Intrapartum care

Intrapartum care refers to the care provided to the woman during labor and delivery.
Labour is a sequence of uterine contractions that results in:
- effacement and dilatation of the cervix
- and voluntary bearing-down efforts leading to the expulsion per vagina of the products of
conception
- The settling of the fetal head into the brim of the pelvis, known as lightening,
- usually occurs 2 or more weeks before labor in first pregnancies.
- In women who have had a previous delivery, lightening often does not occur until early labor.
• Cervical Effacement

• Cervical Dilatation

• Station or descent

• Engagement of presenting part

The mechanism responsible for initiating parturition is still unknown

• The onset of labour occurs when factors which inhibit contractions and maintain a
closed cervix diminish and are succeeded by the actions of factors which do the
opposite.

• Both mother and fetus make contributions toward this.

Myometrial activity

• During pregnancy

• Inactive uterus

• Periodic episodes of weak and slow rhythmical uterine contractions (Braxton Hicks)
during 3rd trimester

• Towards end of pregnancy

• Uterine contractions become progressively stronger

• Suddenly uterine contractions become very strong leading to:

- Cervical effacement and dilatation

Cervical ripening

• Refers to the softening of the cervix that typically begins prior to the onset of labour
contractions and is necessary for cervical dilation and the passage of the fetus.

MECHANISM OF LABOUR

When it comes to labour, we have two types. So we will have to distinguish true labour from false

labour.

1. Physiology of labour pains

The precise mechanism of initiation of labour is still obscure. However, it involves endocrine,
biochemical and mechanical stretch pathways. Put forth the following hypotheses:

Uterine distension: Stretching effect on the myometrium by the growing foetus and liquor

Estrogen increases the release of oxytocin from maternal Pituitary and increases the excitability of
the myometrium.

Progesterone levels fall before labour.

Oxytocin stimulates synthesis and release of prostaglandins from amnion and decidua which initiate
and maintain labour.

“Lightening”:

Few weeks prior to the onset of labour, the presenting part sinks into the true pelvis. It is due to
active pulling up of the lower pole of the uterus around the presenting [Link] diminishes the fundal
height and minimizes the pressure on the diaphragm. The mother experiences a sense of relief from
the mechanical cardiorespiratory embarrassment.

Uterine contraction in labour:

The character of contractions changes with the onset of labour.

- Intensity: The intensity gradually increases with advancement of labour until it becomes
maximum in the second stage during delivery of the baby.
- Duration: Contractions gradually increase in duration with the progress of labour.

- Frequency: In early stage of labour, the contractions come at intervals of 10–15 min. The
intervals gradually shorten with advancement of labour until in the second stage, when it comes
every 2–3 min
 1. False labour

These are false labour pains that usually appear prior to the onset of true labour pain. They are
also called prodromal labour or Braxton Hicks contractions. False labour pains are
characterized by:

 Irregularity of contractions,

 Confinement to the lower abdomen ,

 No show (loss of the operculum as a blood stained mucous discharge)

 No increase in duration, intensity or frequency (Usually relieved by enema, sedative or

rest).
 Not accompanied by cervical change
NB: A midwife should pay attention to the occurrence of false labour and offer adequate care
and support to allay anxiety and reassure the pregnant woman.
2. True labour

- Regular Painful uterine contractions at regular intervals, felt at the lower back
then radiating to the lower abdomen
- Frequency of contractions increase gradually,

- Intensity and duration of contractions increase progressively,

- Associated with bloody “show”,

- Accompanied by cervical changes (effacement and dilatation)

- Descent of the presenting part,

- Formation of the “bag of fore waters”

- Not relieved by enema, sedatives or rest

PRIMIPARA MULTIPARA

Duration the 1st stage 6–18 hours 2–10 hours

Rate of cervical dilatation during 1.2 cm per hour 1.5 cm per hour
the active phase

Duration of 2nd stage 30 minutes to 3 hours 5–30 minutes

Duration of 3rd stage 0–30 minutes 0–30 minutes

 ❖ Effacement and dilatation of the cervix

Effacement of the cervix is the process by which the muscular fibres of the cervix are pulled
upward and merges with the fibres of the lower uterine segment. In primigravidae,effacement
precedes dilatation of the cervix, whereas in multiparae, both occurs simultaneously. Dilatation
of the cervix is the process of enlargement of the uterine os from a tightly closed aperture to an
opening large enough to permit the passage of the foetal head.

Remark: with the primiparous we first of all have cervical effacement before cervical dilatation;
while with the multiparous the both are simultaneous. When doing the vaginal examination we
can also do bishop score evaluation. Its main pursose is to evaluate the ripening state of the
cervix prior to the pharmacological or mechanical induction of labour. Five different criteria are
evaluated, each on 3 and scored over 15 as showed in the following table:
Bishop score 0 1 2 3

Dilatation 0 1-2 cm 3-4cm 5cm and

+
Effacement 30% 40 - 50% 60 - 70% 80%

Foetal head high and ready to fixed engaged

position mobile be fixed

Cervix Firm semi-firm semi- soft

consistency soft
Cervix posterior middle middle anterior
position

- A score of 7/15 and above is favourable to induction with synto drip

- A score of less than 7/15 is favourable to induction with ¼ of misoprostol tablet

or with folley catheter
NB: Engagement is the crossing of the pelvis inlet by the largest diameter of the engaging part of the foetus.
While a presentation is said to be fixed when its greatest circumference has crossed the pelvic inlet with the
sacral promontory not being reachable by the fingers during vaginal examination.
 3. Mechanism of normal labour

The cardinal movements in the mechanism of normal labour are:

(1) Engagement,

(2) Descent,

(3) Flexion,

(4) Internal rotation of the head,

(5) Extension of the head and crowning,

(6) Restitution

(7) External rotation, and

(8) Expulsion of the trunk.

STAGES OF LABOUR

There are normally four stages of labour but in some litteratures three might be seen and documented

 First stage : onset of true labour pains to full dilatation of cervix

 Second stage: full dilatation of cervix to expulsion of foetus from birth canal

 Third stage: Expulsion of placenta & membranes

 Fourth stage: immediate monitoring of the mother and baby in the delivery room minimum 2 hours
First stage: Cervical dilatation

❖ The first stage is chiefly concerned with the preparation of the birth canal so as to
facilitate expulsion of the foetus in the second stage.
❖ It starts from the onset of true labour pain and ends with full cervical dilatation.

❖ Its average duration is 12-18hrs in primigravidae and 8-10hrs in multiparae.

❖ The main events of the first stage are divided into 02 phases as follows:

- Latent Phase characterized by: a cervical

dilatation < 5 cm, weak contractions are weak
(2contractions per ten minutes )
- Active phase characterized by a cervical
dilatation > or = 5 cm, Contractions >3 per 10
 min lasting 45 - 50 sec and a rate of dilatation of
1cm / hour or more with descent present

Second stage: expulsion of the foetus

❖ Begins with complete cervical dilatation and ends with the expulsion of the foetus.

❖ This stage is concerned with the descent and delivery of the foetus through the birth
canal.
❖ Second stage has two phases:

(1) Propulsive: from full dilatation until head touches the pelvic floor.

(2) Expulsive: from the time mother has irresistible desire to “bear down” and push until
the baby is delivered.
❖ Rupture of membranes and escape of good amount of liquor amnii (Amniotic Fluid).

❖ Uterine contraction and retraction become stronger.

❖ Delivery of the foetus is accomplished by the downward pressure offered by UC.

❖ Bulging of the perineum and gaping anus and vagina

❖ Head visible at the perineum

Third stage: delivery of the placenta and control of bleeding

❖ It begins after expulsion of the foetus and ends with expulsion of the placenta and
membranes.
❖ Its average duration is about 15 minutes.

❖ Comprises the phase of placental separation; its descent to the lower segment and its
expulsion with the membranes.
❖ Placental separation:

Sudden diminution in uterinesize

2 ways separations:
• Central separation (Beaudeloque mode) = Schultze method

• Marginal separation (Duncan mode) = Matthews Duncan method

❖ Expulsion of placenta: after complete separation of the placenta, it is forced down into
the lower uterine segment by effective contraction and retraction of the uterus.
Thereafter, it is expelled out either by contraction of abdominal muscles or by manual
procedure (Control Cord Traction).
 ❖ Blood loss: 150-250 ml (average)

NB: The third stage of labour normally lasts 30 minutes, if it exceeds 45 minutes; it is called an
extended third stage

MANAGEMENT OF NORMAL DELIVERY

The management of labour starts with the reception of the woman in the ward still the delivery of her
baby:

i. Reception of a parturient

The admission of a parturient in the labour room is an integral part of care and entails that a
proper diagnosis of active labour be made in order that admission be carry out. A number of
indicators are considered during parturient admission.
A/ History

The following are essential point in obtaining history from the parturient.
1. Detailed information on previous birth and size of previous babies i.e. normal,
macrosomic or small for date etc. A previous C/s is an important finding especially if it
was performed due to a mechanical problem.
2. Frequency, duration, and perception of strength of contractions as they began

3. Presence of abnormal discharge or bleeding

4. Recent activity of the foetus

5. Any medical issues of note that may have an impact on the labour and delivery e.g.

pregnancy induced hypertension

6. The parturient need for any special requirement e.g. a translator in case of language
barrier or particular psychological need such as needing the husband‟s presence.
7. The expectation of labour and delivery i.e. does she has a birth plan? Does she want to
use analgesics?

B/ General examination

The Nurse/midwife assesses the general state of the parturient upon admission. Vital signs must
be checked and recorded, and any anomaly reported immediately. It is very important to note
women with raised BMI due to the risk of breast cancer, endometriosis and type II diabetes. A
sample of urine is tested for protein, blood, ketones, and glucose every time the parturient passes
out urine.
C/ Abdominal examination
- Initial inspection is conducted to detect previous surgery scar.

- Measurement of fundal height and abdominal circumference

 - The determination of foetal lie and presenting part is of utmost importance. For a
cephalic presentation, the degree of engagement is determined.
- The FHR is monitored and recorded

- The contractions are assessed by palpation for at least 10min and the frequency, intensity
and duration are noted.
D/ Vaginal examination

- Explain the procedure and obtain consent from the parturient

- Make sure privacy is ensured

- The index and middle fingers are gloved with a sterile glove and passed through the
vagina to the cervix
- Cervical examination denotes the state of dilatation, effacement, consistency, position
and application of presenting part. Inability to perceive the cervix could be indicative of
a full dilatation at 10cm. Record the length of the cervix.
- In normal labour, presentation is vertex and the position is determined by locating the
occiput. The occiput is marked by perceiving the triangular posterior fontanel. If the
fontanel is not felt, the occiput is posterior, or there is so much caput succedaneum that
the suture cannot be felt, in which case, suspect a prolonged or obstructed labour.
- The vaginal assessment of station should always be taken together with the assessment
of engagement by abdominal palpation. A head at or below the ischial spine with an
anteriorly positioned occiput is a favourable outlook for vaginal delivery.
- The foetal membranes are also assessed and their state is noted. If ruptured, the colour
and amount of amniotic fluid are noted. A copious amount of clear fluid is a good
prognostic feature, whereas a scanty, heavily blood or meconium stained fluid is a
warning sign for foetal compromise.

NB: Women not diagnosed to be in established labour, are sent home or treated as situation
warrant or return when contractions are increased in frequency and strength.
The examination on admission screens for abnormal labour and increased maternal
and/or foetal risks. When all features are normal and reassuring, the woman is kept under
midwife‟s care i.e. a partogram is opened for labour monitoring. In the occurrence of risk
factors, medical attention is requested.
E/ Foetal assessment

It is carried out to note the health state of the foetus. This is done through the following:
- Observation of the colour of liquor

- Intermittent auscultation of foetal heart using a pinard foetoscope or a second hand

Doppler
- Continuous foetal assessment using a CTG
 ii. Care offered during labour

During the labour process, the midwife/nurse must:

- Protect the life of the mother and the foetus

- Monitor critically the labour (diagnose and treat complications early)

- Support, answer to the needs oft he woman, her partner and the family

- Educate the the future mother on how to behave during labour

- Keep a good relationship with the parturient (psychological support), maintain

confidentiality and intimacy oft he woman
- Keep an hygienic environment fort he woman during delivery (encourage the parturient
to take a warm bath before the onset of labour, clean the vulva before every vaginal examination,
clean any liquid discharge from the vagina, wash hands before and after any examination)
- Encourage the future mother to : be mobile by doing small steps within the ward, emty
the bladder, drink to her convinience
- Do not encourage the parturient to push before complete cervical dilatation

- Teach her respiratory technics and position to adopt during the labour and delivery

iii. Management of labour

Labour events have great psychological, emotional and social impact on the woman and her
family. She experiences stress, physical pain and fear of dangers. The care provider should be
tactful, sensitive and respectful to her. Continuous emotional support during labour may reduce
the need for analgesia and decrease the rate of operative delivery. Privacy must be maintained.
She is explained about the events from time to time and the environment is kept comfortable.
Management of normal labour aims at maximal observation with minimal active intervention.
The idea is to maintain the normalcy and to detect any deviation from the normal at the earliest
possible moment. It is important to diagnose labour for confirmation. So we can say labour has
started or will start if the woman has:
- Lower abdominal pains after 28 weeks

- Lower abdominal pains associated with show

 [Link] of the first
stage Latent Phase
❑ Monitor every 1 hour

❖ Contractions:

• Frequency: How many contractions in 10 min

• Duration: Each lasting for how many seconds

❖ Foetal Heart Rate (FHR)

❑ Monitor the following every 4 hours:

❖ Temperature, pulse, BP

❑ Record time of ROM and colour of amniotic fluid

❑ Look for presence of any danger signs

❑ Encourage ambulation, upright position, supine or left lateral position

Active phase

❑ Monitor the following every 30 minutes: Maternal pulse, uterine contractions, FHR

❑ Look for presence of Meconium or blood stained liquor or cord prolapse should
membranes rupture
❑ Continue monitoring:

❖ Cervical changes by VE

❖ Temperature

❖ Blood pressure

❖ Respiratory rate

❑ Never leave the woman alone

 ❑ Open a partogram: Graphic recording of the progress of labour & condition of mother
and foetus
❑ Ensure adequate hydration

❑ Avoid solid foods

❑ Encourage left lateral position

❑ Refer immediately if no progress

b. Management of the second
stage of labour Signs of second stage
The only positive sign in diagnosing second stage of labour is full dilatation of the cervix.
However, if the mother has 2 or more of the following signs, she is probably in second stage of
labour:
- She feels an uncontrollable urge to push (she may say she feels as to pass stool)

- She hold her breath or grunt during contractions

- She start to sweat

- Her mood changes

- Her external genitalia or anus begin to bulge out during contractions

- She feels her baby‟s head begin to move into the vagina

Equipment, supplies and drugs for delivery

- Good light and heat sources

- Blood pressure machine and stethoscope

- Thermometer

- Baby scale and foetal and infant stethoscope

- Self-inflating bag and mask – neonatal size

- Suction apparatus

- Delivery instruments: scissors, needle holder, artery forceps or clamp, dissecting

forceps, sponge forceps, vaginal speculum
- Urinary catheter and Jar for forceps

- Material for hand washing

- Gloves (utility, sterile and long sterile) and plastic apron

- Containers for waste: safety box, bucket for soiled pads/swabs, bowl for placenta etc.

- Syringes, drip set, suture material, antiseptic solution, alcohol 70%, swabs, bleach, clean
mackintosh, sanitary pads, clean towels, cord clamp, baby‟s blanket or dresses
- Oxytocin, ergometrine, misoprostol, magnesium sulphate, calcium gluconate, infusions,
local anaesthetic agents, nevirapine, eye ointment
- Proteinuria dip sticks, HIV testing kits, haemoglobin testing kits, container for urine.

- Wall clock, torch, records

 PLACENTA DELIVERY OR MANAGEMENT OF THE THIRD STAGE OF LABOUR

The third stage of labour begins with the birth of the baby and ends with the delivery of the
placenta and foetal membranes. Normally, it should last less than 30 minutes.

Natural process during the third stage

In a complication-free labour, the third stage is when natural physiological processes

spontaneously deliver the placenta and foetal membranes. For this to happen unproblematically,
the cervix must remain open and there needs to be good uterine contraction. In the majority of
cases, the processes occur in the following order:
4. Separation of the placenta: The placenta separates from the wall of uterus. As it
detaches, blood from the tiny vessels in the placental bed begins to clot between the
placenta and the muscular wall of the uterus.
5. Descent of the placenta: After separation, the placenta moves down the birth canal and
through the dilated cervix.
6. Expulsion of the placenta: The placenta is completely expelled from the birth canal.
This expulsion marks the end of the third stage of labour. Thereafter, the muscles of the
uterus continue to contract powerfully and thus compress the torn blood vessels. This,
(together with blood clotting) quickly reduces and stops the postpartum bleeding.

Active management of third stage of labour (AMTSL)

The term „active management‟ indicates that you are not waiting for spontaneous placental
delivery. Rather, you will intervene in a carefully programmed sequential manner.
• As soon as the baby is delivered, put it on the mother‟s abdomen in skin-to-
skin contact with her. Cover them with a blanket.
• Clamp the baby‟s umbilical cord at two sites and cut it in between Then
follow the 10 steps below.
1. Check or palpate the uterus for the presence of a second baby.

2. Administer oxytocin 10IU IM to the mother

3. Roll the cord on the forceps and leave it hanging on the vulva and wait for
contractions
4. Apply controlled cord traction.

5. After delivery of the placenta, immediately start massaging the uterus.

6. Examine the placenta to make sure it is complete and none of it has been retained in
the uterus.

7. Examine the woman‟s vagina, perineum and external genitalia for lacerations and
active bleeding. Repair as required.
 8. Empty the bladder

9. Clean the woman and keep her comfortable

10. Document the procedure.

NB: The third stage of labour normally lasts 30 minutes, if it exceeds 45 minutes; it is called
an extended third stage. When the placenta fails to detach naturally, artificial delivery of the
placenta is done. The natural delivery of the placenta is either by the Duncan or Beaudelocque
mode.

Beaudelocque mode: mode of placenta delivery by which the presentation of the

foetal face is obtained.

Duncan mode: mode of placenta delivery in which the presentation of the maternal
face is presented. Duncan mode occurs when the placenta is low inserted.