Intrapartal Nursing Care:
Labor and Birth
Linda L. Franco RN MSN NE-BC
Green = must know
Red = Important to know
Blue = history
Factors Important to Birth
• Birth Passage
• Baby
• Relationship Between the Passage and the
Baby
• Physiologic Forces of Labor
• Psychosocial Considerations
Birth Passage
• Consists of bony pelvis and soft tissues
• Bony Pelvis
– False pelvis above linea terminalis
– True pelvis below linea terminalis
• Types of pelvis
– Gynecoid – female, most common
– Android – male, usually not adequate
– Anthropoid – narrow from side to side, usually
adequate
– Platypelloid – narrow from back to back, usually not
adequate
Pelvic Types
Fetal Head
• Composed of bony parts that can assist or
hinder childbirth
• Bones involved in birth not fused
– 2 frontal bones
– 2 parietal bones
– occipital bones
• Sutures – membranous spaces between
cranial bones
Fetal Skull
Fontanelles
• Intersections of the cranial sutures
• Used in identifying position of fetal head and
assessing newborn after birth
– Anterior Fontanelle, diamond shaped, closes by 18
months
– Posterior Fontanelle, triangle shaped, closes by 2–
3 months
Landmarks of Fetal Skull
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Mentum – fetal chin
Sinciput – brow
Bregma – anterior fontanelle
Vertex – between anterior and posterior
fontanelles
• Occiput – occipital bone
Diameters
• Biparietal – major transverse diameter, average
9.25 cm
• Anterior-Posterior – varies with how much head is
flexed, most favorable when head is fully flexed
• Fetal Attitude – position of fetus
• Fetal Lie – position of fetus compared to mother
– Longitudinal
– Transverse
Fetal Presentation
• Cephalic (most common, what we want,
occurs 97% of the time)
– Vertex – occiput is presenting part (most
common)
– Military – head is in neutral position, top of
head is presenting part
– Brow – head partially extended, brow is
presenting part (tough on baby’s neck, could
have neck or shoulder injuries during delivery)
– Face – head hyperextended, face is presenting
part
Fetal Presentations con.
• Breech (occur in 3-4% of all births)
– Complete – both knees are flexed, buttocks and
feet present. Kind of sitting indian style
– Frank – buttocks presents to pelvis, legs are
usually up in front of the baby’s face
– Footling – one or both feet present to pelvis
• Shoulder Presentation
– Aka Transverse Lie, occurs in 0.3% of all births,
shoulder, arm, back, abd, or side is presenting. In
this case a C-section will be performed
Transverse Lie
• External Version
– Where they have the mom lay on her back in the
exam room and the dr tries to make the baby
move just by pushing it and turning the baby.
Usually doesn’t work
• Cesarean Section
– They will usually do this on these babies
• Assess FHR
– To make sure the baby isn’t in distress
Engagement
• When largest diameter of presenting part
reaches or passes through pelvic inlet
– If the baby is engaged it’s starting to drop down…
the top part of the pelvis is adequate, but they
may still have to have a c section
– Primigravida – 2 weeks before term
– Multigravida – several weeks or at onset of labor
Station
• Relationship of presenting part to an
imaginary line drawn at the ischal spines
(ischial spines mark the narrowest part thru
which a baby must pass)
– Zero station at level of ischial spines
– Negative numbers above ischial spines
• Baby hasn’t passed them yet
– Positive numbers below ischial spines
• After they’ve reached the spines and the baby’s head is
descending
Station
Fetal Position
• Relationship of the landmark on the presenting part
to the maternal pelvis
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Left (L) or Right (R)
Vertex – Occiput (O) (this is the one we want)
Face – Mentum (M)
Breech – Sacrum (S)
Shoulder – Acromion process (A)
Anterior(A), Posterior (P), or Transverse (T)
Could say LOP for left occiput posterior
Forces of Labor
• Primary - uterine contractions
– Increment – building up to the contraction, longest phase
– Decrement – the decline or letting up of the contraction
– Frequency – time between the beginning of one to the
beginning of the next
– Intensity – refers to the strength of the contraction at the
peak. Measured by palpating the fundus something or
other
• mild, moderate, and strong
– Duration – from the beginning of a contraction to the end
of that contraction
Psychosocial Considerations
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New role transition
Self expectations
Coping mechanisms
Support systems
Preparation for childbirth
Cultural influences
Fear
Enhancing birth experience
Psychosocial Factors
Physiology of Labor
• Causes
– Hormones
• Progesterone – relaxes smooth muscle tissue
• Estrogen – promotes uterine contractions, also helps soften
connective tissue which leads to the opening of the cervix
• Oxytocin
• Prostaglandins
• Fetal Cortisol
• Corticotropin-Releasing Hormone
– Uterine Distention
– Myometrial Activity
– Intraabdominal
Premonitory Signs of Labor
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Lightening – when the fetus begins to setting into the pelvic inlet, the uterus moves
downward and the fundus no longer presses on the diaphragm, the mom can breathe easier.
Also causes leg cramps, increased pelvic pressure and increased urine frequency, and
increases venous stasis which causes swelling of their lower extremities. Increased vaginal
secretions resulting from congestion of the vaginal mucosa
Braxton Hicks – irregular intermittent contractions that occur thru ought pregnancy. Can be
uncomfortable and exhausting to the mom
Cervical changes – at beginning of pregnancy it is firm, and over time it stretches and dilates.
The softening of the cervix is called ripening
Bloody show – the mucus plug is expelled and the result of that is small amount of blood
loss from the exposed cervical capillaries. That blood tinged secretion is called the bloody
show. Usually a sign that labor will begin in 24-48 hours
Rupture of Membranes – when the membranes do rupture the ambiotic fluid may be
expelled in large amounts… when you’re water breaks. Sign of impending labor, once this
happens the woman can’t get up and walk around
Sudden burst of energy – very common, approx 24-48 hours before labor, no one really
knows why they have this. May experience “nesting” at this time.
Other vague signs – weight loss of 1-3 lbs may occur, diarrhea, indigestion, N/V may occur
before labor, cause is unknown
True and False Labor
• True
– Regular contractions
– Cervical changes
– Contractions start in
back and radiate around
to abdomen
– Pain not relieved with
activity
• False
– Irregular contractions
– No cervical changes
– Contractions primarily in
abdomen
– Pain may be relieved
with activity
Stages of Labor
• Stage One – Effacement and Dilatation
– Latent Phase – 0-3 cm; able to cope, talkative, high excitement,
uterine contractions become established. Effacement begins, but
little or no fetal descent
– Active Phase – 4-7 cm; sense of helplessness, begins to fear loss of
control, pain level is much worse at this level and you can see
them kind of getting to the end of their rope. Contractions are
usually 2-3 mins apart and last about 60 seconds and very strong
in intensity
– Transition Phase – 8-10 cm; significant anxiety, fears being left
alone, feels she may be torn apart, contractions are 1.5-2 mins
with duration of 60-90 seconds. As it approaches 10 there is
increased pressure and a desire to “bear down” and maybe
increase in bloody show. Sometimes these moms get the urge to
push and we have to tell them not to because it’s too early. If they
push and bear down it can cause the cervix to swell which slows
the process because we have to wait for that swelling to go away
to birth the baby
Stage Two – Maternal Pushing
• Begins with complete cervical dilation and
ends with the birth of the baby
• Maternal urge to push
• May feel relieved that birth is imminent
• Apologetic
• Primagravidas – 2-3 hours
• Multigravidas – 5-30 mins
Cardinal Movements of Fetal Head
• Descent – occurs because of 1 pressure of amniotic fluid, 2 direct
pressure of the uterine fundus, 3 contractions of the abd muscles, 4
straightening of the fetal body
• Flexion- flexion of the baby’s head because of resistance from the soft
tissue of the pelvis, the pelvis floor, and the cervix
• Internal Rotation – the fetal head must rotate with the diameter of the
pelvic cavity which is widest in the anterior posterior diameter
• Extension – the resistance of the pelvic floor and the mechanical
movement of the vulva opening anteriorly and forward with extension
of the fetal head as it passes under the symphysis pubis
• Restitution – the shoulders of the fetus enter the pelvis inlet something
or other. Because of this rotation the pelvis the neck becomes twisted.
Basically the baby’s head becomes twisted around
• External Rotation – as the shoulders rotate the head turns further to
one side
• Expulsion – the shoulder moves under the symphysis pubis.
• On pg 391 and she’s reading it word for word
Stage Three – Delivery of Placenta
Placental Separation
Globular shaped uterus
Rise in fundus in abdomen
Sudden gush of blood
Further protrusion of the umbilical cord
Signs usually start after about 5 mins after the birth of the baby. When these signs
start appearing the woman may feel the need to bear down again. Firm
pressure may be applied to the fundus and gentle tugging on the cord to get
it out
Placental Delivery
Maternal pushing can assist delivery
Retained if > 30 minutes
Shiny Schultze – inside out
Dirty Duncan – outer edge to inside
If the placenta or a piece of it is still stuck inside the mom there will be tons of
bleeding
*placenta is only made correctly for about 40 weeks and after that it’s kind of
shitty
Stage Four - Recovery
• Recovery 1-4 hours
• Hemodynamic changes
– In the mom and in the baby, but really looking at mom…
• Blood loss of 250 – 500 ml’s
• Decreased blood pressure
– Along with increase in pulse pressure and moderate
tachycardia, because of the blood loss mentioned above
• Fundus between symphysis and umbilicus
• Fatigued, thirsty and hungry
• Bladder hypotonic
– Check mom for bladder fullness if they aren’t able to void
Maternal Systemic Response to Labor
• Cardiovascular
– Stressed by Uterine Contractions
• Pain, anxiety, apprehension
– Increased cardiac output
• 300-500ml blood forced back into maternal circulation with each
contraction
• BP increases with uterine contractions
– Position lowers cardiac output
• Supine  cardiac output
• Left lateral  BP
Maternal Response con.
• Respiratory
– Oxygen demand increases
– Hyperventilation may occur
• Because of stress and pushing and what not
• Fall in pH O2 and respiratory alkalosis may occur
– Pushing increases lactate levels
– S/S of hyperventilation
• Tingling/numbness in nose, lips, fingers or toes, might have them
breathe into a paper bag
• Renal system
–  maternal renin, plasma renin, and angiotensiogen –
important in uteroplacental blood flow
– Trauma to bladder
– Blood and lymph drainage impaired from presenting part
Maternal Response con.
• GI system
– Gastric motility and absorption 
– Emptying time is  causing  risk of aspiration
– Glucose levels  causing  insulin levels
– More food in their stomach which sometimes comes
up…
• Immune system
– WBC 25 – 30,000 stress response
Pain
• Causes of pain
– Dilatation of cervix
– Hypoxia of uterine muscle
• This is what causes pain. When they are contracting as hard as they can
contract they’re not getting oxygen which will cause pain
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Stretching of lower uterine segment
Pressure on adjacent structures
Distention of vagina
Uterine contractions
Delivery of placenta
Episiotomy repair
Factors Affecting Response to Pain
• Preparation for birth – childbirth classes
• Respond by what is acceptable to culture
– Some cultures it’s ok for woman to go nuts and yell,
some cultures they’re supposed to be stoic and not
express pain. Sign of weakness or whatever, but this
doesn’t mean that they aren’t feeling pain.
• Fatigue and sleep deprivation
– Fatigued woman has less energy and it will be harder to
get them to focus on what we need them to do.
• Previous experience
• Anxiety
Fetal Response to Labor
• Heartrate changes
– Early decelerations
•  intracranial pressure causes vagal response
• During labor
– Late decelerations
•  uteroplacental blood flow
– Variable decelerations
• Cord compression
• Acid-Base Status in Labor
– As uterine contractions increase, pH decreases slowly in
response to hypoxia
– Blood flow is decreased to the baby during contractions
• Hemodynamic changes
– Fetal BP and placental reserves protective mechanism during
anoxic periods