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Normal Labor and Delivery

Intrapartal & Postpartal Care Competencies

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Objectives

At the end of session, the students will be able to:

Gain intrapartal & postpartal care competencies

Assess maternal and fetal condition

Assess progress of labor Manage the 4 stages of labor Describe factors influence

vaginal birth

Describe mechanisms of normal vaginal delivery

Describe steps for conduction vaginal delivery

Appreciate nursing care & responsibilities in each stage of labor

Describe the different principles in new born care .

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TERMINILOGY USED IN MATERNITY NURSING Gestation- pregnancy or maternal

condition of having a developing fetus in the body.

Embryo- human conceptus up to the 10th week of gestation (8th week postconception).

Fetus- human conceptus from the 10th week of gestation (8th week postconception) until delivery.

Viability- capability of living, usually accepted as 24weeks, although survival is rare.

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Gravida (G) - woman who is or has been pregnant, regardless of pregnancy outcome.

Para (P) - refers to past pregnancies that have reached viability.

Example: Gravida 1 Para 0 - a woman who is

pregnant for the first time is a primigravida and is described and summarized as G1P0.

Gravida2 Para 1 - a woman who delivered one fetus carried to the period of viability and who is pregnant again is described as Gravida2, Para1.

Gravida2 Para 0 - a woman with two pregnancies ending in abortions and no viable children is Gravida 2, Para 0.

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PREGNANCY PERIODS ANTEPARTUM PERIOD - refers to

the period from conception to the onset of labor.

INTRAPARTUM PERIOD - extends from the onset of contractions that causes cervical dilatation to the first 1-4 hours after birth of the neonate and the placenta.

POSTPARTUM PERIOD - refers to the 6 weeks after delivery of the neonate and the placenta. Also called as Puerperium, this stage ends when the reproductive organs return to the non-pregnant state, termed as Involution.

 

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 PREGNANCY TRIMESTERS:

1ST TRIMESTER = 1-12 WEEKS

2ND TRIMESTER = 13-27 WEEKS

3RD TRIMESTER = 28- 42 WEEKS

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 ANTEPARTAL PERIOD:

PRENATAL ASSESSMENT HEALTH HISTORY

A. Age

@ Risk: younger than age 19 & advanced maternal age (over age 35).

B. Family History

C. Woman’s Medical History

D. Nutritional History

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E. Woman’s Past Obstetric History Problems of infertility, date of previous

pregnancies, and deliveries- dates; infant’s weights; length of labors; types of deliveries; multiple births; abortions; and maternal, fetal, and neonatal complications.

Woman’s perception of past pregnancy, labor, and delivery for herself and effect on her family.

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F.Woman’s Present Obstetric History

1.Gravidity, Parity TPAL A woman’s obstetric history is summarized by a series of four digits, such as 5-0-2-5. These digits correspond with the abbreviation TPAL.

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T-represents full term deliveries, 37 completed weeks or more.

P- represents preterm deliveries, 20 to less than 37 completed weeks.

A- represents abortions, elective or spontaneous loss (miscarriage) of a pregnancy before the period of viability.

L- represents the number of children living.

If, for example, a particular woman’s history is summarized as G7, P5-0-2-5, then she has been pregnant seven times, had five term deliveries, two abortions, and five living children.

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GTPALMIn some institutions, a woman’s obstetric history can also be summarized as GTPALM.•G- represents gravida.•T- represents full-term deliveries, 37 completed weeks or more.•P-represents preterm deliveries, 20 less than 37 completed weeks.•A- represents abortions, elective or spontaneous loss

of a pregnancy before the period of viability.•L- represents the number of children living. If a child

has died, further explanation is needed for clarification.•M- represents the number of multiple gestations and births (not the number of neonates delivered).

If, for example, a particular woman’s history is summarized as G5, P5-0-0-6-1, then she has been pregnant five times, had five term deliveries, zero preterm deliveries, zero abortions, six living children, and one multiple gestation/birth.

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2. LMP - last Menstrual Period (1st day of the last menstrual period).

3. EDC/EDD - Expected Date of Confinement/Expected Date of Delivery (40 weeks of Gestation)

4. Signs & Symptoms of Pregnancy

5. Rest and Sleep Patterns

6. Activity and Employment

7. Sexual Activity

8. Diet History

9. Psychosocial Status

Delivery Room

Is a specialized area equippe

d for deliverin

g babies.

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Intrapartal Care Competencies Obtaining Obstetrical History-

parity, gravidity, scoring (TPAL), LMP, AOG, Bag of Water, Onset of True Labor

Checking of Vital Signs Conducting Physical

Examination- assess for danger signs of pregnancy:

Edema on hands and faceVaginal bleedingBeing pail or anemicHypertension, Headache, Dizziness, Blurred vision

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Estimation of fetal age

1. Naegele’s rule:

*EDC = LMP + 7 days - 3

months

2.Fundal height

3. Quickening

4. Lightening

5. Ultrasonography

6. Fetal weight

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Fundal height measurement

3632,402824

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Biparietal diameter - BPD

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Femur length -FL

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Abdominal circumference -AC

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Diagnosis of true labor pain

History A history of regular painful uterine

contraction in every 5- 8 min, accompanied by the history of a bloody show or spontaneous rupture of membrane

Physical examination Reduction of interval between

uterine contractions Abdominal pain of increasing

intensity Cervical effacement (≥ 50%) Cervical dilation (≥ 2cm)

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Difference between true labor and false labor

Uterine contraction regular irregular

Interval decrease irregular

Duration increase irregular

Intensity increase irregular

Cervical change progress no change

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Vaginal birth

Power Passage Passenger

5 P’s- Components of Labor

Good contraction? Contracted pelvis ? Large baby ?

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Vaginal birth

Psyche Placental Factor

5 P’s

Emotionally ready? Location of the placenta?

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Stages of labor First stage ( true labor pain

until cervix fully dilated or 10

cm)

Latent phase

Active phase

Transition phase

Second stage (cervix fully

dilated

until the delivery of the

baby)

Third stage (delivery of the

baby until the expulsion of

placenta)

Fourth stage(delivery of the

placenta to the first four

hours to 12 hours).

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Management/Nursing Responsibilities in First Stage of labor

Admission assessmentAdmission Assessment

1.Take history: LMP, EDC , labor pain ,

bleeding, ruptured membrane, fetal

movement, maternal diseases, review

ANC records , lab test

2. Perform physical examination :

2.1 General examination

2.2 Leopold maneuver,

2.3 Auscultation fetal heart sound

2.3 Uterine contraction

2.4 Pelvic examination

Purpose of Leopold’s Maneuver

Determine the position of the baby in utero

Determine the expected presentation

during labor and delivery

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First Leopold Second Leopold

Third Leopold Fourth Leopold

The lie is either:

Longitudinal long axis of the fetus is aligned to the mother’s

this is the only NORMAL position

Transverse long axis of the fetus is perpendicular to that of the mother’s

Oblique long axis of the fetus is 0-90 degrees (or 90-180 degrees) to that of the mother’s

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Uterine contraction (Power)

Duration Interval Intensity

Good contraction I= 2-3 min, D= 45-60 sec

If not : correct by using oxytoxic drug

DInterval

Intensity

Engagement

Determined by the amount of head that is above or below the pelvic brim

This is usually done by dividing the head into ”fifths” if the head is still palpable abdominally, it is “2/5” or less engaged

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Pelvic Examination/Vaginal

Examination/Internal Examination

1. Birth canal

2. Cervical condition and

related part.

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Birth canal ( passage)

Inlet

diagonal conjugate diameter >

12 cm Mid pelvis

interspinous diameter > 10 cm Outlet

subpubic angle > 90 0

intertuberosity diameter > 10

cm

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Cervical condition and related parts

1.Cervical condition

* dilatation 0-10 cm

* effacement 0-100%

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Cervical dilatation

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2. Presenting part : cephalic

VertexFace

Sinciput Brow

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3. Position

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45

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Presenting part : Breech

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Presentation Denominating

point

Vertex

Face

Breech

Shoulder

Occiput

Mentum

Sacrum

Acromium

484. Station

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.

5. Membrane

Status : intact or rupture

Color : clear or meconium stain

Amount : normal or abnormal

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Assess fetal condition Auscultation of fetal heart (normal range 120-160

bpm)

High risk : 1st stage every 15 min , 2nd stage

every 5 min

Low risk : 1st stage every 30 min , 2nd stage

every 15 min Electronic fetal heart rate monitoring (not essential in

low risk pregnancy)

Ultrasound (not essential in low risk pregnancy)

Biophysical profile (not essential in low risk

pregnancy)

: 5 components: fetal tone , fetal breathing ,

fetal movement, NST, Amniotic fluid

pocket

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Assess fetal condition Auscultation of fetal heart

Fetal Stethoscope & Fetal Doppler

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Assess fetal condition Electronic fetal heart rate monitoring – External &

Internal

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Assess fetal condition Ultrasound/Sonogram

Biophysical profile

5 components: fetal tone , fetal breathing

, fetal movement, NST, Amniotic

fluid pocket

Sonography Machine gives the best pictures & 4D sonographic images

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Characteristics of normal low-risk labor

1. No pregnancy complications that may affect labor( with adequate ANC)

2. Spontaneous onset of labor between 37-42 week of gestation

3. Singleton fetus with cephalic presentation

4. Estimate fetal weight > 2,500 g, < 4,000 g

5. Adequate volume of clear amniotic fluid

6. No abnormal intrapartum bleeding7. Acceptable rate of cervical dilatation

(1 cm/hr in active phase)8. Normal fetal heart rate

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Characteristics & Stages of Labor

1st Stage of Labor- Dilatation Stage Starts from true labor contraction &

ends with complete effacement and full dilatation of the cervix.

Phases:A.Latent Phase

Dilatation 1-3cms.Interval 5-10mins apartDuration 20-40 secs.

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Characteristics & Stages of Labor

B.Active phaseDilatation 4-7cms.

Interval 3-5 mins apartDuration 40-60 secs.

C. Transition PhaseDilatation 8-10cms.

Interval 2-3 mins apartDuration 60-90 secs.

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Summary

Nursing Responsibilities in each Stage of Labor

First stageIndependent Maternal vital signs & assessment of

risk factors Regular record uterine contraction and

fetal heart rate Food / IV fluid consideration Maternal position Coaching & deep breathing exercises Pain scale & management Record and assess progress of labor-

Partograph

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Summary

Nursing Responsibilities in each Stage of Labor

Dependent Analgesic drug consideration Enema Catheterization Induction of labor- Oxytocin

administrationCollaborative Follow up lab. Results

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Partograph

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PartographProgress of labor

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Characteristics & Stages of Labor

2nd Stage of labor- Delivery Stage

Starts from complete effacement and full dilatation of the cervix to the delivery or expulsion of the baby.

The cervix is usually 10cm in dilatation & 100% effaced or is not palpable anymore.

BOW will rupture

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Characteristics & Stages of Labor

Rupture of MembranesTypes: spontaneous artificial amniotomy

Amniotomy is an artificial rupturing of the membrane to induce or accelerate labor.

Amniotomy

Cristina Manzano

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Characteristics & Stages of Labor

2nd Stage of labor- Delivery Stage

Signs of Fetal Delivery: Bloody show Rupture of membranes Contraction of short intervals and

durations lasting for more than a minute occurring every2-3 mins.

Bulging of the perineum Urgency to bear down

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Second Stage

Mechanism of labor : 7 cardinal movements in occiput anterior presentation engagement descent flexion internal rotation extension external rotation expulsion

Conduct vaginal delivery

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Episiotomy

types 1. median or midline

2. mediolateral

Routine

episiotomy

Restrictive

episiotomy

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Nursing Care & Responsibilities during actual Delivery

Preparing the DR, instruments &

equipments needed.

Transporting patient safely to the

delivery room

Provision of privacy/Draping

Proper positioning

Perineal Care

Hand washing & wearing proper

attire

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Nursing Care & Responsibilities during actual Delivery

Coaching mother on breathing &

pushing Techniques

Deliver baby safely- Ritgen’s

Maneuver

Noting time of fetal delivery and

gender

Immediate assessment of mother’s

condition

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Video viewing

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Third stage (PLACENTAL STAGE)

From the delivery of the fetus to the

expulsion of the placenta.

-the placenta should be delivered

1hour after the baby has been born.

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Third stage (PLACENTAL STAGE)

Signs of placental separation sudden gush of blood

Calkin’s signs (firm & globular ) cord sign - lenghtening

Delivery of placentaModified Crede

Brandt Andrew

Controlled cord traction

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Delivery of the placenta : Modified Crede’s maneuver

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Delivery of the placenta :Brandt-Andrew Maneuver

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Controlled cord traction

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Nursing Care & Responsibilities on the third stage of labor

Watch/note signs of placental

separation

Expel placenta through different

maneuvers

Inspect placenta for completeness of

cotyledons

Note time placenta was expelled

Administer Oxytoxic (IM) to contract

the uterus

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Nursing Care & Responsibilities on the third stage of labor

Maintain asepsis

Vital signs taking

Note mother’s condition

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4th stage (POSTPARTUM STAGE)

stage from the expulsion of the

placenta to the first 12 hours after

delivery.

This is the most critical stage among

the 4 stages of labor.

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4th stage (POSTPARTUM STAGE)

Nursing Responsibilities:

Assess amount of blood loss –

normal:<500cc in NSD

Prevent & control hemorrhage Uterine massage

Cold compress

Administration of Oxytocin or

Methergine (IM)

Assessment of presence & degree of

lacerations.

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4th stage (Postpartum STAGE)

Assisting in episiorrhapy

Checking of size, consistency &

location of the uterus

Performing perineal care & application

of pads

Provision of psychological support

Evaluation of client’s condition &

record

Transfer patient safely to recovery

room/ward.

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Prevent postpartum

hemorrhage expel all placental fragments &

blood clots Keep uterus well contracted Inspect for cervical, vaginal or

perineal lacerations

oxytocic drugsSyntocinon® : IV push, IV drip, IM

Methergin® : IM, IV

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Repairing episiotomy wound

Perineal tear during vaginal

birth First-degree tear Second-degree tear Third-degree tear Fourth-degree tear

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Length of Normal Labor

PRIMI (14 hours)

1st stage 12 hours & 30 mins

2nd stage80 mins

3rd stage 10 mins

Prolonged labor = add 4 hours

MULTI (8 hours)

7 hours & 30 mins.

30 mins

10 mins

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Postpartum care : 10 Bs

Blood pressure Bladder Bloody discharge Basket Bowel Breast engorgement Breast feeding Baby Blue Brain

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After Care

Sterilization procedures of equipments & materials

Maintaining adequacy of supplies

Proper disposal of hospital waste including blood & other fluids.

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Immediate Newborn Care

Principles in Newborn Care

1. Establish & Maintain Airway Patency

2. Maintain Appropriate Body Temperature

3. Immediate Latching On/ Skin to Skin Contact

4. Immediate Assessment of the Newborn

APGAR ScoreAssessment of Gestational

AgeCephalometry

5. Proper Identification- Footprints/ identification band

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Immediate Newborn Care

Principles in Newborn Care

6. Specific Nursing Actions/ Nursery Care Check Identification band Antropometric Measurements

Administration of Vit.K, Hepa B & Crede’s Eye Prophylaxis

Weight / Vital signs Taking

7. Rooming-in