PROCESS OF LABOR

AND DELIVERY
(INTRAPARTUM)
NURSING PROCESS OVERVIEW

- Labor and birth are enormous emotional and physiologic

accomplishments, not only for a woman but for her support person as
well.
- As a nurse you should facilitate interventions that make the
experience more positive and memorable for her.
Assessment:
- Assess how much discomfort a woman is having (E.g.Pain scale,Facial
tenseness,etc)
• Nsg. Diagnosis:
Planning:
-Review & education about normal labor process
- Planning must be flexible changing with the progress of labor and individualized,
allowing the woman to experience the significance of the event herself.
- Promotion of comfort is vital.
Implementation:
- Interventions in labor must be carried out in between contractions.
- Remember that whether a woman enjoys being touched or not during labor is in
part culturally determined.
The NCP for a woman in labor includes
• Providing information regarding labor and birth.
• Providing comfort and pain relief measures
• Monitoring mother’s vital signs and fetal heart rate.
• Facilitating postpartum care.
• Preventing complications after birth.
• Here are some Nursing Diagnoses for the different stages of labor;
Labor Stage IA: Latent Phase
• Deficient Knowledge
• Risk for Fluid Volume Deficit
• Risk For Fetal Injury
• Risk For Maternal Infection
• Risk For Ineffective Coping
• Risk For Anxiety
Labor Stage IB: Active Phase
• Acute Pain
• Impaired Urinary Elimination
• Risk For Impaired Fetal Gas Exchange
• Risk For Maternal Injury
• Risk For Ineffective Individual/Couple Coping
Labor Stage IC: Transition Phase
• Acute Pain
• Fatigue
• Risk For Decreased Cardiac Output
• Risk for Fluid Volume Deficit/Excess
• Risk for Ineffective Coping
Labor Stage II: Expulsion
• Acute Pain
• Altered Cardiac Output
Labor Stage III: Placental Expulsion
• Acute Pain
• Knowledge Deficit
• Risk For Fluid Volume Deficit
• PREPARING FOR LABOR
• At about the midpregnancy, along with cautioning women about
discomforts of pregnancy and possible teratogen situations, it is time
to review the events that signal the beginning of labor so that women
will not be surprised by these happenings or dismiss them as
something other than what they are.
• Although the exact mechanism that initiates labor is unknown.
Theories have been proposed to explain how and why labor occurs.
Uterine Stretch Theory
• The idea is based on the concept that any hollow body organ when
stretched to its capacity will inevitably contract to expel its contents.
The uterus, which is a hollow muscular organ, becomes stretched due
to the growing fetal structures. In return, the pressure increases
causing physiologic changes (uterine contractions) that initiate labor.
Oxytocin Theory
• Pressure on the cervix stimulates the hypophysis to release oxytocin
from the maternal posterior pituitary gland. As pregnancy advances,
the uterus becomes more sensitive to oxytocin.
• Presence of this hormone causes the initiation of contraction of the
smooth muscles of the body (uterus is composed of smooth muscles).
Progesterone Deprivation Theory
• Progesterone is the hormone designed to promote pregnancy. It is
believed that presence of this hormone inhibits uterine motility. As
pregnancy advances, changes in the relative effects estrogen and
progesterone encourage the onset of labor. A marked increase in
estrogen level is noted in relation to progesterone, making the latter
hormone less effective in controlling rhythmic uterine contractions.
• Also, in later pregnancy, rising fetal cortisol levels inhibit progesterone
production from the placenta. Reduce progesterone formation
initiates labor.
Prostaglandin Theory
• In the latter part of pregnancy, fetal membranes and uterine decidua
increase prostaglandin levels. This hormone is secreted from the
lower area of the fetal membrane. A decrease in progesterone
amount also elevates the prostaglandin level. Synthesis of
prostaglandin, in return, causes uterine contraction thus, labor is
initiated.
Theory of Aging Placenta
• Advance placental age decreases blood supply to the uterus.
• This event triggers uterine contractions, thereby, starting the labor.
What is normal labor and delivery?
• In 1997,the WHO defined normal birth as "spontaneous in onset, low-
risk at the start of labor and remaining so throughout labor and
delivery. The infant is born spontaneously in the vertex position
between 37 and 42 completed weeks of pregnancy
Preparation for Labor and Delivery
Beginning/Prodromal Signs of Labor
• Lightening – Is the settling of the fetal head into the inlet of true
pelvis at approximately 2 weeks before labor in primiparas but
unpredictable among multiparas.
• Show – the common term used to describe the release of cervical
plug(operculum) that formed during pregnancy. It consists of mucous,
bloodstreaked vaginal discharge and indicates the beginning of
cervical dilatation.
• Rupture of the Membranes – a sudden gush of clear fluid(amniotic
fluid) from the vagina indicates rupture of membranes(danger for
cord prolapse and uterine infection).
• Excess Energy(“Nesting”) – feeling extremely energetic, part of the
body’s physiologic preparation for labor.
- Advise not to exhaust her energy but rather conserve it in preparation
for labor.
• Uterine contractions (Braxton-Hicks) – for most women, labor begins
with contractions
• True labor contractions usually start in the back and sweep forward
across the abdomen like the tightening of a band. They gradually
increase in frequency and intensity
• Cervical changes – there is “ripening of the cervix”. It changes from
being long and close with a firm consistency to shortened, thinned,
dilated and becomes butter-soft
Intrapartal care
• Is the care of the mother undergoing labor and delivery.
• Labor – is the bridge between pregnancy and motherhood and for the
laboring woman, it often is the most intense experience of the
pregnancy.
• Finally, the neonate is going through the transition between
intrauterine and extrauterine life.
Definition of Labor
• As the onset of regular contractions with progressive effacement and dilatation of
the cervix accompanied by decent of the presenting part leading to expulsion of the
fetus or fetuses and placenta from the mother.
PHYSIOLOGY OF LABOR
• LABOR (Parturition) – the physiologic process by which the fetus, placenta and
membranes are expelled from the uterus. It has four stages.
4 STAGES OF LABOR
I. Stage of Dilatation
II. Stage of Expulsion
III. Placental Stage
IV. Stage of Recovery
• SIGNS OF TRUE LABOR
• 1. Uterine contractions – the surest sign that labor has begun is the
initiation of effective, strong, productive uterine contractions.
Pain in uterine contractions results from:
- Contractions of uterine muscles when in an ischemic state.
- Pressure on nerve ganglia in the cervix and lower uterine segment.
- Stretching of ligaments adjacent to the uterus and in the pelvic joints
- Stretching and displacement of the tissues of the vulva and perineum
• PHASES OF UTERINE CONTRACTIONS
• Increment or Crescendo
• Acme or apex
• Decrement or decrescendo
2. Effacement
3. Dilatation
4. Uterine changes
FETAL MONITORING
- FHT should not be mistaken for uterine soufflé
- Normal range – 120-160 bpm
- It should not be taken during a uterine contraction because it tends to decrease.
- Should be taken every hour during the latent phase, every half hour
during the active phase and every 15min during the transition phase - -
- For any abnormality in FHR, just change mother’s position as initial
nursing action
MONITORING OF DURATIONS,
INTERVAL, FREQUENCY AND
INTENSITY
• DURATION – from the beginning of one contraction to the end of the same contraction(A to B).
From increment to decrement.
• INTERVAL – from the end of one contraction to the beginning of the next contraction(B to C).
• FREQUENCY – from the beginning of one contraction to the beginning of the next contraction(A to
C).
- Time 3-4 contractions to have a good picture of the frequency of the contractions.
• INTENSITY
is the strength of contractions at the acme.
 maybe mild, moderate or severe.
The duration of a contraction should not be longer than 90 seconds nor should the interval be less
than 60 seconds.
Contractions lasting longer than 90 seconds reduce uteroplacental circulation because of prolonged
compression of the vessels.
Factors Affecting Labor and Delivery Process
• Also known as the 5P’s or 5 components of labor
• 1. PASSAGEWAY(birth canal)
• 2. PASSENGER ( fetus)
• 3. POWERS (uterine contractions)
• 4. POSITION OF THE MOTHER
• 5. PSYCHOLOGIC RESPONSE OF THE MOTHER( psyche)
PASSAGEWAY
• Refers to the woman’s pelvis or birth canal
• It is the route a fetus must travel from the uterus thru the cervix and
vagina to the external perineum
• it is composed of the Ilium, ischium and pubis, the sacrum and the
coccyx.
• The PELVIS is divided into:
• 1. False pelvis – is the shallow upper section of the pelvis.
• 2. True pelvis – is the lower curved bony canal including the inlet,
cavity and outlet.
- The size and shape of the true pelvis must be adequate for the fetal
head to pass through for a vaginal birth. This is determined thru
palpation, ultrasound and pelvimetry.
STATION – refers to the relationship between the ischial spine in the
passage and the presenting part of the fetus.
• Station 0 = level of the ischial spine. =Synonymous with
“engagement”.
• Station -1=presenting part above the level of the ischial spine
• Station +1= presenting part below the level of the ischial spine
• Stations +3 or +4 – the presenting part is at the perineum & can be
seen if vulva is separated =synonymous with “crowning”.
• ENGAGEMENT – is a term which indicates that the largest diameter of
presenting part has passed through the inlet into the true pelvis
• Four Types of Female Pelvis
• 1. Gynecoid – most common type(50%)
• 2. Anthropoid – 2 nd most common
• 3. Platypelloid – least common type(3%)
• 4. Android – narrow arches. Increased the likelihood of caesarian and
forceps deliveries.
PASSENGER
• The ease with which the passenger goes through the pelvis is
determined by many fetal factors:
• a. Fetal head size(fetal skull) – from an obstetrical point of view, the
fetal skull is the most important part of the fetus because:
• It is the largest part of the body.
• It is the most frequent presenting part.
• It is the least compressible of all parts.
• Fetal head is composed of bony parts consisting of:
• a frontal bone
• 2 parietal bones
• 2 temporal bones
• an occipital bone
• The skull bones are united by membranous sutures and the points of intersection of
these are called fontanels.
• The two most important fontanels for delivery are the anterior & posterior fontanels.
• The fontanels are important during the birth process because they allow molding to
occur.
• Molding – is the overlapping of the fetal skull that helps the fetal head
to adapt to the size and shape of the maternal pelvis.
B. Fetal Presentation – refers to the anatomic part of the fetus that is
either in or closest to the birth canal . It is determined by performing a
vaginal examinations and feeling the part through the cervix.
3 Major Presentations;
1. Cephalic(96%)
2. Breech or buttocks( 3%)
3. Shoulder(1%)
• Presenting Part – is the fetal part which enters the pelvis first and covers
the internal cervical os.
I. Vertical
a. Cephalic – head is the presenting part(vertex, face, brow and
chin/mentum).
b. Breech –buttocks are the presenting parts (complete, frank and
footling).
II. Horizontal – transverse lie – shoulder presentation.
c. Fetal Lie – describes the relationship of the fetal long axis(head to foot)
to that of the maternal long axis or spinal cord.
• Longitudinal lie – when the fetal cephalocaudal axis is parallel to the
mother’s.(99% of term pregnancies have this)
• Transverse lie – when the fetal cephalocaudal axis is at a right angle to
the mother’s.
d. Fetal Attitude
- refers to the relationship of fetal body parts to one another (V,S,B,F). -
The typical fetal attitude include flexion of the head wherein the chin
rest on the sternum, the arms and legs are flexed against the chest and
the back is bowed out. Whereas, extension if any part is extended.
e. Fetal Position
• refers to the relationship of the fetal presenting part to the left or right
side of the maternal pelvis.
• The pelvis is divided into four quadrants; ( RA, RP, LA, LP).
• POINTS OF DIRECTION IN THE FETUS
• Occiput – in vertex presentations.
• Chin( mentum) – in face presentations.
• Sacrum – in breech presentations.
• Scapula – (acromio) in horizontal presentation.
• POWERS
• the primary power during labor is the involuntary contractions of the
uterus which cause cervical effacement and dilatation during the first
stage of labor
• the secondary power is the voluntary use of the abdominal muscles
by the mother to push during the second stage of labor
• UTERINE CONTRACTIONS
• The smooth muscle of the uterus has the ability to contract and relax
rhythmically
• the “relaxation period” between contractions allows the muscles and
the mother to rest and also restores uteroplacental circulation, which
is important for fetal oxygenation and effective circulation in the
uterus.
• Contraction begins in the fundus and spread over the uterus in about
15 seconds.
UTERINE RETRACTION
• the muscle fibers of the uterus have the unique property of
remaining permanently shortened to a small degree after each
contraction.
• as the muscle fibers in the fundus retract, the lower uterine segment is
pulled up
• These 2 actions efface and dilate the cervix
STAGES OF LABOR
A. First Stage
Power/Forces – Involuntary uterine contractions
3 Phases of Labor
I. Latent
• early time in labor
• Cervical dilatation is minimal
• Cervix dilates 3-4 cm only
• Contractions are of short duration and occur regularly 5-10 minutes
apart.
• Mother is excited with some degree of apprehension but still with
ability to communicate
II. Active/Accelerated
• Cervical dilatation reaches 4-8 cm
• Rapid increase in duration, frequency and intensity of contractions.
• III. Transition Phase
• Cervical dilatation reaches 8-10 cm
• Mood of the woman suddenly changes and the nature of the contractions
intensified
• Show becomes more prominent
• If membranes are still intact, this period is marked by a sudden gush of AF
as fetus is pushed into the birth canal
B. Second Stage
• Power/Forces – involuntary uterine contractions and contractions of the
diaphragmatic and abdominal muscles.
MECHANISMS OF LABOR (Mnemonic: D-FIRE-ERE)

• 1.Descent– fetus goes down in the birth canal.

• 2.Flexion- as descent occurs, pressure from the pelvic floor causes the
chin to bend forward unto the chest.
• 3.Internal Rotation- from AP to transverse then AP to AP.
• 4.Extension- as head comes out, the back of the neck stops beneath the
pubic arch. The head extends and the forehead, nose, mouth, and chin
appear
• 5. External Rotation - also called “restitution” - anterior shoulder rotates
externally to the AP position.
• 6. Expulsion - delivery of the rest of the body.
• MOTHER’S PUSHING
• once the cervix has dilated completely, it’s time for the fetus to navigate thru
the mechanisms of labor
• mother has to take a deep breath, hold her breath and voluntarily push in a
Valsalva-type bearing down throughout a contraction(this” pushing
technique” is directed by the nurses and or physicians)
• Ferguson’s Reflex
• the spontaneous onset of the urge to bear down which is triggered when the
presenting part reaches the pelvic floor where stretch receptors in the
posterior vagina cause the release of Oxytocin which increases the pushing
sensation
POSITION OF THE MOTHER
• Contractions are affected by the mother’s position. If mother lies on her back,
contractions are more frequent but less intensity
• If mother lies on her side, contractions are less frequent but have greater intensity
thus, a sidelying position improves progress in labor as well as prevent supine
hypotensive syndrome
PSYCHOLOGIC RESPONSE OF THE MOTHER or PSYCHE
• refers to the mother’s attitude towards labor and her preparation for labor
• Cultures shape values about and responses to childbirth
• Anxiety and/or fear causes the mother’s body to secrete catecholamine which
suppress uterine contractions and restrict placental blood flow
ADDENDUM:
• 2nd Stage of Labor – at this time an episiotomy or incision in the
perineum to facilitate passage of the baby may be performed.
• Types of Episiotomy
• a. Median – from middle portion of the vaginal border directed towards
the anus
• b. Medio-lateral – begin at the midline but directed laterally away from
the anus
• Natural anesthesia is used in episiotomy or as per OB doctor’s
preference.
• 3rd Stage of Labor – Signs that the placenta has separated should be
observed about 5-10 min. after birth of the baby(max. of 20min)
• Signs of Placental Expulsion
• Calkin’s sign or globular shape of the uterus.
• Sudden gush of blood from the vagina.
• Lengthening of the cord from the vagina.
• Upward movement of the fundus.
• TYPES OF PLACENTAL DELIVERY
• a. Schultze presentation – the placenta separate first at the center
and presents the shiny and glistening fetal surface(most common-
80%).
• b. Duncan presentation – placenta separates first at its edges, slides
along the uterine surface and presents the maternal surface(20%). - it
looks raw, red and irregular with the ridges or cotyledons
showing(normal: 15-28 cotyledons).
DANGER SIGNS DURING LABOR & DELIVERY
Maternal Danger Signs
• High or low BP – > 140/90mmHg
• Abnormal pulse – normal is 70-80 bpm
• Inadequate or prolonged contractions
• Pathologic retraction ring – may be a sign of extreme uterine stress or possible
impending uterine rupture
• Abnormal lower abdominal contour – if a woman has a full bladder during labor
• Increasing apprehension – can be a sign of Oxygen deprivation or internal
hemorrhage
Fetal Danger Signs
• High or low FHR – An FHR of more than 160bpm(fetal tachycardia) or
less than 120bpm(fetal bradycardia) is a sign of possible fetal distress.
• Meconium staining – may indicate that fetus is experiencing hypoxia
which stimulates the vagal reflex and leads to increase bowel motility. It
may be normal in breech presentation.
• Hyperactivity – may be a sign that hypoxia is occurring because frantic
motion is a common reaction to the need for Oxygen.
• Oxygen saturation – normal fetal O2 sat is 40-70%. Under 40 indicates
acidosis which suggests that fetal well-being is becoming compromised.
• CARE OF CLIENTS EXPERIENCING LABOR AND DELIVERY PROCESS
a. Care of a Woman during the 1ST Stage of Labor
• Managing pain by breathing exercises and pain relief
• Help the woman feel confident in her ability to control the pain and
progress of labor
• Respect contraction time
• Promote change of position e.g. early labor – woman may be out of
bed, squatting, walking or in whatever position she prefers
• Promote voiding and bladder care – encourage to void if possible
every 2-4 hours
• Avoid hyperventilation – occurs when a woman exhales more deeply
than she inhales resulting to extra CO2 is blown off = Respiratory
alkalosis
• Offer support – there is no substitute for personal touch and contact
as a way to provide support during labor
• Respect and promote the support person at the birthing area and
allow him/her to remain with the woman throughout the birth
• Encourage hydration to avoid risk for fluid and volume deficit due to prolonged lack of oral
intake and diaphoresis from the effort of labor
b. Care of a Woman during the 2nd Stage of labor
• Actively assist the mother in the descent of the fetus by contracting the abdominal muscles
and bearing down with each contraction – should have sense of control.
• Coach her as she pushes.
Effective pushing in upright or squatting position – flexes chin on her chest and bends over her
uterus – with elbows bent, pull on her flexed knees then exhales and vocalizes when pushing.
c. Care of the woman during the 3rd Stage
• As uterus continues contracting, explain to the mother the signs of placental separation
usually 5-10 min. after birth
• Uphold cultural expectation of the placental disposal.
d. Care of a Woman during the 4th Stage
- As the mother’s body begins with its physiological readjustment, tell her that:
• blood loss is usually 250- 500 ml.
• there’s moderate decrease in the systolic and diastolic BP and an increase in PR.
• Uterus should remain contracted to control bleeding and be positioned in the
midline of the abdomen at the level of the umbilicus.
- Offer food and drinking beverage to her.
- Be at bedside as shaking chill may be experienced in response to the ending of
physical work of labor.
- Urinary retention might be experienced as the bladder may be hypotonic due to
either trauma during 2nd stage and/or to decrease sensation from anesthesia
PHYSICAL & PSYCHOLOGICAL PREPARATION OF THE CLIENT
• Explanation of the procedure.
• Securing informed consent.
• Providing of safety, comfort and privacy. o proper positioning- to
avoid contractures.
- Draping – provides privacy & preserve dignity.
- Constant feedback
- Therapeutic touch – the use of touch to comfort and relieve pain
MONITORING OF PROGRESS OF LABOR AND DELIVERY
1. It is important to determine which stage of labor the mother may be in at the time of admission
2. Establish nurse-client relationship
- making the woman & her partner or family feel welcome
- Determining their expectations about the birth
- Identify cultural values related to birth process
3. Prenatal record is provided to the client for filling up
4. Perform physical assessment/exam
- vital signs (BP,PR, RR,Temperature)
- Auscultations of heart and lungs
- Leopold’s maneuver to determine fetal lie and presentation
- Check FHT
- Assess uterine contractions for frequency, duration and intensity
- Nitrazine test if mother is not sure whether the membranes have ruptured
- Vaginal exam to det. cervical dilatation/station
- Inspection for signs of edema of face, hands, legs or generalized edema
- Provision of Personal Hygiene, Safety and Comfort Measures
- Perineal care= thus promoting hygiene
- Management of labor pains and bladder and bowel elimination= thus
promoting comfort and safety
Coping Mechanisms of Woman’s Partner and Family of the Stresses of
Pregnancy, Labor, Delivery and Puerperium
– the support person many times is the father but it could be anyone
close to the mother
Some breathing techniques used during the coping stage of labor:
1. Breathing techniques – has three patterns:
a. Slow, deep chest breathing – inhales thru the nose and exhales thru pursed lips(6-
9bpm)
b. Shallow breathing – inhales and exhales thru the mouth about 4 times every 5
seconds. This may increase to 2 breaths/second the usually at the peak of a contraction
c. Pant-blow breathing – generally used when the contractions become very
intense.Similar to shallow breathing except that every 3-4 breaths are forceful
exhalation thru pursed lip
2. All clients and significant others should be kept informed of the progress of labor.
3. Positive feedback to the client and support person is also important.
PREPARATION OF THE LABOR & DELIVERY ROOM

A. Labor Room – should be relaxed and more comfortable to stay. Nurse and client
should establish rapport.
• Greet client in a calm and pleasant manner
• Escort client and orient to the physical set-up to the facility e.g. restrooms, phone.
• Explain monitoring equipment or other unfamiliar technology e.g. Doppler device
• Let client sign informed consent or advanced directives must be told/made.
• Identification bracelet is placed.
• Preparation of client’s bed and assist in positioning of client.
• ask all the necessary things needed by the mother and baby.
B. Delivery Room – according to hospital protocol. All equipment should be ready and
functional.
• PREPARATION OF HEALTH PERSONNEL
• Usually the doctor (OB) doing the prenatal is the one who will assist
the pregnant mother on the day of her delivery.
• All documents of the client should be secured by the personnel,
intact and ready for future reference.