Intrapartum 11

THE STAGES OF LABOR|NRG 203| Jane Pathay

The Stages of Labor distraction, or assuming

acupressure whatever position experience a
1. The first stage of dilatation, which begins with the is most feeling of loss of
initiation of true labor contractions and ends when the comfortable for control, anxiety,
cervix is fully dilated them during this panic, and/or
time, except flat irritability
2. The second stage, extending from the time of full on their back
dilatation until the infant is born

3. The third or placental stage, lasting from the time the

infant is born until after the delivery of the placenta
THE SECOND STAGE
4. The fourth stage , the first 1 to 4 hours after birth of
the placenta to emphasize the importance of close  From full dilatation and cervical effacement to birth
maternal observation needed at this time. of the infant.
 Uncontrollable urge to push or bear down with each
THE FIRST STAGE
contraction as if to move her bowels.
 Which takes about 12 hours to complete, is divided  fetus begins descent, fetal head touches the internal
into three segments: perineum to begin internal rotation.
1. Latent  Bulging of the perineum.
2. Active  The anus may become everted, and stool may be
3. Transition phase. expelled.
 Longest stage of labor.  Crowning
 Pain may disappear as all of her energy and
thoughts are directed toward giving birth.
 Delivery of the baby
“Labor Actively Transitioning”
THE THIRD STAGE
LATENT ACTIVE TRANSITION
 Placental Stage
onset of regularly cervical dilatation contractions reach  Begins with the birth of the infant and ends with the
perceived uterine occurs more their peak of delivery of the placenta.
contractions and rapidly. intensity.  Two separate phases:
ends when rapid 1. Placental separation
cervical dilatation Contractions every 2 to 3 2. Placental expulsion
begins. grow stronger, minutes with a
lasting 40 to 60 duration of 60 to
Cervical seconds, and 70 seconds. Placental Separation
effacement occur
occurs, dilatation approximately maximum cervical  The placenta has loosened and is ready to deliver
is minimal. every 3 to 5 dilatation of 8 to 10 when:
minutes. cm occurs 1. There is lengthening of the umbilical cord.
analgesia at this 2. A sudden gush of vaginal blood occurs.
point, she Show (increased Show will occur as 3. The placenta is visible at the vaginal opening.
shouldn’t be vaginal the last of the 4. The uterus contracts and feels firm again.
denied of it. secretions) . mucus plug from
perhaps the cervix is  Can take anywhere from 1 to 30 minutes and still be
encourage spontaneous released, if not considered normal
women to rupture of the previously  Blood loss of about 300 to 500 ml
continue to walk membranes occurred.
about .
Encourage full dilatation (10
Placental presentation:
she could begin women to be cm) and complete
alternative active cervical
methods of pain participants in effacement
relief such as labor . (obliteration of the
aromatherapy, cervix)
 Abnormal Lower avoid a full bladder, ask
Abdominal Contour women to try to void about
every 2 hours during labor.

Increasing Apprehension “You seem more and more

concerned. Could you tell
me what is worrying you?”

1. Schultze presentation- shiny and glistening

2. Duncan presentation - looks raw, red, and irregular,

with the ridges or cotyledons; dirty

Normal # of Cotyledons = 15-20

FETAL DANGER SIGNS OF LABOR

MATERNAL DANGER SIGNS OF LABOR
High or Low Fetal Heart more than 160 beats/min
Rate (fetal tachycardia) or less
than 110 beats/min (fetal
bradycardia) is a sign of
possible fetal distress
Meconium Staining sign of fetal distress; may
indicate a fetus has or is
experiencing hypoxia,
which stimulates the vagal
reflex and leads to
increased bowel motility
Hyperactivity Hypoxia
Low Oxygen Saturation Normally 40% to 70%; A
fetus can be assessed for
this by a catheter inserted
next to the cheek (under
High or Low Blood (>140/>90) or an increase 40% oxygenation needs
Pressure in the systolic pressure of further assessment).
more than 30 mmHg or in
the diastolic pressure of
more than 15 mmHg (the
basic criteria for
gestational hypertension)
Abnormal Pulse (70-80 b/m) if more than
100 report ASSESSMENT

Inadequate or Prolonged
Contractions
 THE DETAILED ASSESSMENT DURING THE FIRST
STAGE OF LABOR

A. The History
B. The Physical Examination
C. Leopold Maneuvers
D. The Vaginal Examination
E. Sonography
F. Assessing Rupture of Membranes
G. Assessment of Pelvic Adequacy
H. Vital Signs
I. Laboratory Analysis

THE INITIAL FETAL ASSESSMENT

 Auscultation of Fetal Heart Sounds

FETAL HEART RATE AND UTERINE CONTRACTION
RECORDS

FETAL HEART RATE PARAMETERS

Baseline Fetal Heart Rate - analyzing the pace of fetal

heartbeats recorded in a minimum of 2 minutes obtained
between contractions. A normal rate is 110 to 160
beats/min.

Variability

 Difference between the highest and lowest heart

rates shown on a strip is one of the most reliable
indicators of fetal well-being.
 Variability should be recorded as:
a) Absent: No amplitude range is detectable.
b) Minimal: Amplitude range is detectable but is 5
beats/min or fewer.
c) Moderate (normal): Amplitude range is 6 to 25
beats/min.
d) Marked: Amplitude range is greater than 25
beats/min.

 Other patterns in the baseline rate that can be

detected include fetal bradycardia (FHR is lower
than 110 beats/min for 10 minutes) and fetal
tachycardia (FHR is faster than 160 beats/min for a
ELECTRONIC MONITORING
10-minute period).
Watch this link:

https://www.youtube.com/watch?v=ac14n5uD4_0 Periodic Changes

 fluctuations in FHR occur in response to contractions

and fetal movement and are described in terms of
accelerations or decelerations.
 Accelerations
 Decelerations
 Late Decelerations
 Prolonged Decelerations
 Variable Decelerations
Accelerations -Nonperiodic accelerations are temporary
normal increases in FHR caused by fetal movement, a
change in maternal position, or administration of an
analgesic.
Decelerations - Decelerations are visually apparent,
usually symmetrical, periodic decreases in FHR resulting
from pressure on the fetal head during contractions as
parasympathetic stimulation in response to vagal nerve
compression brings about a slowing of FHR.
Late Decelerations
 Late decelerations are those in which the onset,
nadir, and recovery of the deceleration occur after
the beginning, peak, and ending of the contraction,
respectively (Fig. 15.19).
 This is an ominous pattern in labor because it
suggests uteroplacental insufficiency or decreased
blood flow through the intervillous spaces of the
uterus during uterine contractions.
 May occur with marked hypertonia or increased
uterine tone.
Prolonged Decelerations
 Decelerations that are a decrease from the FHR
baseline of 15 beats/min or more and last longer
than 2 to 3 minutes but less than 10 minutes.
 May signify a significant event, such as cord
compression or maternal hypotension.
 Must be reported and documented.
Variable Decelerations
 decelerations that occur at unpredictable times in
relation to contractions.
 May indicate compression of the cord, which can be
an ominous development in terms of fetal well-being
Cord compression- may be occurring because of a
prolapsed cord, but it most often occurs because the
fetus is simply lying on the cord.
Sinusoidal Pattern
 In a fetus who is severely anemic or hypoxic, central
nervous system control of heart pacing may be so
impaired that the FHR pattern resembles a smooth,
frequently undulating wave with a cycle frequency of
3 to 5 per minute and persisting 20 minutes or more.
 Needs to be reported.
CARE OF A WOMAN DURING 1ST STAGE OF
LABOR
6 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 Provide Bladder Care impede fetal descent, so
caring support person during labor. encourage a woman to
 No interventions such as intravenous fluid should be void, if possible, at least
used routinely. every 2 to 4 hours during
 Women should be allowed to assume a nonsupine labor.
position such as upright and side lying for birth.
 Mother and baby should be housed together after
the birth, with unlimited opportunity for breastfeeding

CARE OF A WOMAN DURING 2ND STAGE OF

Nursing Diagnoses and Related Interventions LABOR
Nursing Diagnosis: Powerlessness related to duration of
labor
The second stage of labor is the time from full
Outcome Evaluation: cervical dilatation to birth of the newborn.
 Patient voices she feels in control of happenings  Some women react to this by growing argumentative
 Expresses preferences for positions and techniques and angry, or by crying and screaming.
to control pain  Other women react by tensing their abdominal
 Asks questions about her progress muscles and trying to resist pushing, thus making
 States feelings about what is happening the sensation even more painful and frightening.
 Holding the breath for a prolonged time, however,
Intervention impairs blood return from the vena cava (a Valsalva
Help Empower Women Most women want to feel maneuver), so this should be discouraged.
in control of what is  Encourage women to assume any position that is
happening to them during comfortable for them and breathe any way that is
labor in order to be able to natural for them, except by holding their breath while
face this big an event in they push
their life.
Respect Contraction Do not interrupt a woman
Time who is in the middle of Nursing Diagnosis: Pain related to uterine contractions
breathing exercises during and pressure on pelvic structures from labor
labor. Allow her to finish Outcome Criteria:
breathing with her
contraction, then ask  Patient manages her discomfort in labor with
questions or announce nonpharmacologic methods,
what procedure needs to  Identifies additional pain relief measures if needed,
be done next
 Responds to questions and instructions;
Promote Change of In early labor, however, a  States labor and birth were a positive experience for
Positions woman should be out of her.
bed walking or sitting in a
chair, kneeling, squatting,
on all fours, or in whatever
position she prefers
because active movement
can shorten the beginning
stage of labor
Help With Fetal A baby’s birth is easiest
Alignment from an ROA or LOA
position because a fetus
that presents in an LOP or
ROP position needs to
rotate into an anterior
position to be born. Either
squatting or an “all fours”
position may help the fetus
turn and shorten labor.
Promote Voiding and A full bladder or bowel can
 TIME INTERVALS FOR NURSING INTERVENTIONS
DURING THE SECOND STAGE OF LABOR

PREPARING THE PLACE OF BIRTH

 Open the sterile packs of supplies on waiting tables

when the cervix has dilated.
 Be certain drapes and materials used for birth are
sterile so no microorganisms can be accidentally
introduced into the uterus.
 A table arranged with equipment such as sponges,
drapes, scissors, basins, clamps, vaginal packing,
and sterile gowns, gloves, and towels can be left, if
covered, for up to 8 hours
 To provide for baby care, open the partition at the
end of the room to reveal the “baby island,” or
newborn care area.
 Turn on the radiant heat warmer in advance. Place
sterile towels and a blanket on the warmer.

POSITIONING FOR BIRTH

 Lithotomy position was the preferred position for

birth because it offers a clear view of the perineum,
but it is no longer a position of choice

 More effective birth positions include the lateral or

Sims position, a dorsal recumbent position (on the
back with knees flexed), semi-sitting, or squatting.
 Using these positions plus warm compresses to
the perineum place less tension on the perineum
and result in fewer perineal tears

The Water Birth

 with the increased buoyancy pregnant women feel

from the water helps them change positions easily; a
sitting posture helps with fetal descent (Impey &
Child, 2012).
 if the infant is born in the tub, he or she will be born
into as clean an environment as possible.
 Newborns have dive reflex
 Newborns, however, have a dive reflex, which
alerts them not to breathe while under water, so
this is not usually a problem. A dive reflex may
not be operative if the baby’s head is brought to
the surface before the entire baby is born so
 the timing of this is important.
PROMOTING EFFECTIVE SECOND-STAGE PUSHING
 A woman should wait to feel the urge to push even
though a pelvic exam has revealed she is fully
dilated (Lemos, Amorim, Dornelas de Andrade, et
al., 2015).
 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
 If there is a reason such as a nuchal cord (cord
located around the baby’s neck), which must be
removed before the infant is fully born, it may be
necessary to prevent a woman from pushing
immediately after delivery of the fetal head. To
help her do this, ask her to pant with
contractions.
 Remember: pushing is involuntary. Regardless
of how much a woman wants to cooperate,
stopping this
 overwhelming urge to push is almost beyond her
power.
 Demonstrating panting with her may be most
effective. Be sure she is inhaling adequately with
panting. Otherwise, she might hyperventilate
and become light-headed. Have her take deep
cleansing breaths between contractions to
prevent this.
PERINEAL CLEANING AND MASSAGE
 Massaging the perineum as the fetal head enlarges
the vaginal opening helps to keep it supple and
prevent tearing.
 Perineal flushing
The Birth
1. As soon as the
head of a fetus
is prominent
(approximately
8 cm across) at
the vaginal
opening ->
Ritgen
maneuver
Note: Pressure should never be applied to the fundus of
the uterus to effect birth because uterine rupture could
occur.
2. The woman is asked to continue pushing until the
occiput of the fetal head is firmly at the pubic arch. The
head is then gently born between contractions if
possible.
3. Immediately after birth of the baby’s head, the primary
care provider passes his or her fingers around the
newborn’s neck to determine whether a loop of umbilical
cord is encircling the neck.
4. After expulsion of the fetal head, external rotation
occurs (a woman can feel this happening by gently
touching the head if she wants to).
 Gentle pressure is then exerted downward on the
side of the infant’s head by the primary care provider
so the anterior shoulder is born.
 Slight upward pressure on the side of the head
allows the anterior shoulder to nestle against the
symphysis pubis and the posterior shoulder to be
born.
 The remainder of the body then slides free without
any further difficulty.
5. A child is considered born when the whole body is
born.
 This is the time that should be noted and recorded
as the time of birth, which is a nursing responsibility
(most primary care providers regard it as their
responsibility or pleasure to announce the sex of the
infant).
6. The newborn is immediately laid on the mother’s
naked abdomen and covered with a warmed blanket and
cap to conserve heat and encourage mother–infant
bonding
CUTTING AND CLAMPING THE CORD
 Delaying cutting (also called physiologic clamping)
until pulsation ceases and maintaining the infant at a
uterine level allows as much as 100 ml more of
blood to pass from the placenta into the fetus.
 Helps ensure an adequate red blood cell and white
cell count in the newborn (Popat, Robledo,
Sebastian, et al., 2016).
 Cutting the cord is part of the stimulus that
initiates a first breath or marks the newborn’s
most important transition into the outside world,
the establishment of independent respirations.
INTRODUCING THE INFANT
 The infant can remain on the mother’s abdomen for
skin-to-skin contact.
 Most newborns receive prophylactic eye ointment
against the possibility of a chlamydia infection.
 Optimal time for a mother to begin breastfeeding,
sucking at the breasts stimulates the release of
endogenous oxytocin, encouraging uterine
contraction and involution, or the return of the uterus
to its prepregnant state (World Health Organization,
2014).
 Don’t administer this until after the parents have
had this chance to see their infant for the first
time (and the infant has had a chance to see
them)
CARE OF A WOMAN DURING 3RD AND 4TH
STAGES OF LABOR
 The third stage of labor is the time from the birth of
the baby until the placenta is delivered.
The fourth stage of labor includes the first few hours
after birth
THE DELIVERY OF THE PLACENTA
 The placenta will be delivered spontaneously
following most births; 30 minutes is considered
normal.
 Inspect the placenta
 Normally, a placenta is one sixth the weight of the
infant, you may be asked to weigh it.
 If the mother’s uterus has not contracted firmly on its
own, the primary care provider will massage the
fundus to urge it to contract.
 Oxytocin (Pitocin 10 units) may be prescribed to be
administered (IM or IV)
 Excessive bleeding with poor uterine contraction
remains:
 Carboprost tromethamine (Hemabate) or
 methylergonovine maleate (Methergine)
 The administration of these drugs is a nursing
responsibility in most healthcare facilities.
Because Pitocin causes hypertension by
vasoconstriction, be certain to obtain a baseline
blood pressure measurement before
administration. Question the use of such a drug
if the woman had an elevated blood pressure
during pregnancy that is still present
THE PERINEAL INSPECTION
 Perineal tears are rated grade 1 to grade 4, grade 1
being minimal and grade 4 extending to and
including the rectum
Classification of perineal lacerations:
 If a tear is large enough to require suturing, a
woman usually has enough natural perineal
anesthesia from pressure of the fetal head or
enough effect from epidural anesthesia, she will
not feel pain from the suturing. If she does have
pain, a local anesthetic can be given to make
the process pain-free.
THE IMMEDIATE POSTPARTUM ASSESSMENT AND
NURSING CARE
 This is the beginning of the postpartal period or the
fourth stage of labor.
a) There is a high risk for hemorrhage during this
time (it is the most dangerous time of birth for
the mother).
b) VS q 15 for 1 hour
c) Wash perineum
d) Palpate a woman’s fundus
e) Observe the amount and characteristic of lochia
and record
 Return the birthing bed to its original position.
 Offer a clean gown and a warmed blanket because
a woman often experiences chills and a shaking
sensation 10 to 15 minutes after birth - reassure the
mother that this is a transitory sensation, is very
common, and passes quickly.
 This may be due to the low temperature of a
birthing room but may also be a result of the
sudden release of pressure on pelvic nerves or
of excess epinephrine production during labor.
Key points
 Labor is the series of events by which uterine
contractions expel a fetus and placenta from a
woman’s body.
 The exact reason why labor begins is unknown.
It most likely occurs because of an interplay
between fetal and uterine factors that registers
as progesterone withdrawal.
 Effective labor depends on interactions between
the passage, the passenger, the power of
contractions, and a woman’s psychological
readiness.
 Labor is an almost overwhelming experience
because it involves intense sensations and
emotions never felt before. Urge women to bring
a support person with them to help cope with the
experience. Orient and explain what is
happening to this person as well as the woman
in labor.
 The fetal presentation (the fetal body part that
will initially contact the cervix), the position (the
relationship of the fetal presenting part to a
specific quadrant of the woman’s pelvis), and
the lie (whether the fetus is presenting the head
or breech to the birth canal) are important
determinants of the success of labor.
 The first stage of labor lasts from the onset of
cervical dilatation until dilatation is complete (10
cm). The second stage extends from the time of
full dilatation until the infant is born. A third or
placental stage lasts from the time the infant is
born until after delivery of the placenta. A fourth
stage comprises the first few hours after birth.
 Danger signs of labor include an abnormal FHR,
meconium staining of amniotic fluid, abnormal
maternal pulse or blood pressure, inadequate or
prolonged contractions, development of an
abnormal lower abdomen contour, or increasing
apprehension.
 Monitoring of uterine contractions and FHR is an
important nursing responsibility.
 Fetal bradycardia, tachycardia, and FHR
variability are important observations to make.
 Interventions such as keeping a woman active
during labor and promoting voiding help to
strengthen contractions and make labor more
effective.
 Offering psychological support is crucial to
maternal well-being and helps in planning
nursing care that not only meets QSEN
competencies but also best meets the family’s
total needs.
 Pushing during the second stage of labor should
be guided by the woman’s need to push. Urge
her to breathe out while pushing, if possible.
 The placental stage follows birth and consists of
both placental separation and expulsion.
Observe for excessive bleeding during this time.
Do not pull on the cord to hasten separation
because this can lead to uterine inversion.
 A fetus is in potential danger when the
membranes rupture because of the possibility of
cord prolapse. Always assess FHR at this point
to safeguard the fetus.
 A woman is at potential risk for hemorrhage
throughout labor because of the possibility that
the placenta could dislodge. Following birth,
hemorrhage remains a possibility. Assess for
vaginal bleeding and vital signs during both
times to be certain this is not occurring.