B.

INTRAPARTUM

INTRAPARTUM CARE
• refers to the medical and nursing care given to a pregnant woman and her family during labor
and delivery
• Extends from the beginning of contractions that cause cervical dilation to the first 1 to 4 hours
after delivery of the newborn and placenta.

1. Factors affecting labor and delivery

a. Passageway – refers to the adequacy of the pelvis and birth canal allowing fetal
descent; factors include:
i. Types of female pelvis (INSERT PICTURE)
A. Gynecoid – typical female pelvis with a rounded inlet
B. Android – normal male pelvis with a heart shaped inlet
C. Anthropoid – is an “apelike” pelvis with an oval inlet
D. Platypelloid – is a flat, female-type pelvis with a transverse oval inlet

ii. Structure of Pelvis

A. False pelvis vs. true pelvis

FALSE PELVIS - Superior half formed by the ilia. Offers landmark for
pelvic measurements. Supports the growing fetus into the true pelvis
near the end of gestation

TRUE PELVIS - Inferior half formed by the pubes in front, the ilia and
the ischia on the sides and the sacrum and coccyx behind.

iii. Adequate delivery diameter

A. Pelvic Inlet diameter
Inlet – entrance way to the true pelvis. Its Transverse diameter is
wider than its anteroposteror diameter. Also known as pelvic brim.

B. Pelvic Outlet diameter

Outlet – inferior portion of the pelvis, bounded on the back by the
coccyx, on the sides by the ischial tuberosities and in front by the
inferior aspect of the symphysis pubis and the pubic arch. Its
anteroposterior diameter is wider than its transverse diameter.

*Engagement- refers to settling of the presenting part of the fetus into

the pelvis to be at the level of the ischial spine, a midpoint of the
pelvis.
- descent to this point means the pelvic inlet is proven adequate for
birth
- “Floating”- a presenting part that is not engaged.
- “Dipping”- one that is descending but has not reached the ischial
spine

*Station- or degree of engagement; refers to the relationship of the

presenting part of a fetus to the level of the ischial spines
- minus stations (-1 to -4)= presenting part above ischial spine,
measurement in cm
- plus stations (+1 to +4)= presenting part below ischial spine,
measurement in cm
- station 0= presenting part engaged
- station -4= presenting part is floating
- station +4= presenting part is at outlet or it is crowning (the
encirclement of the largest diameter of the fetal head by the vulvar
ring)

C. Ability of the uterine segment to distend, the cervix to dilate and the
vaginal canal and introitus to distend.
o DILATATION
 Enargement of the external cervical os from 0 to 10
cm
  As a result of uterine contractions and additionally as
a result of pressure on the presenting part

o EFFACEMENT
 Shortening and thinning of cervical canal from 0 to
100%
 Primigravida – effacement occurs before dilatation
 Mutligravidas – dilatation may precede effacement
b. Passenger

This refers to the fetus and its ability to move through the passageway.
i. Fetal skull
• Size of the fetal head and capability of the head to mold to the
passageway.
o Molding- change in shape of fetal skull produced by force of
contraction pressing the head against the not-yet dilated
cervix
 Parents are reassured that molding only lasts a day
or two and is not a permanent condition
 No molding when fetus is breech.
• The fetal skull is the most important part of the fetus because:
o It is the largest part of the body
o It is the least compressible of all parts
o It is the most frequent presenting part
Fetal lie or presentation
The part of the fetus that enters the maternal pelvis first; the body part that
will be born first or contact the cervix first
A. Cephalic = head first; ideal presentation for NSVD because the bones
of the skull are capable of molding so effectively to accommodate the
cervix and may actually aid in cervical dilation
a. Vertex – head is sharply flexed, making the parietal bones the
presenting parts
b. Face
c. Brow
d. Chin or mentum

B. Breech – either buttocks or feet first; difficult birth; can be delivered

NSVD
a. Complete breech – thighs are flexed on the abdomen and legs
are on thighs
b. Frank breech – thighs are flexed and legs are extended,
resting on the anterior surface of the body
c. Footling
i. Double – legs unflexed and extended; feet are
presenting parts
ii. Single – one leg flexed and extended; one foot is the
presenting part
iii.
C. Shoulder presentation- presenting part can be one of the shoulders
(acromion process, an iliac crest, a hand or an elbow; CS delivery)

iii. Fetal Lie- relationship between the long axis of the fetal body and the long axis f the woman’s body
(cephalocaudal)
a. Horizontal (transverse)
b. Vertical (longitudinal)- cephalic or breech

iv. Fetal Attitude

The relationship of fetal parts to one another; degree of flexion a fetus assumes
during labor
GOOD ATTITUDE- if in complete flexion; the spinal column is bowed forward, the head is flexed forward
so much that the chin touches the sternum, the arms are flexed and folded on the chest, the thighs are
flexed onto the abdomen and the calves are pressed against the posterior aspect of the thighs

MODERATE ATTITUDE- if chin is not touching the chest but is in alert or military position

POOR ATTITUDE- the back is arched, the neck is extended and a fetus is in complete extension

v. Fetal position
The relationship of presenting part and the maternal pelvis which is divided into
4 quadrants:

1. Right anterior
2. right posterior
3. left anterior
4. left posterior

Four parts of the fetus have been chosen as point of direction

1. Occiput -= in vertex presentation

2. Chin (mentum) – in face presentations
3. Sacrum – breech presentations
4. Scapula (acromion) – in shoulder presentations.

Possible fetal positions:

LOA (left occipitoanterior)- most common fetal position (birthing is fast)
LOP (left occipitoposterior)- difficult delivery; more painful
LOT (left occipitotransverse)
ROA (right occipitoanterior)- second most frequent (birthing is fast)
ROP (right occipitoposterior)- difficult delivery, more painful
ROT (right occipitotransverse)
*Posterior positions may be more painful for the mother, because the
rotation of the fetal head puts pressure on the sacral nerves causing sharp back
pain.

Other fetal positions found in p. 497

c. Power refers to the frequency, duration and strength of uterine contractions to cause
complete cervical effacement and dilatation.

Labor monitoring/ monitoring uterine contractions:

> fingers should be spread lightly over the fundus
> three phases of uterine contractions:
i. crescendo/increment- intensity of the contraction increase. This phase is
longer than the other two phases combined.
ii. acme/apex- the height or peak of the contraction
iii. decresenco/ decrement- intensity of the contraction decreases

 Duration of contractions “How Long”

o From the beginning of one contraction to the end of the same
contraction
 Duration during early labor- 20-30 seconds
 Duration in late labor- 60-70 seconds
 Should never be longer than 60-70 seconds because any muscle
that is contracted does not have any blood supply and so will
jeopardize the fetus

 Interval
o From the end of one contraction to the beginning of the next
contraction
 Interval during early labor- 40-45 minutes
 Interval in late labor- 60-70 seconds
 It is an important aspect of contaction because it is during this
relaxation period when the uterine blood vessels refill themselves
with blood to supply the fetus with adequate oxygen

 Frequency “How Often”

o From the beginning of one contraction to the beginning of the next
contraction. T
o Three to four contractions are timed to get a good picture of the
frequency.

 Intensity “How Strong”

o The strength of contraction; may be mild, moderate, strong or
severe
o Measured by the consistency of the fundus at the acme of the
contraction
o When estimating intensity, check fundus at conclusion of
contraction to determine whether it relaxes.
o More strong: more pain

d. Psyche refers to the client’s psychological state, available support systems, preparation
for childbirth, experiences and coping strategies.

e. Placental factors refer to the site of placental insertion.

2. Premonitory/preliminary/ prodromal signs of labor

a. Lightening – is the descent of the fetus and uterus into the pelvic cavity 2-3 weeks
before the onset of labor.

Effects of lightening
• Shooting pains down the legs because of pressure on the sciatic nerve
• Increased lordosis as the fetus enters the pelvis and falls further forward
• Increased amount of vaginal discharges
• Resurgence of sign of pregnancy like urinary frequency, as the gravid uterus
impinges on the bladder
• Relief of abdominal tightness and diaphragmatic pressure

b. Loss of weight

2- 3 lbs is loss 2 days prior to onset of labor, probably due to loss of appetite and
decrease in progesterone level that leads to fluids excretion thus causing loss weight.

Progesterone – is known to cause fluid retention

c. Burst of energy or Increased tension and fatigue “Nesting behavior” – may occur
right before the onset of labor.

Sudden burst of energy is due to increase in epinephrine in response to the stress

brought about by the approaching delivery.

Pregnant woman should be caution not to use this energy to carry out household chores
because it is meant to prepare the body for the labor.

d. Braxton Hicks contraction irregular intermittent contractions that have occurred

throughout the pregnancy, become uncomfortable and produce a drawing pain in the
abdomen and groin; painless uterine tightening

Also known as practice contraction.

e. Cervical changes include softening “ripening” describe as butter soft and effacement
of the cervix that will cause expulsion of the mucous plug (bloody show).
 f. Rupture of amniotic membranes or “the bag of water” may occur before the onset
of labor.

• Its rupture may be seen as a sudden gush, or a scanty, slow seeping of

amniotic fluid from the vagina.

It is important to remember that once membranes (BOW) have ruptured;

• Therefore labor is inevitable. Labor pains will set in within the next 24 hours.
• Since the integrity of the uterus has been destroyed, infection can easily set in.
Thus, ASEPTIC TECHNIQUE should be observed in doing perineal care. Doctors
do less of the IE and enema s no longer given.
• Check for any umbilical cord compression and or cord prolapsed especially in
breech presentation)
o A woman seeking admission claims that her BOW has ruptured. FIRST
NURSING ACTION: Put her to bed right away, then take the fetal heart
tones. She should be allowed to remain in the standing position or
sitting position because if its true that BOW has ruptured, the
possibility of cord compression is high.
o If a woman in labor says that she feels a loop of the cord coming out
of her vagina (cord prolapse), IMMEDIATE ACTION: Place her in
trendelenberg position – to reduce pressure on the cord. REMEMBER:
only 5 minutes of cord compression can already lead to CNS
damage or even death
 Apply a warm saline saturated OS on the cord to prevent
crying of the cord.
• Color should be noted
o Normal: clear, almost colorless and contains white specks of vernix
caseosa.
o Abnormal:
 green staining – amniotic fluid has been contaminated with
meconium which signifies fetal distress if the fetus is in a non-
breech presentation
 yellow staining – may mean blood incompatibility
 Pink stain – may indicate bleeding
• If labor does not occur within the next 24 hours, the woman will have to be
induced to go into labor by administering intravenous drip of oxytocin (Pitocin).

g. Show This is the blood-tinged mucus discharged from the vagina because of pressure of
the descending fetal part on the cervical capillaries, causing their rupture. Capillary
blood mixes with mucus when operculum is release that is why SHOW than a pinkish
vaginal discharge.

Show should be distinguished from bright red vaginal bleeding because the later is a
danger sign during this phase of pregnancy.

ONSET OF LABOR
• Labor normally begins when a fetus is sufficiently mature to cope with extrauterine life, yet not to
large to cause mechanical difficulties with birth.

h. Onset of labor theories

Possible Causes of the Onset of Labor

Maternal Factor Theories Fetal Factor Theories
Uterine Stretch Theory Theory of Aging Placenta
Uterine muscles stretch to capacity, causing Placental aging and deterioration triggers
release of prostaglandin initiation of contraction.

Oxytocin stimulation Theory

Pressure on the cervix stimulates nerve plexus, Fetal cortisol, produced by the fetal adrenal
causing release of oxytocin by maternal glands, rises and acts on the placental to
posterior pituitary gland. This is known as reduce progesterone formation and increase
Ferguson reflex. prostaglandin.
 Prostaglandin Theory
Oxytocin stimulation in circulating blood
increases slowly during pregnancy rises
dramatically during labor, peaks during second
stage. Oxytocin and prostaglandin work
together to inhibit calcium binding in muscle
cells, raising intracellular calcium and thus
activating contractions.
Prostaglandin produced by fetal membranes
(amnion and chorion) and the deciduas
stimulates contractions. When arachidonic
acid stored in fetal membranes is released at
term, it is converted to prostaglandin.

Progesterone Deprivation Theory

Estrogen/progesterone ratio shift----estrogen
excites the uterine response, and progesterone
quiets the uterine response. A decrease of
progesterone allows estrogen to stimulate the
contractile response of the uterus

3. Differentiation between true and false labor

False Labor Pains True Labor Pains

Remain irregular May be slightly irregular at first but become
regular and predictable within a matter of hours

First felt in the lower back and sweep around to

Generally confined to the abdomen. the abdomen in girdle-like fashion

Increase in duration, frequency and intensity

No increased in duration, frequency and Continue no matter what the woman’s level of
intensity activity

Often disappear if the woman ambulates Accompanied by cervical effacement and

dilatation
Absent cervical changes

.
4. Stages of Labor
a. First stage ( Stage of Dilatation) begins with the onset of regular contractions which
cause progressive cervical dilation and effacement. It ends when the cervix is
completely effaced and dilated.
1. Latent phase - 1-4 cm
2. Active phase - 4-7 cm
3. Transitional phase - 7-10 cm

• Power/Forces at work: involuntary uterine contracts

• PHASES
I. Latent phase – early time in labor
 Regular contraction
 Cervical dilation – 1 to 4 cm
 Intensity: mild to moderate
 Uterine contractions occur Q15-30 minutes and are 15-30
seconds in duration and of mild intensity
 Mother is talkative and eager to be in labor
II. Active Phase –
 Cervical dilation 4-7 cm
 Uterine contractions occur Q3-5 minutes and are 30-60
seconds in duration
  Contraction: moderate to strong, frequent, longer more
painful
 Mother may experience feeling of helplessness and becomes
restless and anxious as contractions intensifies
 Woman fears losing control of herself
•

III. Transitional Phase

 Cervical dilation 8-10 cm
 Uterine contractions occur every 2-3 minutes and are 45-90
seconds in duration and of strong intensity
 Mother becomes tired, is restless and irritable and feels out of
control
 Mood change
 AMNIOTOMY (if not yet ruptured)
 Gaping (bulging) of vagina or anus or perineum
AMNIOTOMY is not done if the station is still negative because this can
lead to cord compression

b. Second Stage( STAGE OF EXPULSION) – Begins with complete dilatation of the

cervix and ends with delivery of the newborn.
- Duration may differ among primiparas (longer) and multiparas (shorter),
but this stage should be completed within 1 hour after complete dilatation.

*Power/Forces at work: INVOLUNTARY UTERINE CONTRACTIONS; CONTRACTIONS OF THE

DIAPHRAGMATIC AND ABDOMINAL MUSCLES
i. Contractions are severe at 2-3 minute intervals, with a duration of 50-90
seconds
ii. Cervical dilation is complete
iii. Progress of labor is measured by descent of fetal head thru the birth canal
(change in fetal station)
iv. Uterine contractions occur every 2-3 minutes, lasting 60-75 seconds, and the
intensity is strong.
v. Increase in bloody show
vi. Mother feels the urge to bear down

The newborn exits the birth canal with the help from the following cardinal movements, or mechanisms of
labor (D FIRE ERE)
DESCENT- fetus goes down the birth canal (preceded by engagement)
FLEXION- pressure on the pelvic floor causes the fetal chin to bind towards the chest
INTERNAL ROTATION – from antero-postero to transverse then AP to AP
EXTENTION – as the head comes out, the back of the neck stops beneath the pubic arch. The
head extends and the forehead, nose, mouth and chin appear
EXTERNAL ROTATION (also known as restitution) – anterior shoulder rotates externally to the AP
position so that it is just behind the symphysis pubis
EXPULSION – the delivery of the rest of the body

Episiotomy
 Prevent prolonged & severe stretching of the muscles
 Natural anesthesia (synchronized with pushing of the woman)
 Done to facilitate delivery and avoid laceration of the perineum
 Reduce duration of second stage
 Enlarge outlet in breech presentations or forcep delivery

TYPES OF EPISIOTOMY
 Median
 Mediolateral

Application of Ritgen’s Maneuver is the best method for delivery As soon as crowning is taking phase,
cover anus with sterile towel to exert.
 c. Third Stage (Placental Expulsion) - Begins with the delivery of the baby
and ends with the delivery of the placenta.

– Placental separation and expulsion occur

– Placental birth occur 5-30 minutes after birth of baby.

Placental Separation(Mechanisms)
o SCHULTZE MECHANISM: center portion of placenta separates first and
its shiny fetal surface emerges from the vagina. SHINY AND
GLISTENING
o DUNCAN MECHANISM: margin of placenta separates, and the dull, red,
rough maternal surface emerges from the vagina. DIRTY, RAW, RED
AND IRREGULAR WITH THE RIDGES OR COTYLEDONS

Signs of Placental Separation

o uterus becoming globular (calkin’s sign)
o Fundus rising in abdomen
o gushing of blood
o Lengthening of the cord

Contractions of the uterus controls uterine bleeding and aids with placental
separations and delivery.

Generally, oxytocic drugs (oxytocin 10-20 units) are administered to help the
uterus contract (after placenta out)

METHERGINE
 PROMOTES UTERINE CONTACTION AND PREVENTS POSTPARTUM HEMORRHAGE
 PRODUCE STRONG AND EFFECTIVE CONTRACTION
 ASSESS VITAL SIGNS (BP)
 DO NOT ADIMINISTER IF BP IS 140/90 mmHg
 LEADS TO HYPERTENSION
 DISCONTINUE: MARKED VASOCONSTRICTION (COLDNESS, PALENESS, NUMBNESS
OF THE FEET AND HAND); NOTIFY THE PHYSICIAN

OXYTOCIN
 INCREASES UTERINE CONTRACTION
 MINIMIZED UTERINE BLEEDING
 INCREASES BLOOD PRESSURE (VASOCONSTRICTION)

d. Fourth Stage ( Recovery and Bonding)- From the delivery of the placenta until
the postpartum condition of the woman has become stabilized (usually after 1 hour after delivery).

– the period of time from 1-4 hours after delivery

– the mother and newborn recover from the physical process of birht
– The maternal organs undergo initial readjustment to the nonpregnangt state
– The newborn baby systems begins to adjust to extrauterine life and stabilize

Monitoring the Blood Pressure

Blood Pressure should not be taken during a contraction as it tends to INCREASE, because no
blood supply goes to the placenta during contraction. All the blood is in the periphery, which
explains the increased BP during contraction

BP taking should be taken at least every half hour during active labor
Whenever a woman complains of a HEADACHE, remove the blood pressure apparatus from the
arm right away (priority intervention)

5. Managing Discomforts
A. During Labor
1. Physical Assessment. General physical examination, Leopold’s maneuvers and/or internal
examination are done.
 2. Bath. Bath is advisable if contractions are still tolerable or are not too close to one
another. Bathing will not only ensure cleanliness but will also provide comfort and
relaxation.

3. Perineal Preparation. Perineal flushing is done to prevent contamination of the birth

canal and reduce possibilities of postpartum infection.

4. Ambulation. Unless contraindicated (by medications, intravenous infusion or ruptured

membranes), ambulation is advised during the latent phase of labor in order to help
shorten the first stage of labor.

5. Diet. Solid or liquid foods are avoided for the following reasons:
a) Digestion is delayed during labor.
b) A full stomach interferes with proper bearing down.
c) Aspiration may occur during the reflex nausea and vomiting of the transition
phase or when anesthesia is used.

6. Enema Administration. Enema is not a routine procedure for all women in labor but may
be done for the following reasons:
a) A full bowel hinders labor progress; enema increases the space
available for passage of the fetus and improves frequency and
intensity of uterine contractions.
b) Enema decreases the possibility of fetal contamination of the perineum
during the second stage of labor.
c) A full bowel can add to the discomfort of the immediate postpartum
period.
Contraindications of enema:
a) Vaginal bleeding
b) Premature labor
c) Abnormal fetal presentation or position
d) Ruptured membranes
e) Crowning

7. Voiding. The woman in labor should be encouraged to empty her bladder every
2-3 hours because:
a) full bladder retards fetal descent.
b) urinary stasis can lead to urinary tract infection.
c) a full bowel may be traumatized during delivery.

8. Breathing Technique. The woman in the 1st stage of labor should be instructed
not to push or bear down during contractions because it will not only lead to
maternal exhaustion but, more importantly, unnecessary bearing down can lead
to cervical edema bacause of the excessive pounding of the fetal presenting
part of the pelvic floor, thus interfering with labor progress. To minimize bearing
down, the patient should be advised to do abdominal breathing during
contractions.

9. Position. Encourage the woman in labor to assume Sim’s position because:

a) It favors anterior rotation of the head.
b) It promotes relaxation between contractions.
c) It prevents Supine Hypotensive Syndrome.

The inferior vena cava, the blood vessel which carries unoxygenated blood back to the heart, lies just
above the spinal column. When a pregnant woman lies flat on her back, the inferior vena cava is caught
between the gravid uterus and the spinal column, causing a drop in arterial blood pressure, which leads
the woman to complain of dizziness.
10. Contractions. Uterine contractions are monitored every hour during the latent
phase of labor and every 30 minutes during the active phase by spreading the
fingers lightly over the fundus.
 11. Vital Signs. Blood Pressure (BP) and Fetal Heart Rate (FHR) are taken every
hour during the latent phase and every 30 minutes during the active phase.
Definitely, BP and FHR should never be taken during a contraction.
During uterine contractions, no blood goes to the placenta. The blood is pooled to
the peripheral blood vessels which results in increased BP. Therefore, the blood
pressure should be taken in between contractions and whenever the mother in labor
complains of a headache.

12. Danger Signals. The nurse must be aware of the following danger signals during
labor and delivery.
a) Signs of fetal distress
1) Tachycardia (FHR more than 180)Bradycardia (FHR less than
100)
2. Meconium-stained amniotic fluid in non-breech presentation
3. Fetal thrashing or hyperactivity due to fetal struggling for
more oxygen
b) Signs of maternal distress
1. BP over 140/90, or a falling BP associated with clinical signs of
shock (pallor, restlessness or apprehension, increased respiratory
and pulse rates)
2. Bright red vaginal bleeding or hemorrhage(blood loss of more
than 500 cc)

3. Abnormal abdominal contour (may be due to uterine rupture

or Bandl’s pathological ring, a condition wherein the muscles
at the physiological retraction ring become very tense,
gripping the fetus causing possible fetal distress)
13. Administration of Analgesics. Narcotics are the most commonly used analgesics,
specifically Demerol (meperidine hydrochloride). Demerol acts to suppress the
sensory portion of the cerebral cortex. A dose of 25-100 mg is given and it
takes effect within 20 min when the patient experiences a sense of well being
and euphoria. Demerol, being also an antispasmodic, should not be given very
early in labor because it will retard labor progress.

It should not also be given when delivery is less than an hour away because it can
cause respiratory depression in the newborn.
It is , therefore, preferably given when cervical dilatation is around 5-8 cm.

14. Administration of Anesthetics. Regional anesthesia is preferred over any other

form because it does not enter the maternal circulation and therefore does not
retard labor contractions nor cause respiratory depression in the newborn.

15. Transfer of Patients. A sure sign that the baby is about to be born is the bulging
of the perineum. In general, multiparas are transported to the delivery room
when cervical dilatation is about 7-9 cm, while primiparas are transferred to the
delivery room at full dilatation with perineal bulging when crowning is taking
place.

B. During Delivery
1. Positioning on the Delivery Table. When positioning the woman on lithotomy on the
delivery table, the legs should be put up slowly at the same time on the stirrups in order
to prevent trauma to the uterine ligaments and backaches or leg cramps. The same
should be done when putting the legs down from the stirrups after delivery.

2. Bearing Down Technique. At the beginning of a contraction, the woman is asked to take
two short breaths, then to hold her breath and bear down at the peak of contraction.
She should also be told to use blow-blow breathing pattern to prevent pushing between
contractions.

3. Care of the Episiotomy Wound. Episiotomy, a perineal incision done to facilitate the birth
of the baby, is made by the doctor primarily to prevent lacerations. No anesthesia is
necessary during episiotomy b/c the pressure of the fetal presenting part against the
 perineum is so intense that the nerve endings for pain are momentarily deadened
(natural anesthesia).

4. Breathing Technique. As soon as the head crowns, the woman is instructed not to push
any longer because it can cause rapid expulsion of the fetus. Instead, she should be
advised to pant (rapid and shallow breathing).

5. Ritgen’s Maneuver.
a) Support the perineum during crowning by applying pressure with the palm
against the rectum. This will not only prevent lacerations of the fourchette but
will also bring the fetal chin down the chest so that the smallest diameter of the
fetal head is the one presented at the birth canal.
b) in order to prevent rapid expulsion of the fetus which could result not only in
lacerations, abruptio placenta, and uterine inversion but also to shock because
of sudden decrease in intraabdominal pressure, the head should be pressed
gently while it slowly eases out.
6. Time of Delivery. Take note of the time the baby is delivered.

7. Handling of the Newborn. Immediately after delivery, the newborn should be held below
the level of the mother’s vulva so that blood from the placenta can enter the infant’s
body on the basis of gravity flow.

The newborn should be held with his head in a dependent position to allow drainage of
secretions.
A newborn is never stimulated to cry unless he has been drained of his secretions
because he can aspirate these secretions into his lungs.
The newborn should be immediately wrapped in a clean diaper to keep him warm
because chilling increases the body’s need for oxygen.
He should then be placed on his mother’s abdomen so that the weight of the baby can
help contract the uterus; a noncontracted uterus can lead to death due to hemorrhage

8. Cutting of the cord. Cutting of the cord is postponed until pulsations have stopped
because it is believed that 50-100 ml of blood is flowing from the placenta to the
newborn at this time. It is then clamped twice, an inch apart, and cut in between.

9. Initial Contact. Maternal-infant bonding is initiated as soon as the mother has eye-to-eye
contact with her baby. The mother is informed of her baby’s sex and helped to hold and
inspect her baby if she wishes.

Nursing Diagnosis

• Fear r/t uncertainty about the outcome of the birth process

• Acute Pain r/t uterine contraction, cervical dilatation and fetal descent
• Health seeking behaviors: Information about the fetal monitor r/t an expressed desire to
understand equipment used
• Readiness for enhanced family processes r/t opportunity to incorporate newborn into the family

Fetal Heart Monitoring

Goal: to detect signs that identifies fetal distress in its early stages
PARAMETERS INTERPRETATION
Baseline heart rate 120-160 bpm Normal
Tachycardia
Moderate 161-180 bpm Nonreassuring
Marked >180 bpm Abnormal
Bradycardia
Moderate 100-119 bpm Non reassuring
Marked <100 bpm Abnormal
Acceleration >15 bpm for >15 sec Stimulation
Maternal fever
Deceleration
Early 10-40 bpm Head compression
Late 50-60 bpm Hypoxia/acidosis
Variable 10-60 bpm Cord compression
Non reassuring
Severe bradycardia- FHR less than 80 bpm

Persistent severe bradycardia- severe bradycardia that persists for longer than 5 minutes

Accelerations
 FHR increases than 15 bpm for more than 15 seconds
 Appear as smooth patterns on electronic fetal monitoring
 Good indicators of fetal well-being
 Triggered in the normal mature fetus by fetal body motions, sounds stimulations of the fetal scalp
and other stimuli

Early decelerations
 Normal and common
 Deceleration pattern matches the contraction with the most deceleration occurring at the peak of
the contraction
 FHR rarely goes below 100 bpm
 Cause: head compression during uterine contraction

Late decelerations
 Decrease in FHR from the baseline rate with a lag time of greater than 20 seconds from the peak
of contraction
 First appear at or after the peak of the uterine contractions. The FHR improves only after the
contraction has stopped.
 May be mild or severe based on how low the FHR goes and how long it takes for the FHR to
recover
 Caused by reduced blood flow to the uterus and placenta during contraction
 Associated with uteroplacental insufficiency and is a consequence of hypoxia and metabolic
abnormalities

Variable deceleration
 Common type of FHR deceleration in labor
 Cause by umbilical cord compression
 Significance depends on how low the heart rate drops and how long the episode lasts
 Classified severe if they last more than 60 seconds or to a FHR of less than 90 bpm

Interventions for late or variable decelerations lasting more than 60 seconds:

1. Reposition the patient
2. Administer oxygen by face mask
3. Discontinue oxytocin’
4. IV fluids to increase maternal volume
5. Notify physician
6. Vaginal exam to check for prolapsed of cord
7. Prepare for emergency caesarean section

TYPES OF CHILDBIRTH:
1. Vaginal delivery
• A natural process that usually does not require significant medical intervention
• NSVD- normal spontaneous vaginal delivery
• Forceps delivery- vaginal delivery with the use of obstetric forcep (an instrument
designed to extract the baby’s head)
o Indications:
 Uterine inertia or poor uterine contraction and the second stage has
gone pass two hours
 Face presentation; OA in flat pelvis, OP position
 Relative CPD
 Cardiac and pulmonary disorders of the mother, maternal exhaustion
 Late deceleration pattern, excessive fetal movement, meconium
stained in cephalic presentation

2. Leboyer method
• Postulated that moving from a warm, fluid-filled intrauterine environment to noisy air
filled, brightly lit birth room creates a major shock for newborn
 • He proposed that birthing room should be darkened, kept pleasantly warm, soft music is
played, infant is gently handled, cord is cut late and placed immediately into a warm
water bath
• Advantage: ideal for most birthing institution
• Disadvantage:
o warm bath could reduce spontaneous respiration and high level of acidosis;
o late cutting of the cord causes excess blood viscosity in newborn

3. Hydrotherapy and Water Birth

• Baby is born underwater and immediately brought to the surface for a first breath
• Advantage: reduce discomfort in labor
• Disadvantage:
o Contamination of bath water with feces expelled
o Aspiration of bath water by fetus: pneumonia
o Maternal chilling
o Uterine infections- pushing efforts in 2nd stage of labor

4. Caesarean birth
• Latin word “caedore” means to cut
• Birth accomplished through abdominal incision into the uterus, after 28 weeks AOG
• Emergency procedure (under general anesthesia) or elective procedure (under spinal)
• Indications :
o CPD
o Placenta previa
o Abruption placenta
o Malpresentation or malposition
o Preeclampsia/eclapmsia
o Fetal distress
o Cord prolapsed
o Previous CS
o Cervical dystocia
o Cancer of the cervix
o Other factors: poor obstetrical history, vaginoplasty, vesico-vaginal fistula

• Complications
o Uterine rupture in subsequent pregnancy
o Postop infection
o Injury to urinary system
o Injury to uterine vessels
o Embolism

• Types:
o Classic caesarean section
 Incision made vertically through the abdominal skin and uterus
 Advantage: incision is made high on the uterus to avoid cutting the
placenta and be used with placenta previa
 Disadvantage:
• Leaves a wide skin scar
• Scar could rupture during labor and not be able to have a
subsequent vaginal birth
o Low segment incision
 Lower segment transverse caesarean section (LSTCS)
 Made horizontally across the abdomen over the cervix
 Referred to as pfannesteil incision or bikini incision
 Advantage:
• Less likely to rupture in subsequent labours
• Less blood loss- easier to suture
• Decrease postpartal infections
• Less possibility of GI complications
 Disadvantage:
• Longer procedure
• No assurance for small skin incision and small uterine incision