid - 7.0 cm (smallest transverse).
-Antero-Posterior Diameter (APD)
• *Occipitomental - 13.5 cm (hyperextension).
• *Occipitofrontal - 12.0 cm (partial flexion).
• *Submentobregmatic - (face presentation).
• *Suboccipitobregmatic - 9.5 cm (complete flexion).
PASSAGEWAY

4 MAIN PELVIC TYPES:

1. Gynecoid - round, wide, deeper most suitable for pregnancy.
2. Anthropoid -oval, ape-like pelvis.
3. Android -heart shape "male pelvis". The anterior part: pointed while
the posterior shallow.
4. Platypelloid - flat.

Only the gynecoid and anthropoid pelvic types can deliver via NSVD.
POWER
• The forces acting to expel the fetus
and placenta.
• Involuntary contractions.
• Voluntary bearing down efforts.
• Characteristics: wave like
• Timing, frequency, duration,
intensity.
PSYCHE AND PERSON
• Psychological stress exists
when the mother is fighting the
labor experience.
• Cultural interpretation.
• Preparation.
• Past experience.
• Support system.
 Maternal and Child Health Nursing

NORMAL LABOR AND

DELIVERY
Reymart B. Bolagao, RN, MAN, PhDc
PRE-EMINENT SIGNS OF LABOR
LIGHTENING - settling of presenting part into
pelvic brim. Occurs 2 weeks prior to delivery in
primi.

SHOOTING PAIN RADIATING TO LEGS. (Leg

cramps during labor due to pressure of gravid
uterus to the lumbosacral nerve plexus.
Urinary frequency.
PRE-EMINENT SIGNS OF LABOR
Engagement: Settling of presenting part into pelvic
inlet.

Braxton Hicks Contractions: painless or irregular

uterine contractions.

Increased activity of the mother. Also known as the

"nesting instinct," caused by hormone epinephrine.
Nursing Intervention: let the mother save her
energy as fatigue can affect the type of analgesia
needed.
PRE-EMINENT SIGNS OF LABOR
RIPENING OF THE CERVIX: "butter softness" of the
cervix.

DECREASE IN WEIGHT: 1.5 - 3.0 lbs. prior to labor.

BLOODY SHOW: pinkish vaginal discharge (leukorrhea,

operculum and blood combined).

RUPTURE OF MEMBRANES. Nursing Intervention:

check FHT. Check temperature every 2 hrs because
mother is more prone to infection after membranes
rupture.
Duration of Labor:
Primipara: 14 hours but not more
than 20 hours.

Multipara: 8 hours but not more

than 14 hours.
FIRST STAGE OF LABOR
Onset of contractions to full
dilatation and effacement of
the cervix.
Divided in 3 Phases:
1. Latent
2. Active
3. Transitional
FIRST STAGE OF LABOR
Effacement - softening and thinning of
cervical canal denoted in percentage.

Dilatation - widening of the external

cervical os to 10 cm, primarily as a result of
uterine contractions and, secondary as a
result of pressure of the presenting part and
the bag of water (BOW) denoted in
centimeters.
FIRST STAGE OF LABOR
Effacement & Dilatation
STATION - relationship of presenting part to
the ischial spine denoted in centimeters.

• -3 to -5, means that the fetus is 3 to 5 cm above the ischial spine and still
floating, hence nursing care is therapeutic rest.
• -1, means that the presenting part is 1 cm above the ischial spine.
• O, fetus is at the level of the ischial spine and is already engaged.
• +1 to +2 - means that the fetus is 1 to 2 cm below the ischial spine.
• +3 to +5 - means that the fetus is at 3 to 5 cm below the ischial spine.
• At these levels, crowning occurs and signals the 2nd stage of labor.
PRESENTATION – Relationship of the LONG AXIS of the
FETUS to the LONG AXIS of the MOTHER
LONGITUDINAL (PARALLEL) OR
VERTICAL LIE - 99% of all presentations.

CEPHALIC is 95% of all presentations.

BREECH is 4% of all presentation

CEPHALIC is 95%
of all presentations.
a. Vertex - fetus is completely flexed.
b. Brow - partial flexion or the military attitude
c. Chin - means fetus is in hyperextension.
d. Face - poor flexion
BREECH is 4% of all presentation
A. COMPLETE BREECH - thighs
rest on abdomen while legs rest
on thighs.
B. INCOMPLETE BREECH
1. Frank - thighs rests on
abdomen while legs extend to
head.
2. Footling - Single: 1 leg flexed
and 1 foot is extended;
Double: 2 legs unflexed and
extended.
3. Kneeling - the knees presents.
TRANSVERSE LIE (PERPENDICULAR).
Shoulder presentation represents 1% of all the
deliveries
POSITION - RELATIONSHIP OF THE FETAL
PRESENTING PART TO SPECIFIC QUADRANT OF
THE MOTHER’S PELVIS
OCCIPUT SACRO/ MENTUM/ ACROMNI
/VERTIX BREECH FACE ODORSO
LOA LSA LMA LADA

LOT LST LMT LADT

LOP LSP LMP LADP

ROP RSA RMA RADA

ROT RST RMT RADT

ROA RSA RMA RADA

*LOA - most common and favorable birthing
position.

*For breech position, place stethoscope just

above the umbilicus when monitoring FHT.

*LOP and ROP - most common malposition and

most painful as well. Put mother in squatting
position to lessen low back
pain.
*LOA - most common and favorable birthing
position.

*For breech position, place stethoscope just

above the umbilicus when monitoring FHT.

*LOP and ROP - most common malposition and

most painful as well. Put mother in squatting
position to lessen low back
pain.
Monitoring the Contractions and Fetal Heart Tones:
Related Terminologies:
• Increment or Crescendo - from the beginning of contraction until it
increases.
• Acme or Apex - height/peak of contraction.
• Decrement or Decrescendo- from the height of contraction until it
decreases.
• Duration - beginning of the contraction to the end of the same
contraction.
• Interval - end of one contraction to the beginning of next contraction.
• Frequency - beginning of one contraction to the beginning of next
contraction.
• Intensity - strength of contraction.
Monitoring the Contractions and Fetal Heart Tones:
Best time to get MBP and FHT is midway of
contractions.
• During contraction blood vessels constrict, increasing maternal blood
pressure and decreasing fetal heart rate.
• Placental reserve of oxygen lasts for only 60 seconds therefore,
duration of contractions should not exceed 60 seconds.
• Contractions of more than 60 seconds may lead to fetal distress.
Signs of fetal distress:
(a) FHT of <120 >160 bpm.
(b) Meconium-stained amniotic fluid.
(c) Fetal thrashing - hyperactivity of fetus due to lack of oxygen.
• Oxytocin infusion should be discontinued if it lasts for more than 40
seconds because it may result to fetal distress.
Health Teachings on the First Stage of Labor:
• If the mother complains of headache, take BP.
• Allow mother to take a rest if the BP is within
normal and refer if above normal limits.
• Encourage the mother to bathe.
• Prohibit food intake (NPO) as GIT stops to function
during labor, risking the mother for vomiting and
aspiration and such intake limits anesthesia
options in case it is needed as labor progresses.
• Administer enema as ordered to cleanse the bowel
and prevent infection.
Health Teachings on the First Stage of Labor:
• Position: SIDE-LYING OR LATERAL SIMS.
• Rectal tube height: 12-18 cm. Pull the rectal tube when
there is resistance, while letting a small amount of solution
enter. Clamp the tube if there is contraction.
• After enema, check FHT (Normal: 120-160, irregular).
• Encourage mother to maintain on left lateral position to
prevent "Supine Hypotension" or "Supine Vena Caval
Syndrome.' The pressure of gravid uterus presses onto the
inferior vena cava which decreases venous return and
cardiac output.
PERINEAL PREPARATION
Maternal Analgesia and Anesthesia

• Narcotic and Analgesic Drugs (Per Doctor’s Order)

1. Meperidine HCL or Pethidine (Demerol)
2. Fentanyl (Sublimaze)
3. Butorphanol (Stadol)
4. Epidural Anesthesia
5. Spinal Anesthesia
 Nursing Intervention in Analgesia and Anesthesia
• Observe mother and newborn for respiratory depression if narcotic
analgesic is given; monitor mother for hypotension.
• Narcotics should be avoided if their peak action will not have
diminished by the time of delivery.
• Have NALOXONE (Narcan®) prepared at the bedside at all times to
counter respiratory depression. Dosing: Adults, 0.4 mg IV or IM
and neonates, 0.01 mg/kg.
• If delivered baby shows signs of respiratory depression administer
naloxone via umbilicus to facilitate the crying of the baby.
• After epidural: Monitor for hypotension. If hypotension occurs,
position client on left side, increase IV infusion and administer
oxygen.
• Evaluate client's response to medication
SECOND STAGE OF LABOR
• From COMPLETE CERVICAL
DILATATION & EFFACEMENT
to BIRTH OF THE BABY, also
known as the “FETAL STAGE”
SECOND STAGE OF LABOR
• Lithotomy and dorsal recumbent are positions most comfortable for the
attendant, and lithotomy is indicated for forceps application, repair of
lacerations, other procedures.
• Place legs up in lithotomy position simultaneously to prevent trauma to
uterine ligaments.
• Sitting, squatting, standing, kneeling, all-fours, side-lying positions may
be more comfortable for the patient and may be more physiologic.
• Delivery position should be determined by mother if not dictated by
obstetric procedure.
• BULGING OF PERINEUM is the surest sign that the baby is about to
be delivered.
• Advise mother to do panting, breathing exercises much like blowing a
feather. Pushing should be done with an open glottis to prevent
hypotension.
 KEY STAGES OF LABOUR
Descent
Engagement
Neck flexion
Internal rotation
Crowning
Extension of the presenting part
Restitution
External rotation
Lateral flexion
Delivery of Baby with Shoulders and
Body Presentation
Delivery of the Anterior Shoulder
Upward Traction
Delivery of the Posterior Shoulder
EPISOTOMIES
PERINEAL TEARS
 REPAIR OF EPISIOTOMY:
Note: It is important that absorbable sutures be used for closure.

Vaginal mucosa

1. Identify apex

2. Begin suturing
1.0 cm above apex

3. Continuous sutures

4. Ends at the level of

vaginal opening

Continuous sutures Interrupted sutures Interrupted suture or

subcuticular
TYPES OF ANESTHESIA
1. Natural Anesthesia – Pressure of fetal presenting part
against the perineum is so intense that the nerve endings
for pain are temporarily numbed.
2. Pudendal Anesthesia – Local anesthesia produced by
blocking the pudendal nerves near the ischial spine of the
ischium. Relieves only the vulvar pain but not pain caused
by contractions. “Ironing the Perineum” is done to
prevent laceration. Dosing: 1%, Lidocaine
Hydrochloride 10ML (100mg) each side.
SECURE AIRWAY
THIRD STAGE OF LABOR
● It begins immediately after the baby is
born, until the placenta is delivered.
● The third stage lasts between 5-15
minutes but any period up to 1 hour is
normal.
● If it lasts more than 1 hr it is
considered as retained placenta.
After expulsion of fetus to
expulsion of placenta &
membranes (afterbirths)

Duration : 15 min.
(primigravida
multigravida)
PHYSIOLOGY OF THE THIRD
STAGE OF LABOR

1. Separation of the placenta

2. Descent of the placenta
3. Expulsion of the placenta
4. Control of bleeding
MECHANISM OF PLACENTAL SEPARATION

● It is brought by the contraction and retraction of the

uterine muscles.
● Separation usually begins in the center of the
placenta.
● At the area of the separation the blood sinuses are torn
across.
● 30to 60ml of blood is connected between maternal
surface of the placenta and the decidua basal.
 MECHANISM OF PLACENTAL SEPARATION

● The uterine contractions detaches the

placenta from the uterus and the
placenta forced out of the upper
uterine segment into the lower uterine
segment.
 METHODS OF PLACENTAL SEPARATION

CENTRAL (SCHULTZE) SEPARATION MARGINAL (MATHEWS DUNCAN) SEPARATION

 SIGNS FOR PLACENTAL SEPARATION
1. GUSH OF BLOOD.
2. THE FUNDUS RISES AT THE LEVEL OF UMBILICUS.
3. UTERUS BECOMES GLOBULAR.
4. CORD LENGTHEN.
The uterus contracts during & after the birth of the baby. This causes the
uterus to become smaller, the placenta remains the same size & is
pushed off the uterine wall.
DESCENT OF THE PLACENTA
● When the placenta has completely
separated, the constructing uterus
pushes it down into the lower uterine
segment and into the vagina.
● The weight of the placenta itself pulls
the chorine of the uterine wall.
SIGN OF PLACENTAL DESCENT
1. The uterus becomes hard, round and movable.
2. The fundus rises to the level of the umbilicus.
3. The cord seems to lengthen.
4. There is a gush of blood
5. When you apply suprapubic pressure the cord
will no received back
6. Placenta can be feet on vaginal examination.
METHOD OF PLACENTAL EXPULSION
1. Using the fundus as a piston
2. The contracted fundus is used as apposition to push the
placenta out.
3. Controlled cord traction with oxytocin drugs
4. Controlled cord traction with out OXYTOCIN drugs
(Brandit Andreivs method)
5. Fundal pressure
6. Traditional method/Bearing down by the woman/
 CONTROL OF BLEEDING
1. The oblique muscles fibers of the uterus run in and out
between the blood vessels when the uterus is contracted
they clump the blood vessels very securely and the
bleeding stops.

2. Extra clotting power: The mother has extra clothing

power in her blood at this time the clotting mechanism is
very powerful.
MANAGEMENT OF THIRD STAGE
● Position of the Mother = The Dorsal

Position.
● Advantage of the position.
● More comfortable to the mother.
● Cord traction is applied more effectively.
● Injuries the birth canal is observed.
MANAGEMENT OF THIRD STAGE

●CLAMPING AND
CUTTING OF THE
UMBILICAL
CORD
MANAGEMENT OF THIRD STAGE
THE OXYTOCIN DRUGS
These drugs stimulate the uterus to contract. It is
used before ,during & after the third stage of labor.
Advantages:
1.It speeds up the delivery of the placenta.
2. Lessen the blood loss.
3. Contract the uterus.
EXAMINATION OF PLACENTA MEMBRANES
EXAMINATION OF MEMBRANES &
CORD