Intrapartum FH 2/11/2026

INTRAPARTUM NURS336 FAMILY HEALTH NURSING

Objectives

  • Theories of the Onset of Labor (Course Outcome #1)

    • Relate theories explaining how labor begins.

  • Distinguishing True and False Labor (Course Outcome #2)

    • Identify the differences between true labor showing cervical change and false labor without such progress.

  • Analyze Characteristics of Labor Stages and Phases (Course Outcome #4)

    • Analyze the stages and phases of labor, along with maternal and fetal adaptations.

  • Assessment Findings During Labor Stages (Course Outcome #3)

    • Differentiating between normal and abnormal findings based on physical and psychological assessments throughout the four stages of labor.

  • Nursing Interventions for Normal Labor and Delivery (Course Outcome #4)

    • Determine appropriate nursing interventions for each stage of normal labor and delivery.

  • Decelerations in Fetal Heart Rate (Course Outcome #2)

    • Differentiate between early, late, and variable decelerations regarding occurrence, causes, potential outcomes, and nursing interventions.

  • Pain Management During Labor (Course Outcome #1)

    • Correlate and contrast pharmacological and nonpharmacological methods for managing pain during labor.

  • Fetal Position Analysis (Course Outcome #4)

    • Analyze fetal position in utero.

Theories of Onset of Labor

  • Changes in Hormones:

    • An increase in estrogen and a decrease in progesterone play a vital role in initiating labor.

    • Oxytocin Receptors:Pituitary Gland

    • Increased in the uterus towards the end of pregnancy, leading to uterine contractions.

Signs of Labor

  • Lightening:

    • The sensation when the fetus drops into the pelvis.

  • Increased Energy Level: (Nesting)

    • Often noted in the days leading up to labor.

  • Bloody Show:

    • Mucus plug is expelled; presence of blood-tinged discharge.

  • Braxton Hicks Contractions:

    • Irregular contractions that can start weeks before true labor.

      • Initiated in the front of abdomen and wrap to back

      • Stops with walking/position changes

  • Spontaneous Rupture of Membranes:

    • The amniotic sac bursts, signaling the beginning of labor for some.

      • Spontaneus Vs Artific

  • Gastrointestinal Changes:

    • Diarrhea or nausea may occur.

  • Backache:

    • Discomfort due to position changes as labor approaches.

True Labor

  • Functions of Contractions:

    • Dilate the Cervix:

    • The cervix opens to prepare for childbirth.

    • Push the Fetus:

    • Contractions aid in moving the baby through the birth canal.

  • Characteristics of True Labor:

    • Contractions result in cervical change.

      • Lower Back to Front of Abdomen

      • More intense with activity

Factors Affecting Labor Process

  • Passageway:

    • Refers to the birth canal and pelvis.

  • Passenger:

    • Involves the fetus and placenta.

  • Powers:

    • The force exerted by contractions.

  • Position:

    • Maternal positioning during labor.

  • Psychological Response:

    • The emotional state and coping mechanisms of the laboring individual.

Passageway - Favorable Pelvis

  • Pelvic Types:

    • Gynecoid:

    • Ideal for childbirth.

    • Anthropoid (Apelike):

    • Can be favorable but less so than gynecoid.

Passageway - Unfavorable Pelvis

  • Pelvic Types:

    • Android & Platypelloid:

    • Types that may complicate childbirth due to shape and size constraints.

Passenger

  • Fetal Head:

    • Comprises bones that allow for molding during delivery.

  • Fetal Attitude, Lie, and Presentation:

    • Fetal Attitude: Relation of fetal body parts to one another (flexion and extension).

      • Flexion: chin tucked

      • Extension: chin extended upward

    • Fetal Lie: The orientation of the fetal spine compared to the mother's spine (longitudinal or transverse).

      • Vertex (head first)

    • Fetal Presentation: The part of the fetus entering the pelvis first (e.g., cephalic, breech).

Pelvic Stations

  • Definition:

    • The relationship of presenting fetal part to the ischial spines (narrowest part of the pelvis).

  • Stations:

    • -5: Indicates engagement at pelvic inlet.

    • 0: At ischial spine.

    • +5: At pelvic outlet (crowning).

Fetal Presentation Types

  • Cephalic (Vertex):

    • Ideally, the occiput is head first.

  • Breech (sacrum) Variants:

    • Frank Breech: Buttocks enter first.

    • Complete Breech: Legs are flexed.

    • Single Footling Breech: One foot presents first.

  • Shoulder (Scapula)

Fetal Position

  • Components:

    • Orientation is described as right/left, occiput/mentum/sacrum, and anterior/posterior/transverse.

    • Example Positions:

    • Right Anterior

    • Left Posterior

Cardinal Positions of Labor

  • Stages of Labor:

    • Engagement

      • Fetal head enters pelvic inlet - Station= 0

    • Descent

      • Fetus moves downward

    • Flexion

      • Fetal Chin tucks to chest

    • Internal Rotation

      • Occiput rotates from transverse to anterior

    • Extension “Crowning”

      • Head presents

    • External Rotation

      • Head rotates back to shoulder alignment

    • Expulsion

      • Anterior shoulder, then posterior

Powers of Labor

  • Uterine Contractions:

    • Essential for cervical effacement and dilation and fetal descent.

  • Contraction Characteristics:

    • Frequency: How often contractions occur during a timeframe.

    • Intensity: Strength of contractions.

    • Duration: How long each contraction lasts.

Maternal Positioning

  • Management of Position:

    • Frequent changes are encouraged.

    • Emptying the bladder regularly (every 1-2 hours).

      • Lithotomy position

        • Supine position with button table, pillow on right side

Psychological Response

  • Factors Influencing Psychological State:

    • Support systems, preparation levels, past experiences, and coping strategies.

    • High anxiety and fear can hinder coping abilities.

    • Maternal catecholamines (stress hormones) can lead to reduced uterine contractions and blood flow.

Labor and Birth Definitions
Cervical Changes True Indicators of Labor

  • Dilation:

    • Cervical opening measured from 0 to 10 cm.

  • Effacement:

    • Thinning of cervix expressed from 0 to 100%.

Rupture of Membranes

  • Types: Amnisure to determine

    • Spontaneous Rupture of Membranes (SROM)

    • Artificial Rupture of Membranes (AROM)

  • C-O-A-T:

    • C: Color

    • O: Odor

    • A: Amount

    • T: Time

Stages of Labor and Birth

  • Stage 1:

    • Latent Phase: 0-3 cm

    • Active Phase: 4-7 cm

    • Transition Phase: 8-10 cm

  • Stage 2: Delivery of fetus (Bloody Show)

    • Full dilation (10 cm) until the infant's birth.

  • Stage 3:

    • From birth until delivery of the placenta.

  • Stage 4:

    • Recovery period lasting 1-4 hours after birth.

Leopold's Maneuver
First Maneuver

  • Assessment of fetal position.

Second Maneuver

  • Further evaluation of fetal position.

Third Maneuver

  • Final assessment of fetal engagement.

Fourth Maneuver

  • Complete evaluation for optimal delivery positioning.

Practice and Discussion Activities

  • Cervical Exams:

    • Use items as metaphors for size (e.g., Cheerio for 1 cm, Grape for 2 cm).

  • Leopold's Maneuvers Practice:

    • Physical assessment practice by palpation.

External Fetal Heart and Contraction Monitoring

  • Devices:

    • Toco transducer is used for how or when contraction monitoring.

    • Ultrasound transducer detects fetal heartbeat.

Intermittent Fetal Heart Rate Monitoring

  • Methods:

    • Doppler for low-risk patients allows free movement.

    • Monitor every 30-60 minutes in latent phase; every 15-30 minutes in active phase; every 5-15 minutes in second stage.

Internal Fetal Heart Rate Monitoring - Fetal Scalp Electrode (FSE)

  • Maternal must be ruptured AROM

  • Use:

    • Detects electrical signals from the fetal heart.

    • Precautions against placement on face or genitalia.

Contraction Monitoring

  • Palpation Methods:

    • Mild (nose), moderate (chin), strong (forehead).

  • External Monitoring:

    • Evaluation of contraction frequency and duration.

  • Internal Monitoring:

    • Intrauterine Pressure Catheter (IUPC) for detailed assessment. How strong contraction is in uterus

Internal Contraction Monitoring - IUPC

  • Uses & Functions:

    • Measure frequency, duration, and intensity of contractions.

    • Membranes must be ruptured for use.

    • Can assist with amnioinfusion in cases of oligohydramnios or fetal cord compression.

Evaluation of Fetal Status: Baseline

  • Normal Baseline:

    • Heart rates between 110-160 BPM.

  • Time Frame for Assessment:

    • Assess over 10-20 minutes; review in 10-minute increments.

Possible Causes of Bradycardia and Tachycardia

  • Bradycardia (<110 BPM):

    • Risks: cord compression, hemorrhage, medications, poor maternal oxygenation, anemia, or maternal hypertension affecting placental perfusion.

  • Tachycardia (>160 BPM):

    • Risks: caffeine, drug use, maternal fever, stress, or lack of O2 leading to poor perfusion.

Baseline Variability

  • Definition:

    • Represents irregular fluctuations in the baseline fetal heart rate pattern.

  • Significance:

    • Indicates adequate oxygenation and the interplay of autonomic nervous functions.

    • Fundamental in fetal assessment.

Variability Classification

  • Fluctuations:

    • Measured within 1-minute timeframes.

    • Categories: absent, minimal, moderate, marked.

      • Minimal- 5 beats/ min or less

      • Moderate 6-25 beats/min

      • Marked- > 25 beats/ min

Causes of Absent or Minimal Variability

  • Associated Conditions:

    • Fetal acidemia, placental insufficiency, cord compression, preterm fetus, maternal hypotension, uterine hyperstimulation, abruption, fetal dysrhythmia, fetal sleep states, drugs, and severe fetal conditions (e.g., anencephaly).

Interventions for Absent or Minimal Variability

  • Increasing Placental Perfusion:

    • Reposition mother laterally, increase IV fluids, administer oxygen at 8-10 L per face mask, consider internal monitoring, document findings, notify physician.

Moderate Variability (Ideal)

  • Indication of Fetal Health:

    • Shows normal development and good oxygenation of the fetus.

Marked Variability Causes

  • Concerns:

    • Can indicate cord prolapse, maternal hypotension, uterine hyperstimulation, or placental abruption.

Interventions for Marked Variability

  • Conduct Actions:

    • Determine the cause, reposition the mother, increase IV fluids, provide oxygen -10 L face mask, consider discontinuation of oxytocin, and communicate findings with a physician.

Accelerations in Fetal Heart Rate

  • Description:

    • Abrupt increases lasting less than 30 seconds, associated with sympathetic activation.

    • Should be 15 BPM above baseline for 15 seconds or more but less than 2 minutes; categorized as reassuring.

Decelerations in Fetal Heart Rate

  • Fall in FHR:

    • Result of the parasympathetic nervous system stimulation; categorized as early, late, variable, or prolonged based on shape and occurrence related to contractions.

Early Decelerations (Ideal)

  • Characteristics:

    • Caused by fetal head compression, non-threatening, often seen during pushing.

  • Interventions Needed:

    • None required as typically non-pathological.

    • Baby’s head is transitioning down into the pelvis

Variable Decelerations

  • Causes:

    • Reduced blood flow through umbilical cord leading to abrupt changes.

    • Interventions:

    • Reposition mother, administer oxygen, consider fluid bolus.

Late Decelerations

  • Symptoms:

    • Associated with uteroplacental insufficiency and fetal hypoxia.

  • Interventions Needed:

    • Lateral positioning, increase IV fluids, administer oxygen, discontinue oxytocin if infusing, internal monitoring, document findings, assess underlying causes, and if required, prepare for cesarean delivery.

Prolonged Decelerations

  • Definition:

    • Lasting more than 2 minutes but less than 10 minutes; needs urgent attention.

  • Interventions for Management:

    • Similar to late decelerations; ensure all actions are communicated with a physician.

      • Consider tocolytic

      • Vaginal Exam

      • C-section if interventions do not work

Sinusoidal Pattern

  • Description:

    • A smooth, sine-wave pattern persisting for over 20 minutes; linked to deranged CNS control often resulting from severe fetal anemia or hypovolemia.

      • Hypoxic Fetus

        • Impending doom

          • Cesarean Section

  • Interventions Needed:

    • Consider fetal intrauterine transfusion or cesarean delivery.

VEAL CHOP Mnemonics

  • V: Variable decelerations - C: Cord compression

  • E: Early decelerations - H: Head compression

  • A: Accelerations - O: OK

  • L: Late decelerations - P: Placental insufficiency

Three-Tier System for Fetal Heart Rate

  • Category I: Normal

  • Category II: Indeterminate, concerning needing further evaluation

  • Category III: Includes sinusoidal patterns, absent variability with recurrent decelerations or bradycardia; indicative of abnormal fetal acid-base status.

Fetal Well Being Assessments

  • Assessment Techniques:

    • Ultrasound: abdominal, transvaginal, Doppler for blood flow; visual assessment of fetal characteristics.

    • Biophysical Profile: ultrasound to visualize responses to stimuli and fetal characteristics.

    • Nonstress Test: client action prompts fetal monitoring; demonstrates fetal movement in relation to HR changes.

      • External Fetal Monitoring

      • Client pushes button when she feels fetal move

    • Contraction Stress Test: evaluate FHR patterns during contractions via nipple/oxytocin stimulation.

    • Amniocentesis: for analysis of amniotic fluid.

Practice Fetal Heart Tracings

  • Conduct drawings of fetal monitor strips and share interpretations as practice.

Pain Management in Labor

  • Perception of Pain:

    • Influenced by cultural factors, caregiver actions, support systems, and individual history.

Types of Pain Management

  • Nonpharmacological Approaches:

    • Includes continuous support, ambulation, position changes, acupressure/acupuncture, hydrotherapy, breathing techniques, effleurage, music, meditation, and guided imagery.

  • Pharmacological Approaches:

    • Systemic Medications:

    • Opioids (e.g., Butorphanol, Nalbuphine, Meperidine, Morphine, Fentanyl) with monitoring due to potential neonatal respiratory depression.

    • Ataractics:

    • Hydroxyzine, Promethazine, Prochlorperazine, Diazepam, Midazolam.

    • Inhaled Pain Relief:

    • Nitrous oxide mixed with oxygen; self-administered with possible side effects including nausea, dizziness, and dysphoria.

    • Regional Anesthesia:

    • Epidural, spinal or intrathecal, local infiltration, and pudendal blocks, each with specific techniques and implications.

Epidural Details

  • Administered Below T8-T10 with a combination of opioids (like Fentanyl) and local anesthetics.

  • Considerations:

    • 500-1000cc Fluid bolus pre-epidural; monitoring for BP (Hypotension) and O2 function post-placement; contraindications include anticoagulant use or prior spinal issues.

    • Platelets greater than 100,000

Local Infiltration/Perineal Anesthesia

  • Used for tearing repairs or episiotomies with minimal side effects.

General Anesthesia

  • Reserved for emergencies like cesarean sections; can cross the placenta and is critical to assist operations.

Nursing Care During Labor and Birth

  • Components of Nursing Care:

    • Comprehensive health history and prenatal assessment, continuous monitoring of fetal well-being, understanding labor stage transitions, and appropriate nursing diagnosis and interventions.