Intrapartum Care

Labor – painful uterine contractions and cervical dilation occur.

Braxton Hicks contractions- tightening in the abdomen that comes and goes. Many
women say these “false” contractions feel like mild menstrual cramps.
- may be uncomfortable, but they do not cause labor or open the cervix.

Signs that the mother should head to the Hospital for labor and delivery (as
prescribed by OB)
 Leakage of fluid
 Vaginal bleeding
 Painful contractions every 5 mins for 1 hr
 Decrease in fetal movements

Unique Assessments for Pregnancy, labor and delivery

 Fetal heart tone
 Fetal presentation: assess whether fetus is vertex or breech, uses abdominal ultrasound or ie
 Sterile vaginal Examination: assesses cervical dilation, effacement (thinning of cervix) and fetal
station
 Complete dilation 10 cm
 Effacement (4cm 0%-2cm 50%-0 100%)
 Fetal Station Numbers
Fetal station is stated in negative and positive numbers.
-5 station is a floating baby
-3 station is when the head is above the pelvis
0 station is when the head is at the bottom of the pelvis, also known as being fully
engaged
+3 station is crowning and beginning to emerge from the birth canal
+5 station is crowning.

Stages of Labor
Labor results severe pain for most women.
Stage 1- onset of labor to full cervical dilation
Latent Phase- The time of the onset of labor until the cervix is dilated to 3 cm.

-can last for days.

Active Phase- Continues from 3 cm. until the cervix is dilated to 7 cm.

-1.2-1.5/hr
Interventions:
 Walking is more comfortable than laying supine. There is decrease GI peristalsis so patients
should limit their solid food intake for this could lead to nausea and vomiting.

What to expect:
 Early labor will last approximately 8-12 hours
 Your cervix will efface and dilate to 3 cm
 Contractions will last about 30-45 seconds, giving you 5-30 minutes of rest between
contractions
 Contractions are typically mild and somewhat irregular but become progressively
stronger and more frequent
 Contractions can feel like aching in your lower back, menstrual cramps, and
pressure/tightening in the pelvic area
 Your water might break – this is known as amniotic sac rupture and can happen anytime
within the first stage of labor

 What to do:
 During this phase, you should just try to relax. It is not necessary to rush to the hospital
or birth center. Try to enjoy the comfort of the familiar surroundings at home. If early
labor occurs during the day, do some simple routines around the house.
 Keep yourself occupied while conserving your energy. Drink plenty of water and eat
small snacks. Keep track of the time of your contractions. If early labor begins during
the night, it is a good idea to try to get some sleep. If you are unable to fall asleep, focus
on doing some light activities like cleaning out your closet, packing your bag, or making
sack lunches for the next day.

Transition Phase

What to do:
During this phase, the mother will rely heavily on her support person. This is the most challenging phase,
but it is also the shortest. Try to think “one contraction at a time” (this may be hard to do if the
contractions are very close together). Remember how far you have already come, and when you feel an
urge to push, tell your health care provider.

What to expect:
 The transition will last about 30 min-2 hrs
 Your cervix will dilate from 8cm to 10cm
 Contractions during this phase will last about 60-90 seconds with a 30 second-2 minute rest in
between
 Contractions are long, strong, intense, and can overlap
  This is the hardest phase but also the shortest
 You might experience hot flashes, chills, nausea, vomiting, or gas

Stage 2- Complete dilation of the cervix (10cm) to delivery of the infant.

Pushing and what to expect:

 The second stage can last from 20 minutes to 2 hours.

 Contractions will last about 45-90 seconds at intervals of 3-5 minutes of rest in between.
 You will have a strong natural urge to push.
 You will feel strong pressure at your rectum.
 You are likely to have a minor bowel or urination accident.
 Your baby’s head will eventually crown (become visible).
 You will feel a burning, stinging sensation during crowning.
 During crowning, you will be told by your health care provider to not push.
Pushing and what to do:

 Get into a pushing position that uses gravity to your advantage.

 Push when you feel the urge.
 Relax your pelvic floor and anal area (Kegel exercises can help).
 Rest between contractions to help regain your strength.
 Use a mirror to view your progress (This can be very encouraging!).
 Use all your energy to push.
 Do not become discouraged if your baby’s head emerges and then slips back into the
vagina (this process can take two steps forward and one step back).

Stage 3- Delivery of the infant to the delivery of the placenta.

- The third stage is the delivery of the placenta and is the shortest stage. The time it takes to deliver your
placenta can range from 5 to 30 minutes.

Stage 4- immediate postpartum period, approximately 2 hours after delivery of placenta.

Monitoring
Fetal heart tone- fetal well-being during labor is monitored by electronic fetal monitoring or
intermittent auscultation.

Uterine activity- assessed using External Tocometer.

Pain Management during Labor

Stage 1- pain results from the contraction of the uterus and dilation of cervix resulting in visceral pain
at levels of t10-l1

Stage 2- fetal head distends the lower birth canal and perineum resulting in somatic pain to s2-s4
*some patients tolerate the pain of labor and delivery without any need for medication.

For women who prefer pain relief during labor here are some safe effective methods:

Epidural block- the most effective form of intrapartum pain relief.

-Local anesthetic/narcotics are infused through a catheter into the epidural space.

-lasts during labor and delivery and can be individually titrated.

IV opioids/opioid aganoists and antagonists- can also be used, however since they are systemically
administered the primary mechanism of pain relief is via sedation.

In stage 2, for women who haven’t had a vaginal delivery it takes up to 2-3 hours to push.

-the length is shorter if the woman has not received an epidural.

-If multiparous, can be faster.

As the fetus crowns it is helpful to support the perineum and facilitate extension of the head.

After delivery of head, there is restitution, then there is delivery of anterior shoulder then the posterior
shoulder.

*The optimum place for the baby after the delivery is skin to skin on the maternal chest

Active management of the third stage of labor decreases postpartum hemorrhage this involves fundal
massage, gentle cord traction and IV/IM oxytocin

Placenta can take up to 30 mins to deliver.

2 classic signs that the placenta is separating from the uterus, these are:
 Gush of blood
 Lengthening of umbilical cord

After the placenta delivers the uterus should be palpated to ensure that it is firm and is contracted.

The placenta must be visually examined to ensure that it has been completely removed.

Operative Deliveries- are accompanied by direct traction to the fetal skull with forceps or by
applying traction to the fetal scalp by a vacuum extractor.

Used if:
 Prolonged or arrested 2nd stage
 Suspicion of immediate or fetal compromise
 Shortening of the 2nd stage for maternal benefit