INTRAPARTUM

PROCESS OF LABOR
AND DELIVERY
Ch-15-p327
Objectives:
After conveying theObjectives
lesson;
1. Describe
1.Describe common common theories
theories explaining
the onset of labor and
explaining thethe role ofof labor
onset
passenger,
and passage,
the rolepowers and psyche in
of passenger,
labor
passage, powers and psyche
2.Assess family in labor and birth and
in labor
identify woman’s readiness, stage and
progression
3.Formulate nursing diagnoses related to
physiologic and psychological aspects of
labor and delivery
4.Implement nursing care for students
during labor such as teaching the stages
of labor
5.Evaluate the expected outcomes
Intrapartal period
- period spanning labor and
birth
- Labor begins between 37
and
42 weeks of pregnancy
-fetus is sufficiently mature to
adapt extrauterine life
-
Labor
- Series of events by which
uterine contractions and
abdominal pressure expels a
fetus and placenta from a
woman’s body
Theories of Labor Onset
❑ Oxytocin Stimulation
Theory
❑ Uterine Stretch Theory
❑ Progesterone
Deprivation
Theory
❑ Prostaglandin Theory
Theories Why Labor Begins?
1.The uterine muscle stretches
from the increasing size of the
fetus , resulted in the release of
prostaglandin
2.The fetus presses on the cervix ,
which stimulates the release of
oxytocin from the posterior
pituitary
3.Oxytocin stimulation works
together with prostaglandin to
initiate contraction
Theories Why Labor Begins?
4. Changes in the ratio of estrogen
to progesterone, which is
interpreted as progesterone
withdrawal
5. The placenta reaches a set age,
which triggers contractions
Theories Why Labor Begins?
6. Rising fetal cortisol levels
reduce progesterone formation
and increases prostaglandin
formation
7. The fetal membrane begins to
produce prostaglandins, which
stimulate contraction
Question?
Does coitus help induce labor?
Answer:
Semen does contain prostaglandin,
which can be helpful in softening , also
known as “ripening” of the cervix, if a
cervix is ready to ripen, semen
prostaglandin could possibly stimulate
the beginning of contractions.
Rhythmical contractions brought on
by woman orgasm can conceivably
help as well
 Oxytocin Stimulation Theory
⚫Oxytocin
❑stimulates uterine contraction
Near term:
❑↑ oxytocin production by posterior
pituitary gland
❑↓oxytocinase production
- hormones that counteract the effect
of oxytocin
 Uterine Stretch Theory
⚫Any narrow organ when
stretch to capacity will
contract and empty
⚫Distention of the uterus
creates pressure on the
nerve endings
◦ Stimulates the uterine
contractions
 Progesterone Deprivation
Theory
⚫Progesterone
◦ maintains pregnancy by its
relaxant affect on smooth
muscles of the uterus
Near term:
⚫↓ progesterone production of the
by the placenta
Note: Uterine contraction occurs
when the level of the
progesterone drops
 Prostaglandin Theory
⚫Prostaglandin
◦ Hormone that helps initiates uterine
contractions
⚫Arachidonic acid
◦ Produced by fetal membranes
◦ which converted by the maternal
deciduas into prostaglandin
During labor:
⚫↑ level of arachidonic acid in amniotic
fluid
◦ increase production of prostaglandin

13
 Other Factors
⚫Uterine muscle stretching
◦ Results in prostaglandin release
⚫Pressure on the cervix
◦ stimulates the release of oxytocin from the posterior
pituitary
◦ Oxytocin stimulation works together with
prostaglandins to initiate contraction
⚫Change in the ratio of estrogen in relation to
progesterone
◦ increasing estrogen in relation to progesterone
stimulates uterine contractions
⚫Placental age
◦ triggers contractions
⚫Rising fetal cortisol
◦ ↓progesterone formation and ↑ prostaglandin
formation
⚫Fetal membrane production of prostaglandin
◦ Stimulates contractions
 Components of Labor
A successful labor depends on
four integrated concepts,
“The 4 P’s”
1.The passage (a woman’s
pelvis) is of adequate size
and contour
2.The passenger (the fetus) is
of appropriate size and in an
advantageous position and
presentation
 Components of Labor
3. The power of labor (uterine
factors) are adequate
4. The psyche a woman's
psychological state which
may either encourage or
inhibit labor. This can be
based on her past life
experiences as well as her
present psychological state
 The Passage
⚫Pelvic shape
⚫Pelvic measurement
◦ Diagonal conjugate
◦ True conjugate or conjugate
vera
◦ Ischial tuberosity diameter
 Diagonal conjugate
⚫ Distance between the
anterior surface of the
sacral prominence and the
anterior surface of the
inferior margin of the
symphysis pubis
⚫ Most useful measurement
for estimation of pelvic
size
⚫ More than 12.5cm
Pelvic
measureme
True conjugate or conjugate
vera
⚫ Measurement between
the anterior surface of
the sacral prominence
and the posterior surface
of the inferior margin of
the symphysis pubis
◦ the anterior-posterior
diameter of the pelvic
inlet
⚫ ave. 10.5cm to 11cm
Ischial tuberosity diameter
⚫ Distance between the
ischial tuberosities or
the transverse
diameter of the outlet
⚫ Ave. 11cm
 1.⚫The Passage
Pelvic shape
- route a fetus must travel
from the uterus through the
cervix and vagina to the
external perineum
Pelvic shape
• Gynecoid
• Android
• Anthropoid
• Platypelloid
2. The Passenger (The Fetal Skull)
• The body part of the
fetus that has the wider
diameter is the head ,
least likely to be able to
pass thru the pelvic ring
Importance
1. Largest part of the body
2. Most frequent
presenting part
3. Least compressible of all
parts
⚫ membrane-covered spaces at
the junction of the main
suture lines
1. Anterior fontanelle
◦ the larger, diamond-shaped
fontanel which closes between
12 to 18 months in an infant
2. Posterior fontanelle
◦ the smaller, triangular shaped
fontanel which closes between
2 to 3 months in the infant

Fontanelles
Fetal Presentation and Position
 ⚫Relationship of
the fetal
presenting part to
a specific
quadrants in the
mother’s pelvis
Fetal Position
4 quadrants of pelvis
• Right anterior
• Left anterior
• Right posterior
• Left posterior on the
maternal sacrum
• Posterior positions result in
more backaches because of
pressure of fetal presenting
part

28
 Fetal Attitude
⚫Describes the degree of flexion a fetus assumes
during labor
⚫Relationships of the fetal parts to each other
⚫Types:

Sinciput Brow Face

Vertex
•moderate flexion •partial • full flexion
•full flexion
•military attitude extension 29 • complete extension
 Fetal Presentation and Position
• Fetus is in good attitude is in complete flexion
• Spinal column is bowed forward
• Head is flexed forward, chin touches the sternum
• Arms are flexed and folded on the chest
• Thighs are flexed onto the abdomen
• Calves are pressed against the posterior aspect of the thigh

Vertex
full flexion
 Fetal Presentation and Position
• Fetus is in moderate flexion if the chin is not touching the
chest but is in alert or “military position”

Sinciput
•Moderate flexion
•military attitude
 Fetal Presentation and Position
• Fetus is in partial extension presents the “Brow” of the
head to the birth canal

Brow
•partial
extension
 Fetal Presentation and Position
• Fetus is in complete extension , the back is arched , neck s
extended , presenting the occipitomental diameter of the
head to the birth canal (face presentation

Face full
flexion
• complete
extension
 Fetal Lie
⚫Lie is a relationship between
the long (cephalocaudal) axis
of the fetal body and the long
(cephalocaudal) axis of the
woman’s body
⚫Fetus is lying horizontally or
transverse or vertical
(longitudinal) position
⚫96% of fetus assume
longitudinal lie where their
long axis is parallel to the long
axis of the woman
 Longitudinal lie
⚫Cephalic – head is
the presenting part
⚫ breech – foot or
buttocks is the
position to contact
the cervix
• Relationship of the long axis of the mother to the
long axis of the fetus

Fetal Lie
❖ Presenting part is the fetal part which enters the pelvis
first and covers the internal cervical os

Presentation
 Cephalic presentation
⚫Most common type occur as
96%
4 Types of Cephalic presentation
1. vertex
2. brow
3. face
4. mentum

38
 Fetal Presentation
⚫breech – foot or buttocks is
the position to contact the
cervix
⚫4% of births
⚫Can cause difficult delivery
Attitude:
- a good attitude brings the
fetal knees up against the
abdomen
- a poor attitude means knees
and legs are extended
 3 Breech Presentation
⚫breech – foot or buttocks is
the position to contact the
cervix
⚫4% of births
⚫Can cause difficult delivery
Attitude:
- a good attitude brings the
fetal knees up against the
abdomen
- a poor attitude means knees
and legs are extended
 Engagement
• Settling of the presenting
part to the pelvis
• “Floating”, presenting
part is not engaged
• “Dipping” one that s
descending but not yet
reached the ischial spine
 Station
⮚ Relationship of the
fetal presenting part to
the level of the ischial
spines
• Station -1
– Presenting part above the
level of the ischial spines
• Station 0
– At the level of schial
spines
– Engagement
• Station +1
– Presenting part below the
level of the ischial spines
• Station +2
• Station +3 or +4
– Crowning
• Encircling of the
largest diameter of the
fetal head by the
vulvar ring
• Station -1
– Presenting part above the
level of the ischial spines
• Station 0
– At the level of schial
spines
– Engagement
• Station +1
– Presenting part below the
level of the ischial spines
• Station +2
• Station +3 or +4
– Crowning
• Encircling of the
largest diameter of the
fetal head by the
vulvar ring
Mechanisms of Labor
⚫Engagement
⚫Descent
⚫Flexion
⚫Internal rotation
⚫Extension
⚫Restitution
⚫External rotation
⚫Expulsion
 Engagement
◦Greatest transverse
diameter of the head
in vertex (biparietal
diameter)
passes through the
pelvic inlet (usually 0
station).
◦The head enters the
pelvis in the
transverse or oblique -
the inlet is a
transverse oval.

46
 Cardinal Movements of Labor
- Downward
movement of the
biparietal diameter
of the fetal head
within the pelvic
inlet
- Occurs due to
pressure on the
fetus by the uterine
fundus

Descent
 Cardinal Movements of Labor
- Full descent occurs when
fetal head protrudes
beyond dilated cervix and
touches the posterior
vaginal floor
- Mother experience
“pushing sensation” as
the pressure on the fetal
head presses on the sacral
nerve

Descent
 Cardinal Movements of Labor
- As descent is
completed and fetal
head touches the
pelvic floor , head
bends forward onto
the chest, causing the
smallest
anteroposterior
diameter to present to
the birth canal
- Flexion is aided by
abdominal muscle
contraction during
Flexion pushing
- During descent, the
biparietal diameter of
the fetal skull was
aligned to fit thru the
anterposterior
diameter of the
mother pelvis.
- As the head flexes at
the end of descent, the
occiput rotates so the
head is brought into
the best relationship to
the outlet of the pelvis
or the AP diameter is
now into the AP plane
of the pelvis
The movement
bring the shoulder
coming next into
the optimal
position to enter
the inlet, puts the
widest diameter of
the shoulder in
line with the wide
transverse
diameter of the
inlet
◦ As the occiput of the
fetal head is born,
the back of the neck
strips beneath the
pubic arch and act as
a pivot for the rest of
the head

◦ The head extends

and the foremost
part of the head ,
face and chin are
born

Extension
 External Rotation (Restitution)
◦ In external rotation, almost immediately after the head
of the infant is born , the head rotates a final time back
to the diagonal or transverse position of the early part
of labor, this bring the shoulder into AP position ,
which is best for entering the outlet
◦ The anterior shoulder is born first, assisted by
downward flexion of the infants head
 External Rotation

◦ While the head has been descending to the pelvic floor,

the shoulders have entered the pelvis and engaged with
the bisacromial diameter in the transverse or in an
oblique diameter
◦ With the descent, the leading (anterior)shoulder meets
the resistance of the side of the pelvic floor and is rotated
anteriorly toward the midline under the symphysis
◦ This movement brings the long axis of the shoulders in
line with the long axis of the pelvic outlet
◦ The movement of the shoulders causes the occiput to
rotate another 45 degrees, to the transverse position.
 Expulsion
◦ Delivery of the anterior
shoulder, posterior shoulder, and
the rest of the body.
◦ Vertex meets resistance from the cervix,
walls of the pelvis or the pelvic floor,
flexion results
◦ The chin is brought into contact with
the fetal thorax and the resenting
diameter is changed from
occipitofrontal to suboccipitobregmatic
(9.5 cms)
 - the third important
3. The Power
3. The Power of Labor

requirement for a
successful labor is
efficient power of labor
-force supplied by the
fundus of the uterus
implemented by uterine
contraction
-caused cervical
dilatation
-Expulsion of the fetus from
the uterus
 False Contractions
Begin and remain irregular
Felt first abdominally and
remain confined to the
abdomen and groin
Often disappear with
ambulation and sleep
Do not increase in duration,
frequency or intensity
Do not achieve cervical
dilatation
True Contractions
Begin irregularly but
become regular and
predictable
Felt first in lower back and
sweep around to the
abdomen in a wave
Continue no matter what is
the woman’s level of activity
Increase in duration,
frequency or intensity
Achieve cervical dilatation
Phases of uterine contractions
✔ Increment
✔ First phase during which the intensity of contraction
increases
✔ Crescendo
✔ Acme
✔ The height of the uterine contractions
✔ Apex
✔ Decrement
✔ Last phase during which intensity of contractions decreases
✔ Decrescendo
 Uterine Changes
1. Uterus is gradually differentiated into 2 distinct
portion
a. Upper uterine segment
● Becomes thick and active
◦ to expel out fetus
b. Lower uterine segment
● Becomes thin-walled, supple and passive
◦ so that the fetus can be pushed out easily

2. Physiological retraction ring is formed

 Uterine Changes
Pathologic retraction ring
⚫ Bandl’s ring
⚫ Abdominal indentation
⚫ Danger signs of labor
◦ Impending rupture of the uterus

63
• Pinkish vaginal discharge
• Blood-tinged mucus
• Operculum
• mucus plug
• Pressure exerted by the presenting part
• Result in rupture of several blood vessels in the cervix
• Cervix softens, ripens and dilates
• Show is released

Show
64
• Sudden gush or scanty, slow
seeping of clear fluid from
vagina
• Caused by:
• pressure of uterine
contractions
• dilatation of the cervix
• Instruct the woman to:
• come to the hospital when she
notices that her bag of water
has already ruptured
Rupture of membranes
65
● Labor is inevitable
●occur within 24 hours
1.Intrauterine infection
●Aseptic technique
●Doctors do less obstetrics
manipulation
◦ Enema is no longer needed
◦ Temperature should be taken
regularly
● Fever, sign of infection

66
3. Umbilical cord compression and/or
cord prolapsed may occur
✔ If seeking admission to the
hospital
● Put to bed immediately
● Take fetal heart tones
✔ In the labor room
● Take the fetal heart tones
Cord prolapsed
❖ Feels a loop of the cord coming
out of the vagina
❖ place in Trendelenburg position
❖ Reduced pressure on the cord
❖ Apply warm saline saturated os
on the prolapsed cord to prevent
drying of the cord
Note:
Labor will be induced if
labor has not occurred
spontaneously by 24
hours after rupture of
the membrane to reduce
the risk of infection
Preliminary/ Signs of True Labor
Prodromal Signs of
Labor ⚫Uterine contractions
⚫Show
⚫Lightening ⚫Rupture of membranes
⚫Increase level of activity
⚫Increased Braxton-hicks
contractions
⚫Ripening of the cervix
 Phases of uterine contractions
Remember:
✔In between contraction, uterus
relaxes
✔As labor progress, relaxation
interval decreases from 10
minutes early in labor to only 2-3
minutes
✔Duration of contraction increases
from 20-30 seconds at the
beginning to a range of 60-70
seconds by the end of the first
stage of labor
 Cervical Changes
2 changes:
❖Effacement
- shortening and thinning of the
cervical canal
- in primipara effacement is
accomplish before dilatation
begin
- in multipara, dilatation may
proceed before effacement is
complete
 Cervical Changes
2 changes:
❖Dilatation
- enlargement or widening of
the cervical canal
- wide enough to permit
passage of the fetus (10cm)
- occurs first before uterine
contraction, gradually
increases the diameter of
cervical canal
 Cervical Changes
2 changes:
❖Dilatation
- fluid-filled membrane push
ahead of the fetus
- an increase amount of vaginal
secretion (show), due to
ruptured minute capillaries in
the cervix
- mucus plug that sealed the
cervix is released
 Cervical Changes
2 changes:
❖Dilatation
- fluid-filled membrane push
ahead of the fetus
- an increase amount of vaginal
secretion (show), due to
ruptured minute capillaries in
the cervix
- mucus plug that sealed the
cervix is released
 Cervical Changes
2 changes:
❖Dilatation
- fluid-filled membrane push
ahead of the fetus
- an increase amount of vaginal
secretion (show), due to
ruptured minute capillaries in
the cervix
- mucus plug that sealed the
cervix is released
 Dilatation
⚫Enlargement of the
external cervical os up
to 10cm
◦ Primarily
●uterine contractions
◦ Secondarily
●pressure of the presenting
part and the BOW

Dilatation chart
Cervical dilation: 1 finger represents aprox 1.5 cm.
The fourth4. Theor Psyche
3. The Power of Labor

“P”, psychological
outlook of woman
- psychological state or feeling of a
woman in labor
✔ strong sense of self-esteem
✔ meaningful support person
✔ encourage to ask questions
✔ attend preparation for child birth
classes
✔ talk and share experiences
“debriefing time” to appreciate
everything
 3. The Power of Labor

Signs of LaborSigns of
✔Preliminary/Prodromal
Labor
⚫Lightening
⚫Increase level of activity
⚫Increased Braxton Hicks
contractions
⚫Ripening of the cervix

■ signs of true labor

 Lightening
⚫ “the baby drop”
⚫ Descent or settling of the presenting part to the pelvic brim or inlet
◦ Approximately 10 – 14 days before labor begin
⚫ Primiparas
◦ 2 weeks before labor onset
⚫ Multiparas
◦ just before or during labor
 Lightening
• EFFECTS OF LIGHTENING

• Relief from diaphragmatic pressure and shortness

of breath
• Increasing abdominal pressure results to:
– Shooting leg pains
• pressure on sciatic nerve
– ↑ amount of vaginal discharge
– Urinary frequency
• pressure on the bladder

81
 Increase level of activity

⚫↑ level of adrenalin or epinephrine

◦ Initiated by ↓ progesterone produced by the placenta
◦ the woman is highly energetic and active
⚫Energy can be use in labor and delivery
• Loss of Weight
• 2 -3 lbs, 1-2 days before labor onset
• ↓progesterone production
–↓ fluid retention

82
 Increased Braxton-Hicks contractions
• Irregular painless contraction of pregnancy become,
stronger, longer, more frequent enough to cause
discomfort and alarm to the mother
• Noticed during the last week or days before labor
begins
• Also known as false contractions

83
Internal signs seen only on pelvic
examination
✔ Ripening of the cervix
✔Cervix becomes butter soft and
tips forward
✔Internal announcement that
labor is near
✔Uterine contractions
✔Show
✔Rupture of the membranes

84
⚫Surest sign that labor
has begun is the ■Pain in the uterine
initiation:
◦ Effective uterine contractions results from:
contractions ✔Pressure on nerve
◦ Productive uterine ganglia in the cervix and
contractions lower uterine segment
◦ Involuntary uterine
contractions ✔Stretching of ligaments
adjacent to the uterus
and to the pelvic joints
✔Stretching and
displacement of the
Uterine Contractionstissues of the vulva and
perineum
85
DANGER SIGNS DURING LABOR
▪ High or low blood pressure
- 140/90mmHg
- gestational hypertension
- falling Bp must be reported
because it can be a sign of
intrauterine hemorrhage
- clinical sign of hypovolemic shock
- apprehension
- increased pulse
- pallor

Box 15.4 p 346 86

DANGER SIGNS DURING LABOR
▪ High or low blood pressure
- 140/90mmHg
- gestational hypertension
- falling Bp must be reported
because it can be a sign of
intrauterine hemorrhage
- clinical sign of hypovolemic shock
- apprehension
- increased pulse
- pallor

87
DANGER SIGNS DURING LABOR
▪ abnormal pulse
- 70-80 normal rate
- maternal rate of 100bpm must be
reported, it may indicate
hemorrhage

88
 DANGER SIGNS DURING LABOR
▪Inadequate or Prolonged Contractions
Normal: more frequent, intense and
longer as labor progress
Abnormal: less frequent, less intense,
or shorter in duration, this may
indicate uterine exhaustion (inertia)

As a rule: uterine contraction lasting

longer than 70 seconds are
becoming long enough to
compromise fetal well being , this
interfere with adequate uterine
filling 89
 DANGER SIGNS DURING LABOR
▪Abnormal lower abdominal contour
- if with full bladder during labor, a
round bulge appears on her lower
anterior abdomen
Danger signal for 2 reasons:
1.Bladder may be injured by the
pressure of the fetal head pressing
against it
2.Full bladder may not allow the fetal
head to descend

To avoid full bladder, advice to void

every 2 hours during labor
 DANGER SIGNS DURING LABOR
▪Increasing Apprehension
- should be investigated for physical
reasons because it can be a sign of
oxygen deprivation or internal
hemorrhage

Intervention:
Use therapeutic approach; “ You seem
more and more concerned , could you
tell me what is worrying you?
 Fetal danger signs of labor
▪High or Low Fetal Heart Rate
- fetal tachycardia-160 and above
- fetal bradycardia- below 110bpm
both are signs of fetal distress
Nursing Intervention:
- Monitor FHT

▪Meconium Staining
- manifested by green color amniotic
fluid
- cause fetal distress
- experiencing hypoxia, which
stimulates the vagal reflex and leads
to increased bowel motility
 Fetal danger signs of labor
▪ Meconium Staining
- may be common among breech
presentation due to pressure in the
buttocks causes meconium loss
- it should always be reported

▪ Hyperactivity
- signs of hypoxia because frantic
motion is a common reaction to the
need of oxygen
▪ Low oxygen saturation
- O2Sat normally among fetus is 40%
to 70%
Danger Signs of Labor and Delivery
1. Passage of meconium-stained
amniotic fluid in non breech
presentation
■ Fetal distress
2. Hypertonicity
■ Presence of persistent and
strong uterine contractions
3. Prolapsed of cord or any of the
small parts
4. Dystocia
■ Prolonged and difficult labor
5. Bleeding
1. Show should be
differentiated from bleeding
Danger Signs of Labor and Delivery
6. Non palpation of the fetal at the
lower abdomen
■ Associated with abnormal
presentation: breech or
shoulder
7. Excessive bleeding after birth of
the baby
■ Loss of 500 or more
8. Prolonged separation and
delivery of the placenta more
than 30 minutes
■ Placenta Accreta
■ Placenta is partially grown
into the endometrium
■ Placenta Increta
■ Placenta is totally grown
in the myometrium
 ⚫DANGER SIGNS DURING LABOR
AND DELIVERY
7. Excessive bleeding after
birth of the baby
■ Loss of 500 or more
8. Prolonged separation and
delivery of the
placenta more than 30 mins
■ Placenta Accreta
■ Placenta is partially
grown into the
endometrium
■ Placenta Increta
■ Placenta is totally
grown in the
myometrium