GEORGIA BAPTIST COLLEGE OF NURSING
OF MERCER UNIVERSITY
NUR 330 Nursing Care of the Childbearing Family
LP 4.3 Nursing Management of the Intrapartum Family
Class Notes - Spring Semester 2008
1. Nursing and collaborative management during the first stage of labor
A. Common Intrapartum Nursing Diagnoses - see "Maternal-Newborn Nursing
Diagnoses," under "Clinical Materials" on Blackboard or Dr. Rayburn's web site.
B. Therapeutic nursing interventions
(1) Ongoing assessments
 VS and FHR per risk classification and/or protocol requirements
 Contractions pattern (frequency, duration, intensity, and resting tone)

Labor progression - cervical position, effacement, dilation; fetal position
and station
 Comfort/Pain
 Stamina/Fatigue
 Hydration & Nutrition (Strict Intake and Output)
 Urinary elimination
 Vaginal secretions
 IV site
 Maternal-fetal response to medications and anesthetics being used
(oxytocin, narcotic analgesics, epidural anesthesia, antibiotics, etc.)
(2) Provide Labor Support
(3) Support family members
(4) Communicate with MD/CNM
C. Common Intrapartum Medical Interventions During Stage 1 Labor
(1) Induction and augmentation of labor
 Definitions:
Induction - stimulation of uterine contractions before the spontaneous
onset of labor.
Augmentation - stimulation of existing uterine contractions to increase
their frequency, duration and/or intensity
 Medically indicated versus "elective" induction
 Medical indications for induction of labor
 Assessments by MD/CNM prior to beginning an induction
 Assessment of fetal lung maturity fluid is required if fetus is less
than 37 weeks gestation unless the induction is a medical necessity
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 Assessment of cervical readiness - Bishop Scoring System ( p. 368,
4th ed. of OB textbook)
 Dilation
 Effacement
 Fetal Station
 Cervical consistency
 Cervical position
 Common Induction Methods
 Cervical ripening methods:
1. Chemical agents - prostaglandins: PGE2 products (Prepidil gel,
Cervidil vaginal insert, Prostin vaginal suppositories) and PGE1
synthetic analog (Misoprostol [Cytoctec])
 Actions
 Nursing Implications
2. Mechanical methods - Laminaria (sea weed), Lamicel
(synthetic dilator), foley catheter
 Methods for Stimulating Uterine Contractions (may be used to
induce or augment labor)
1. Stripping of the amniotic membranes
2. Amniotomy (artificial rupture of membranes [AROM])
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(a) Risk related to ROM: Umbilical Cord Prolapse - A major
obstetrical emergency! Can occur with either AROM or
spontaneous rupture of membranes (SROM).
(b) Nursing Response to Umbilical Cord Prolapse:
(3) Nipple Stimulation (used for augmentation only)
(4) Pitocin (oxytocin) [Be certain that you understand the
differences between the intrapartum and postpartum dosages,
desired action, and administration protocols, and risks
associated with r this medication!
D. Intrapartum Administation of Pitocin (Oxytocin) - a synthetically produced
hormone that is similiar to the endogenous oxytocin produced by the posterior
pituitary gland
(4)
(1)
Classification: Oxytocic
(2)
Actions: (see Drug Guide on p. 370 of 4th ed. of OB textbook)
(3)
Adverse Reactions - may result from hypersensitivity to the drug or
from excessive dosage.
a.
Maternal adverse reactions .
b.
Fetal adverse reactions:
Administration Guidelines for Intrapartum Oxytocin
a.
Obtain 20-30 minutes of EFM to assess fetal well being and
contraction pattern before initiating Pitocin infusion
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b.
Start a primary IV line - usually Lactated Ringers
c.
Mix the Pitocin in a secondary bag of IV fluid according to the L&D
unit' s protocol for mixing Pitocin- should always be mixed with fluid
that contains electrolytes to decrease possibility of water
intoxication
d.
Intrapartum Pitocin (oxytocin) infusions must be administered
through an infusion control pump .
e.
Pitocin (oxytocin) infusion should be piggybacked into the primary
IV line at the port on the primary line that is closest to the IV
catheter.
f.
Begin Pitocin at 1-2 mU/min carefully monitoring the patient for
hypersensitivity.
g.
Increase Pitocin mU/min rate per protocol until . an
active labor pattern is achieved (contractions: 2-3 min apart, lasting
50-70 seconds, strong intensity) or until the upper dose limit of the
protocol is reached.
Low dose protocol: Increase by 1-2 mU/min q 15-30 minutes
High dose protocol: Increase by 6mU/imn q 15-30 minutes after
initial dose at 1-2 mU/min to determine sensitivity to oxytocin.
h.
Patient must remain on continuous electronic monitoring (FHR
& contractions) while pitocin is being infused during the
intrapartum period.
E. Nursing Care of Patient Receiving Intrapartum Pitocin
(1) Maternal & Fetal Assessments
 Maternal BP, FHR, Uterine resting tone, contraction frequency,
duration and intensity are assessed every 15 minutes until a stable
dose level is reached, then at least every 30 minutes.
 Intake and Output should be carefully monitored because of the
water intoxication side effect of oxytocin.
2. Nursing and collaborative management during second stage of labor
A. Ongoing maternal and fetal assessments
 VItal signs, FHR, contraction pattern, fetal descent, bloody show
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B. Second stage management
 "Laboring Down"

Positioning for effective pushing

Open glottis vs. closed glottis pushing
C. Maternal behaviors during second stage
D. Fetal heart rate response during second stage
E. Nurses Role in Preparations for the Delivery
Note: Immediate Newborn Care will be covered under the unit on Newborns
F. Common Obstetric Procedures Used During Second Stage of Labor
(1) Forceps and Vacuum Extraction
 Benefits
 Risks
(2) Episiotomy
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3.
4.
Nursing Care and Collaborative Management During the Third Stage of
Labor
 Maternal assessment
----- Maternal physical status (Vital signs, bleeding)

Oxytocin administration past delivery of placenta

Placental assessment
Nurse Assisted Delivery when MD/CNM not present :
"IntraNsgCare-ClsNotes"
2/08 SKR
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