FAR EASTERN UNIVERSITY

Institute of Nursing
Intrapartum Care Handouts

LABOR and DELIVERY

Theories of Labor Onset
1. Uterine Stretch Theory
2. Oxytocin Theory
3. Progesterone Deprivation Theory
4. Prostaglandin Initiation Theory
5. Fetal Adrenal Response Theory (Fetal secretion of cortical steroids)
6. Placental Aging Theory
7. Mechanical Irritation Theory
Components of Labor
1. Powers
Uterine Contraction
Phases
Contour Changes
Physiological Retraction ring
Pathological Retraction ring
Cervical changes
Effacement
Dilatation
2. Passage
3. Passenger
4. Person
5. Psyche
Prodromal Signs of Labor
1. Lightening – the settling of fetal head into the inlet of the true pelvis; may not occur in
multiparas.
2. Increase in the level of Activity – “nesting instinct”;
3. Braxton Hicks Contraction
4. Ripening of the Cervix (Goodle’s sign)
5. Show-the release of the cervical plugs consisting of mucous, blood streaked vaginal discharge.
Signs of True Labor
1. Uterine Contraction
2. Show
3. Rupture of the Membranes

FIRST STAGE OF LABOR

Phases
Latent Phase – 0-3 cms.
Active Phase – 4-7cms.
Acceleration Phase (4-5 cm.)
Maximum slope (5-9 cm.)
Transition Phase (8-10 cms)
Nursing Care
1. Respect contraction time
Monitor V/S and FHR every 15 minutes
2. Change positions
Bed rest for ruptured membrane
3. Voiding and bladder care
4. Support
5. Pain management
Physiologic Effects of Labor on the Mother
1. Cardiovascular Changes
 Increase in cardiac output
 Average blood loss -300-500ml.
 Decrease in BP due to flooding of blood to the pelvic vasculature
 Blood Pressure: Rise of 15 mm/Hg with each contraction and increase Pulse Rate
2. Hematopoietic Changes – Leukocytosis
3. Temperature Regulation
 4. Fluid Loss due to diaphoresis, hyperventilation and fluid shifts produced by changes in
progesterone and estrogen levels.
5. Urinary Changes

Providing Comfort During Labor and Delivery

PAIN
 Etiology of Pain
i. Anoxia to uterine cells
ii. Stretching of the cervix & perineum
iii. Pressure of the presenting part of the fetus on tissues
 Physiology of PAIN (NOCICEPTORS)
i. C fibers
ii. A delta fibers
MELZACK_WALL gate control theory
Pain Can be HALTED at:
 Peripheral end terminals
 Synapse points in the dorsal horn
Uterus & Cervix (T10 to L1)
Perineum (Pudendal nerve to S2-S4)
 Brain cortex
Perception of pain
Depends on the following:
 Expectations
 Preparation for labor
 Length of labor
 Position of the fetus
 Availability of support person

Second Stage of Labor

From full dilatation to delivery of infant.
-30-60 minutes for primigravida,
-20 minutes for multipara; frequency is 2-3 minutes lasting 60-90 seconds; strong intensity.
Nursing Care
1. Transfer to delivery room for 8-9cm dilation
for multigravidas and full dilatation for primi-
gravidas.
2. Monitor V/S and FHR, prepare perineal area,
3. Encourage pushing with contractions.
4. Immediate newborn care.
Nursing Care
 Preparing for birth
 Positioning for birth
 Pushing
 Perineal cleaning
 Episiotomy
 Birth
 Cutting and clamping the cord

MECHANISM OF LABOR
E ngagement
D escent
F lexion
I nternal Rotation
E xtension
R estitution
E xpulsion of the body
Third Stage of Labor
Placental Separation
Signs: Change in the shape of the uterus
Lengthening of the umbilical cord
Sudden gush of blood
Shultze’s placenta
Duncan Placenta
a. Shultze’s placenta (separation starts at the center then the sides trapping the blood
inside; sudden gush of blood occurs after delivery of the placenta; shiny – fetal side
presenting at the vulva during placental expulsion)
b. Duncan Placenta (separation starts at the sides then the center; sudden gush of blood
occurs prior to placental expulsion; dirty or maternal cotyledons presenting during
placental expulsion.

Placental Expulsion
Credes manuever
From delivery of infant to delivery of placenta
5 to 30 mins. Duration

Nursing Care :
- Assess for placental separation
1. uterus become firm and globular
2. sudden gush of blood from the vagina
3. umbilical cord lengthens outside the vulva
4. uterine fundus rises in the abdomen
Inspection of placenta
- Monitor VS
- Initiate breastfeeding
- Administer oxytocic and antilactation as ordered
- Sending cord blood to laboratory if the mother is Rh-negative
- Allow bonding
Fetal Danger Signs
1. High or low fetal heart rate
2. Meconium –staining
3. Hyperactivity- hypoxia
4. Fetal acidosis –Ph below 7.2

Maternal danger Signs

1. Rising or falling blood pressure
rising- PIH
falling- sign of intrauterine hemorrhage
2. Abnormal Pulse
3. Inadequate or prolong contractions- uterine inertia
4. Pathologic retraction ring – uterine rupture
5. Abnormal lower contour – a full bladder
Reasons:
a. the bladder may be injured by the pressure of the fetal head
b. pressure of the full bladder may not allow fetal head descent

A. Natural Family Planning

Natural, scientific, value-based, intimacy-promoting technology for fertility management
1. Lactational Amenorrheal Method (LAM)
2. Ovulation Method / Mucus Method / Billing’s Method
3. Basal Body temperature (BBT)
4. Symptothermal Method (STM)
NFP SAVES
1. S pacing of children
2. A chieving Pregnancy
3. V alue-based Marital bonding
4. E mpowerment
5. S afe motherhood

Lactational Amenorrheal Method (LAM)

 Within 6 months from delivery
 Mother is amenorrheic
 Infant is fully or almost fully breast-fed
Cervical Mucus Method
 Use the changes in cervical mucus that occur naturally with ovulation
 Before ovulation each month
- cervical mucus is thick and does not stretch
 Just before ovulation (peak day)
- Mucus becomes thin, watery, transparent, feels slippery, stretches at least one inch before the
strand breaks

Basal Body Temperature

 A woman’s basal body temperature elevation about 0.2 to 0.5 degree’s centigrade on ovulation
because of progesterone

B. Artificial Family Planning

1. Contraceptive Pills (OCS)
a. Synthetic estrogen combined with a small amount of synthetic progesterone
b. Estrogen acts to suppress FSH and LH (gonadotrophic hormone of the pituitary)
c. Progesterone decreases permeability of cervical mucus, limiting sperm mobility and access to ova
d. Interferes with endometrial proliferation to such a degree that implantation becomes unlikely
Calendar Method
- Calculation of a woman’s safe and unsafe eriods based on the following
a. Ovulation occurs 14+_2 days before the start of the next menses
b. Sperm can live up to 72 hours in a woman’s body
c. Ovum can be fertilized up to 24 hours after ovulation
Maintain a menstrual calendar cycle to record the length of each menstrual cycle for 6 – 12 cycles.

To predict the first fertile day in the current cycle

Find the shortest cycle in the record.
Subtract 18 from the total number of days.
Count that number of days from day one of the current cycle, and mark that day with an X. Include day
one when counting.
The day marked X is your first fertile day.
To predict the last fertile day in your current cycle
Find the longest cycle in the record.
Subtract 11 days from the total number of days.
Count that number of days from day one of the current cycle, and mark that day with an X. Include day
one when counting.
The day marked X is the last fertile day.
Here is an example:

Predicting first fertile day. If the shortest cycle is 26 days long, subtract 18 from 26. That leaves 8. If day
one was the fourth day of the month, the day that will be mark X will be the 11th. That's the first day to be
fertile. So on that day, start abstaining from sex or start using a cervical cap, condom, diaphragm, or
female condom.

Predicting the last fertile day. If the longest cycle is 30 days, subtract 11 from 30. That leaves 19. If day
one was the fourth day of the month, the day that will be mark X will be the 22nd. That's the last day
likely to be fertile during the current cycle. Start to have unprotected vaginal intercourse after that day.
In this example, the 11th through the 22nd are unsafe days. All the others are safe days.
Non Contraceptive Benefits
 Protection from PID
a. Cervical mucus scanty and thick
b. Decrease menstrual flow
c. Decrease in uterine contractility
d. Protection from endometrial and ovarian cancer
e. Protection against iron deficiency anemia
f. Minimizes menstrual cramps (dysmenorrhea)
g. Protection against benign breast disease
h. Hormonal replacement in menopause
i. Minimizes acne problems
j. Regulation of menstruation

a. Oral Contraceptive Pills (OCP)

 Combined pills
• Monophasic – fixed dose of estrogen and progesterone throughout the 21 day cycle
• Biphasic – constant amount of estrogen throughout the cycle but increased amount of progestin
during the last 11 days
• Triphasic – varying amount of both estrogen and progestin content throughout the cycle; closely
mimic a natural cycle
 Progestin-only pills (POP)
 Minipill – contains synthetic progestins taken daily without any pill free interval.

Oral Contraceptive Pills (OCP)

 Breastfed infants have lower weight gain when the mother is taking OC with a high level of
estrogen
 Estrogen decreases the woman’s blood supply
 Barbiturates, isoniazid, penicillin & tetracycline decrease the effectiveness of OC’s.
 Acetaminophen, anticoagulants & anticonvulsants reduce OC’s therapeutic effect.
 OC’s increase or strengthen the action of caffeine & corticosteroids
 Adolescent should have a well established menstrual cycle for at least 2 years before beginning
intake of OC’s.
 Not effective immediately for the 1st 7 days; Have to use other contraceptive method

5 Warning Signals
 A – abdominal pain
 C – chestpain or shortness of breath
 H – headache or hypertension
 E – eye problems (blurred or double vision, blindness
 S – swelling or severe leg pain

Newer Forms of Hormonal Method

 Transderm Patch, NuvaRing
b. Subcutaneous Implants
1. Norplant – subdermal hormonal implant
2. Levonorgestrel – synthetic progesterone
Inserted after abortion / 6 weeks after delivery
Disadvantages: cost, weight gain, headache, irregular period
c. Injectable Contraceptive
 Medroxyprogesterone Acetate (DMPA, Depo-Provera)
 Single dose every 3 months
 Side effects
 Vaginal spotting
 headache
 Weight gain
 Administration:
 Shake vial gently
 150 mg/ 1 cc suspension injected IM
 Do not massage injection site
 Increase Calcium in the diet = 1,200 mg/day and do weight bearing exercise to decrease risk for
Osteoporosis

Contraceptive Pills (OCP)

Side effects:
- nausea
- Monilial vaginal infection
- Weight gain
- headache
- Breast tenderness
- Break through bleeding
- Mild hypertension and depression
Contraindications:
- Hx of CVA
- Woman who smoke
- > 40 y/o
- obese
- High serum level
- High blood pressure

4. Intrauterine Devices
 Small plastic object inserted into the uterus through the vagina where it remains in place
 Before the client has had coitus, following the menstrual flow
 Side effects :
 Infection, PID (fever, lower abdominal pain, heavier flow)
 Examples:
 Progestasert
 T-shaped, of permeable plastic with drug reservoir of progesterone in the stem
 Copper T380
 T-shaped plastic device wound with copper

5. Barrier Methods
 Physical placement of a barrier between the cervix and sperm so that sperm cannot enter the
uterus and fallopian tubes
 Changes the vaginal pH to strong acid level
 Vaginally inserted spermicidal products (24 hrs)
 Diaphragm – circular rubber disk (6 hrs)
 Cervical cap – timber (48 hrs)
 Condom – latex rubber

C. Permanent Methods of Reproductive Life Planning

 Vasectomy
 Small incision is made on each side of the scrotum, vas deferens is cut, tied, cauterized, plugged
Tubal ligation
 Cautery, clamping, crushing the fallopian tube
Laparotomy: Culdoscopy; Colpotomy
 Informed Consent for Sterilization
 B – benefits – permanent, very effective,
inexpensive
 R – risks (surgery), bleeding, infection
 A – alternatives
 I – inquiries , encouraged to ask questions
 D – decision to change
 E – explanation , clear and complete
 D – documentation, written consent