INTRAPARTAL PERIOD

Methods of Pain Management

1. Discomfort during labor can be minimized if the woman comes in labor informed
about what is happening and prepared with breathing exercises during labor.
2. Discomfort during labor can be minimized if the woman’s abdomen is relaxed and
the uterus is allowed to rise freely against the abdominal wall with contractions.
3. Operates basically on the “Gate Control” theory of pain. To ease pain in one part of
the body, the “gate” to this pain should be closed.

THEORIES OF LABOR
1. Uterine Stretch Theory – any hollow muscular organ when stretched to capacity will
contract and empty.
2. Oxytocin Stimulation Theory – as pregnancy nears term, oxytocin production by the
posterior pituitary increases. Oxytocin causes contraction of the smooth muscles of
the body.
3. Progesterone Deprivation Theory – progesterone being the hormone designed to
promote pregnancy is believe to inhibit uterine motility. Since its amount is now
decreasing, uterine contractions will then occur.
4. 4. Prostaglandin theory – it has been known that when the fetus has reached maturity,
the fetal membranes produce large amounts of prostaglandin, a hormone that initiates
uterine contractions.
5. 5. Theory of the Aging Placenta – as the placenta “ages”, it becomes less efficient,
producing decreasing amount of progesterone. Because of the decrease blood supply
in the placenta, the uterus contracts.

PRELIMINARY SIGNS OF LABOR

1. Lightening
Results in:
 Relief of abdominal tightness and diaphragmatic pressure
 Relief of respiratory discomfort
 Increase frequency of urination as the gravid uterus impinges on the bladder
 Increase in the amount of vaginal discharges
 Shooting pain down the legs because of pressure on the sciatic nerve
 Muscle spasms
 Decreased fundal height
2. Increase in level of activity
 The adrenal gland secretes large amounts of epinephrine or adrenalin about two
weeks prior to labor.
 This high level of adrenalin provides the woman with much energy.
3. Increase Braxton Hicks Contraction
4. Ripening of the cervix
5. Weight loss

SIGNS OF TRUE LABOR

1. Uterine Contractions
- The “pain” in uterine contractions results from:
 Contraction of uterine muscles when in an ischemic state
 Pressure on nerve ganglia in the cervix and lower uterine segment
 Stretching of ligaments adjacent to the uterus and in the pelvic joints
 Stretching and displacement of the tissues of the vulva and the perineum
2. Show
3. Rupture of membranes

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 Differentiation between True and False Labor Contractions

False Contractions True Contractions

1. Begin and remain irregular Begin irregular but become regular and
predictable
2. Felt first abdominally and remain confined to Felt first in lower back and sweep around to
the abdomen and groin the abdomen in a wave
3. Often disappear wit ambulation and sleep Continue no matter what the woman’s level
of activity
4. Do not increase in duration, frequency or Increase in duration, frequency and intensity
intensity
5. Do not achieve cervical dilatation Achieve cervical dilatation

Related terms:
 Effacement
 Dilatation
In Primis, effacement occurs before dilatation
In Multis, dilatation proceeds effacement

Length of Normal Labor

Primi Multi
First Stage 12 ½ hours 7 hours, 20 minutes
Second Stage 80 minutes 30 minutes
Third Stage 10 minutes 10 minutes
___________ _____________
14 hours 8 hours

Components of Labor
 Passage
 Passenger
 Powers of Labor
 Psyche
Presentation
Types:
1. Cephalic – vertex, brow, face, mentum
2. Breech – complete, frank, footling
3. Shoulder

Position
Possible Fetal Position
1. Vertex (Occiput) LOA,LOP,LOT,ROA,ROP,ROT
2. Breech (Sacrum) LSaA,LSaP,LSaT,RSaA,RSaP,RSaT
3. Face (Mentum) LMA,LMP,LMT,RMA,RMP,RMT
4. Shoulder - LAA,LAP,RAA,RAP
Passenger
 Structures of the Fetal Skull
1. Bones
- frontal, parietal, occipital
2. Fontanels
- Anterior and Posterior fontanel
3. Suture lines
- sagittal, coronal, lambdoid suture

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Diameters of the Fetal Skull
1. Suboccipitobregmatic 9.5 cm
2. Occitofrontal 12 cm
3. Occipitomental 13.5 cm

Powers of Labor
-uterotubal pacemaker
 Uterine Change
- Upper Uterine Segment
- Lower Uterine Segment
 Phases of Contraction
- Increment
- Acme
- Decrement
Aspects of Uterine Contraction
 Duration (A – B)
 Interval (B – C)
 Frequency (A – C)
 Intensity

LABOR PROCESS
Admission Procedures for the Laboring Client
 Orientation to a birthing room
 V/S assessment
 Nursing and medical history and physical examination
 Assessment of fetal heart rate
 Vaginal examination
 Urine specimen and necessary blood samples obtained
 Explanation of fetal or uterine monitoring equipment to be used

STAGES OF LABOR
A. 1st Stage - Stage of Dilatation
Phases of the First Stage of Labor
* Latent/Preparatory phase
-cervix dilates 0-3 cm
-contractions lasting to 20-40 seconds
-6 hours in a nullipara and 4 1/2 hours in multipara
* Active/Accelerated Phase
- cervix dilates from 4 to 7 cm
- contractions lasting to 40-60 seconds occurring every 3-5 minutes
- 3 hours in a nullipara and 2 hours in a multipara
* Transition Phase
- cervix dilates 8 to 10 cm
- contractions lasting to 60-90 seconds occurring every 2-3 minutes

Detailed Assessment During the First Stage of Labor

 Abdominal Assessment
* fundic height
* leopold’s maneuver
* palpate the bladder
 Assessing Rupture of Membranes
* by nitrazine paper test
 Vaginal Examination
* to determine extent of cervical effacement and dilation
 Assessment of Pelvic Adequacy
 Sonography may be used at term to determine the diameters of the fetal head
 V/S Assessment

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  Initial Fetal Assessment

Signs of Fetal Distress

 High or Low FHR
- Fetal bradycardia (<100/minute)
- Fetal tachycardia (>180/minute)
 Meconium-stained amniotic fluid
 Fetal Thrashing
 Fetal Acidosis – pH below 7.2
Maternal Danger Sign
 Rising or Falling Blood Pressure
 Abnormal Pulse
 Inadequate or Prolonged Contractions
 Pathologic Retraction Ring
 Abnormal Lower Abdominal Contour
 Increasing Apprehension

B. 2nd Stage – Stage of Expulsion

 Mechanism/ Cardinal Movements of Labor
A. Descent – fetus goes down the birth canal.
B. Flexion – as descent occurs, pressure from the pelvic floor causes the fetal chin to
bend towards the chest.
C. Internal Rotation –from AP to transverse, then AP to AP.
D. Extension – as head comes out, the back of the neck stops beneath the pubic arch.
The head extends and the forehead, nose, mouth and chin appear.
E. External Rotation (Restitution) – anterior shoulder rotates externally to the AP
position so that it is just behind the symphysis pubis.
F. Expulsion – the delivery of the rest of the baby’s body.

Care of the Woman During the

2nd Stage of Labor
 Preparing the Place of Birth
 Positioning for Birth
 Promoting Effective Second-Stage Pushing
 Perineal Cleaning
 Assist in Episiotomy
Purposes of Episiotomy
- to prevent prolonged and severe stretching of muscles supporting the bladder and rectum.
- reduce duration of second stage of labor.
- enlarge outlet in breech presentation or forceps delivery.
Types:
1. Midline
2. Mediolateral

C. 3rd Stage – Placental Stage

 Placental Stage
 Placental Expulsion
Signs of Placental Separation
 Calkin’s sign
 Sudden gush of blood from the vagina
 Lengthening of the cord
Types of Placental Delivery
 Schulze placenta
 Duncan Placenta

D. 4th stage – Recovery Stage

Assessment:
 Fundus

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  Lochia
 Bladder
 Perineum
 Vital Signs
Categories of Perineal Lacerations
1. First degree – involves the vaginal mucous membrane and perineal skin.
2. Second degree – involves not only the vaginal mucous membrane and perineal skin
but also the muscles.
3. Third degree – involves not only the vaginal mucous membrane, perineal skin and
muscles but also the external sphincter of the rectum.
4. Fourth degree – involves not only the vaginal mucous membrane, perineal skin,
muscles and rectal sphincter but also the mucous membrane of the anus.

Pharmacologic Pain Relief During Labor

• Pharmacologic management of pain during labor and birth includes analgesia, which
reduces or decreases awareness of pain and anesthesia, which causes partial or
complete loss of sensation.
• Be sure to caution women not to take acetylsalicylic acid (aspirin) for pain in labor.
Aspirin interferes with coagulation, increasing the risk for bleeding in the newborn or
mother.
Narcotic Analgesic
• Narcotics are often given in labor because of their potent analgesic effect.
Unfortunately, all the drugs in this category cause fetal CNS depression to some
extent. Be sure to question an order for a narcotic if a woman is in preterm labor.
• A preterm infant, because of possible lung immaturity, may have extreme difficulty
coping with the added insult of respiratory depression at birth.
• Narcotic Analgesic commonly used include meperidine hydrochloride (Demerol),
morphine sulfate, nalbuphine (Nubain)
• Meperidine is advantageous as an analgesic in labor because it has additional sedative
and antispasmodic actions. Thus, it is effective in relieving pain and also helps to
relax the cervix and give a feeling of euphoria and well-being.

Analgesics Commonly Used in Labor and Birth

Type: Narcotic analgesic
Drug: Meperidine (Demerol)
Usual Dosage/Route: 25 mg IV, 50-100 mg IM q3-4 h; also epidurally
Effect on Mother: Effective analgesic; feeling of well-being
Effect on labor progress: Relaxation may aid progress during cervical relaxation. Will halt
labor contractions if given too early
Effect on Fetus or Newborn: Should be given 3 h away from delivery to avoid respiratory
depression in newborn. Decreases beat-to-beat variability in FHR

Type: Narcotic analgesic

Drug: Nalbuphine (Nubain)
Usual Dosage/Route: 10-20 mg IM q3-6 h, 0.3-3 mg/kg over 10-15 min IV
Effect on Mother: Slows respiratory rate; effective analgesic
Effect on labor progress: Causes mild maternal sedation
Effect on Fetus or Newborn: Some respiratory depression may occur

Type: Narcotic analgesic

Drug: Morphine sulfate
Usual Dosage/Route: Intrathecally 0.2-1 mg; 5 mg epidurally
Effect on Mother: Pruritus; effective analgesic
Effect on labor progress:
Effect on Fetus or Newborn: Minimal effects

Regional Anesthesia

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 • Regional anesthesia is the injection of local anesthetic to block specific nerve
pathways.
• Regional anesthesia allows the woman to be completely awake and aware of what is
happening during birth. They do not depress uterine tone, leaving the uterus capable
of optimal contraction after birth, so help prevent postpartal hemorrhage.

Type: Lumbar Epidural Block

Drug: Local anesthetic
Usual Dosage/Route: Administered for the first stage of labor; with continuous block,
anesthesia will last through delivery; injected at L3-4
Effect on Mother: Rapid onset in minutes; last 60-90 min; loss of pain perception for labor
contractions and delivery; possible maternal hypotension
Effect on labor progress: Will slow labor if given too early; obliterates pushing feeling, so
second stage may be prolonged
Effect on Fetus or Newborn: May be some differences in response in first few days of life

• Epidural blocks are advantageous for women with heart disease, pulmonary disease,
diabetes and sometimes severe pregnancy-induced hypertension, because they make
labor virtually pain free and reduce stress from the discomfort of labor to minimum.
• Because the woman does not feel contractions, her physical energy is preserved.
• Are acceptable for use in preterm labor because the drug has scant effect on the fetus.
They allow for a controlled and gentle birth with less trauma to an immature fetal
skull.
• Because the woman receives no systemic medication, the infant responds more
quickly after birth than if narcotic analgesics were used.

Local Anesthetics
• Local Infiltration. Local Infiltration is the injection of an anesthetic such as lidocaine
(Xylocaine) into the superficial nerves of the perineum. The anesthetic is placed
along the borders of the vulva. Local infiltration is used for episiotomy incision and
repair.
• Pudendal Nerve Block. It is the injection of local anesthetic into the right and left
pudendal nerves at the level of the ischial spine. The injection, made through the
vagina with the woman in a lithotomy or dorsal recumbent position, provides relief of
perineal pain during birth.
• Anesthesia achieved with this method is sufficiently deep to allow the use of low
forceps during birth and an episiotomy repair. The onset of a pudendal nerve block
takes 2 to 10 minutes; the effect lasts for approximately 60 minutes. Although the
injection is only a local one, the fetal heart rate and the mother’s blood pressure
should be checked immediately after the injection in case maternal hypotension
occurs.

Type: Pudendal Block

Drug: Local anesthetic
Usual Dosage/Route: Administered just before delivery for perineal anesthesia; injected
through vagina
Effect on Mother: Rapid anesthesia through perineum
Effect on labor progress: Non apparent
Effect on Fetus or Newborn: Non apparent

Type: Local infiltration of perineum

Drug: Local anesthetic
Usual Dosage/Route: Injected just before delivery for episiotomy incision
Effect on Mother: Anesthesia of perineum almost immediately
Effect on labor progress: Non apparent
Effect on Fetus or Newborn: Non apparent

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