Topic 4.

3 Intrapartum
Nursing Care
 SLOs

 1. Describe the role of the practical nurse during labour and delivery (vaginal and caesarean section).
 2. Describe the role of the practical nurse in relation to the legal aspect of informed consent for the
client in labor and where consent would be required.
 3. Describe the initial nursing assessment of the client in labour including assessing of fetal
positioning.
 4. Describe fetal heart monitoring (FHM), including indications for FHM, initiating external FHM, the
process for managing abnormal fetal heart tracing, and the associated CLPNA standards of practice
 5. Describe the psychological support required by a client in labour and her partner.
 6.Describe the following medical interventions that may be required during labour and delivery, and
the appropriate nursing care:
 Vaginal exams
 Induction and augmentation
 Forceps birth
 Vacuum extraction
 Amniotomy
 Episiotomy
 Caesarean section and vaginal births after caesarean
 7. Describe the following interventions, and the appropriate nursing care that is performed
immediately after birth:
 cord blood sampling and
 examination of the placenta and cord structure
 8. Compare the outcomes and risks of a vaginal delivery versus a caesarean section for the client and
the newborn.
 9. Describe documentation and reporting of events and nursing interventions in labour and delivery.
LPN Scope of Practice in Intrapartum
Care

 Refer to CLPNA
Continuing Competency
Profile
 Category L – Maternal
& Newborn Care
 https://
www.clpna.com/lpn-
knowledge-hub/
competency-profile-
for-lpns-5th-edition-
complete/
 Overview of Care

Obtain admission history

Check results of routine lab tests and any special tests

(urinalysis, CBC, syphilis screening, GBS)

First Ask about birth plan

Stage of Physical assessment

Labour •
•
Vital signs
SFH
• Leaking amniotic fluid
• Any signs of impending birth (pushing, show)
• Contractions
• Frequency, length and intensity
• Cervical dilation and effacement

Fetal Condition (FHR, amniotic fluid)

Ongoing assessment & Nursing Care
of Mother
Time the contractions
Assess vitals, comfort, Contractions (duration, from beginning of one
observe behaviour frequency, strength) contraction to
beginning of next

Test amniotic fluid if Cervical dilatation –

Observe for “waters
unsure of waters this should not be done
breaking” and show
breaking (nitrazine test) DURING a contraction

Provide ongoing
Fetal station comfort and support
during this time.
Vaginal Exams

Determines:
Do not do vaginal exams
• Cervical effacement
• Cervical dilatation
when fresh bleeding is
• Fetal presentation, position present! Can be an
and station indicator placenta previa

Should be kept to a
minimum to prevent STERILE
infection
Rupture of Membranes
Assessment of the Fetus
Auscultation of the Fetal Heart Sounds

Electronic Monitoring

• External
• Internal

Fetal Heart Rate Patterns

• Baseline Fetal Heart Rate

• Variability – one of the best indicators of fetal well being
• when fetus moves baseline variability increases 5-15bpm
• if no variability then could be due to narcotics in labor, fetal hypoxia
• fetal bradycardia which is <110 bpm for 10min
• fetal tachycardia which is >160 bpm for 10 min
Fetal Decelerations

Decelerations are a drop in

the fetal heart rate.
Early decelerations
Baseline heart rate in labour
is 110 – 160bpm
Late decelerations
There are several types of
decelerations.
Variable Decelerations

Prolonged decelerations
 Stage 2 Labour Assessment
Assess for signs of stage 2

Assess contraction frequency,

duration, intensity

Vital signs

FHR

• Ensure delivery supplies are ready

Prepare for birth • Prepare baby warmer

Position for birth • Encourage to assume to most comfortable position for birth

• Wait until she has the urge to push then she should push with contraction and
Effective Pushing rest between

Birth • Clean perineum frequently

 During and immediately after delivery
 Clean perineal area
 Assist with birth (suctioning of baby, umbilical
cord clamping)

Stage 2  Provide immediate care of baby

Interventions  Drying and providing warmth
 Skin to skin contact
 Apgar score – p.617
 Identification of baby
Nursing Care: Stage 3 of Labour

 Assessment
 Assess placenta and fetal membranes
 Assess perineum for trauma
 Assist with episiotomy/laceration repair as required
 Nursing Care: Stage 4 of Labour

Assessment
Vital Perineal Comfort Bladder
Fundus Lochia
signs area level status

See Table 14.4 p. 512 Summary of Assessments During

the 2nd 3rd and 4th stages of Labour
See p. 516 for assessment postpartum
 Induction vs. Augmentation
Labour
Induction: labour is
started artificially
• Why would we induce
labor?
• Before inducing labor
assess for: fetal position,
cervical ripening,
presenting part engaged,
fetus is deemed mature
Labour Remember Question
Augmentation: *Always remember Question: Oxytocin
labour has begun, to assess fetal well is an important
medication is used being agent used to ripen
to assist the cervix for
“ineffective” labor labour induction?
• In what cases would we T/F
augment labor?
• Oxytocin or AROM
 Forceps delivery

Used only in about 4-8 % of deliveries

Can be used in:

• Physical inability to push with contractions
• Halt in second stage of labor
• Abnormal fetal position
• Prolapsed cord
• Marks are often left on baby’s face – disappear in 1 – 2 days
• FHR must be taken before forceps are applied and after as there is a risk of
cord compression

Forceps increase the risk of maternal injury

Forceps Delivery
Forceps Delivery
Forceps marks-will disappear in 1-3 days
 Vacuum Extraction

Only used in vertex presentation

Fetus has to be in birth canal, vacuum applied to posterior fontanelle

Used when:
Prolonged second stage Abnormal FHR Inability to push effectively

Leads to caput on newborn

Vacuum Extraction
Vacuum
Extraction

 Cannot be used with

premature infants, face
presentation
 Or when mom is unable
to assist with the
delivery process
 Amniotomy

The artificial rupture Allows fetal head to

of membranes contact cervix directly

Can happen accidently

Cervix must be dilated
when performing a
at least 3 cm
vaginal exam

There is a risk for

cord prolapse
Assess amniotic fluid • Assess FHR before and
immediately after!
Amniotomy
 Midline and Mediolateral Episiotomy
 done by doctor or midwife
 not many episiotomies performed now.
Research shows that tears heal better than
Episiotomy incisions.
 Only done if perineum is not stretching (rigid)
or if doing an instrumental delivery for a big
baby
Episiotomy
Surgical enlargement of the vagina during birth
 Perineal lacerations
First degree – vaginal mucous membrane
and skin of perineum

Second degree - above + involves

muscle

Third degree – above + extends to the

anal sphincter

Fourth degree – above + extends through

the anal sphincter
 Informed Consent

Who can be a witness In maternity nursing,

What is it? on informed consent what do we need to
documents? get consent for?
 Classic or low transverse incision

Major surgical procedure with accompanying

risks

Assessment:
Caesarean • History
Birth • Physical exam
• Fetal indications/assessments

Nursing management
• Preoperative care
• Postoperative care
• Think NFDN 2003 information
 Cesarean Birth

Scheduled Emergent
Fetal presentation Placenta previa
Infection that could be passed to fetus during birth (e.g., herpes Premature separation of placenta
type 2) Fetal distress
Cephalopelvic disproportion Failure to progress
Cesarean Section
Surgical delivery of fetus through incisions in the mother’s abdomen and uterus
 Cesarean Birth: Preoperative
Consent needed

Emergent: May be very little teaching done

Elective (“planned”) then teaching would include usual pre-surgical teaching.

• Pre-op teaching to prevent complications: deep breathing, incentive spirometry, ambulation
• NPO
• May have choice of anesthesia
• Partner can come into the OR
• Foley catheter, IV, skin prep, oral antacid
• When can see/hold baby
• Pain management

Baby may go to NICU

 Cesarean Birth

Many patients need debriefing after a

cesarean birth, especially if it was an
Mother is now POST – OP but is also a
emergency. They will always feel
new mother. Not just herself to think
grateful that their baby is safe but labor
about.
has not progressed as they had hoped
and they may still be disappointed.
Cesarean Birth
Vaginal Birth After Caesarean
(VBAC)

Controversy related to risk of uterine rupture and hemorrhage

Contraindications

Special focus areas

• Consent-fully informed
• Documentation-events/activities about client and fetal care
• Surveillance-of client/fetal progress and tolerance
• Readiness for emergency-incase there are problems need to be ready and so these
clients have to be in a hospital setting with emergency care on hand
Cord Blood Banking

 Collected after birth

 Can be used for stem cells
 Primitive hematopoietic stem and
progenitor cells available for clinical
application
 Can be banked:
https://www.healthcord.com/?gclid=Cj0K
CQjwy4KqBhD0ARIsAEbCt6hOpdmBjq
0atk4Xvl1gDMg6vSLebiodlIDuaPuasjJS
sT-eal3RhZ4aAuH6EALw_wcB
Vaginal vs. Caesarean Delivery

 Think about the

advantages &
disadvantages of each
delivery… If you were
given the choice of type
of delivery, what would
you choose?
 Webster, J., Sanders, C., Scott Ricci, S.,
Kyle, T., & Carman, S. (2020), Canadian
References Maternity and Pediatric Nursing, (2nd
Ed.). PA: Wolters Kluwer.