Intrapartum & Postpartum Nursing Care
Key Takeaways
- The first stage of labor is divided into the latent phase (0–5 cm dilation) and active phase (6–10 cm dilation); active monitoring includes assessing contraction frequency, intensity, and duration.
- Moderate fetal heart rate variability (6–25 bpm) is the most critical indicator of adequate fetal oxygenation; late decelerations indicate uteroplacental insufficiency, necessitating immediate intrauterine resuscitation.
- Postpartum Hemorrhage (PPH) is a blood loss of ≥ 1,000 mL accompanied by signs of hypovolemia; uterine atony is the most common cause, requiring fundal massage and assessment for bladder distension.
- Methylergonovine (Methergine) is contraindicated in hypertensive patients, and Carboprost (Hemabate) is contraindicated in patients with asthma.
- Mastitis is a localized breast infection with systemic symptoms (fever, chills); treatment requires antibiotics, but the mother must continue to breastfeed or pump frequently to prevent abscess formation.
Intrapartum & Postpartum Nursing Care
Stages of Labor
Labor is the physiological process by which the fetus, placenta, and membranes are expelled from the uterus. It is divided into four distinct stages:
1. First Stage (Dilation)
Spanning from the onset of true labor contractions to complete cervical dilation (10 cm). It is divided into two phases:
- Latent Phase (0 to 5 cm dilation): Contractions are typically mild and irregular, progressing to every 5–10 minutes. The mother is usually cooperative and anxious but conversational.
- Active Phase (6 to 10 cm dilation): Contractions become stronger, longer (45–60 seconds), and frequent (every 2–3 minutes). The cervix dilates more rapidly. The mother becomes intensely focused, may exhibit difficulty coping, and requires continuous support and pain management.
2. Second Stage (Expulsion)
Spanning from complete cervical dilation (10 cm) to the delivery of the baby. During this stage, the maternal bearing-down reflex (Ferguson reflex) is activated. The nurse encourages effective open-glottis pushing and monitors fetal descent. The cardinal movements of labor occur: engagement, descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion.
3. Third Stage (Placental)
Spanning from the delivery of the baby to the delivery of the placenta (typically within 5 to 30 minutes). Active Management of the Third Stage of Labor (AMTSL) is standard to prevent postpartum hemorrhage. This includes administration of prophylactic oxytocin immediately after delivery of the baby, controlled cord traction, and uterine massage.
- Signs of Placental Separation: Uterine shape changes from discoid to globular, a sudden gush of dark blood from the vagina, lengthening of the umbilical cord, and elevation of the fundal height as the placenta descends into the lower uterine segment.
4. Fourth Stage (Recovery)
The first 1 to 2 hours postpartum, where physiological readjustment occurs. The risk of hemorrhage is highest during this window. The nurse must assess the fundus, lochia, bladder status, and maternal vital signs every 15 minutes.
| Stage | Start Point | End Point | Nursing Priorities |
|---|---|---|---|
| First Stage | Onset of true contractions | Complete dilation (10 cm) | Pain control, hydration, voiding, fetal monitoring, comfort measures |
| Second Stage | Complete dilation (10 cm) | Birth of the baby | Pushing technique, FHR monitoring, preparation for delivery |
| Third Stage | Birth of the baby | Delivery of the placenta | AMTSL, administer oxytocin, inspect placenta for completeness |
| Fourth Stage | Delivery of the placenta | 2 hours postpartum | Fundal assessment, lochia checks, vital signs, bladder emptying, infant bonding |
Intrapartum Fetal Monitoring
Fetal status is monitored using electronic fetal monitoring (EFM) to evaluate uterine contractions and fetal heart rate (FHR) patterns.
Fetal Heart Rate Features
- Baseline FHR: Normal is 110 to 160 bpm. Tachycardia is > 160 bpm (often caused by maternal fever, infection, or dehydration); bradycardia is < 110 bpm (caused by cord occlusion, maternal hypotension, or fetal hypoxia).
- Variability: Fluctuations in the baseline FHR. Moderate variability (6 to 25 bpm fluctuation) is the most important indicator of adequate fetal oxygenation and an intact central nervous system. Absent or minimal variability indicates potential fetal acidemia, sleep cycle, or medication effects (e.g., opioids).
- Accelerations: Abrupt increases in FHR above baseline (≥ 15 bpm lasting ≥ 15 seconds in gestations ≥ 32 weeks). They are highly reassuring and indicate fetal well-being.
- Decelerations:
- Early Decelerations: Gradual, symmetrical decrease that mirrors contractions (nadir matches peak). Caused by fetal head compression during contractions. These are benign and do not require clinical intervention.
- Late Decelerations: Gradual decrease where the nadir occurs after the peak of the contraction. Caused by uteroplacental insufficiency. This is a non-reassuring sign indicating fetal hypoxia.
- Variable Decelerations: Abrupt, sharp decrease in FHR (looks like a V, W, or U shape). Caused by umbilical cord compression.
Intrauterine Resuscitation Protocol
For non-reassuring FHR patterns (specifically late or severe variable decelerations), the nurse must initiate intrauterine resuscitation immediately:
- Reposition the mother to a lateral position (left or right) to relieve pressure on the inferior vena cava and cord.
- Increase IV fluids (crystalloid bolus) to expand maternal blood volume and improve placental perfusion.
- Administer supplemental oxygen at 8–10 L/min via a tight non-rebreather face mask.
- Discontinue Oxytocin (Pitocin) infusion immediately to decrease uterine contraction frequency and intensity.
- Notify the provider and prepare for potential emergency delivery if the pattern does not resolve.
Postpartum Hemorrhage (PPH)
Postpartum hemorrhage is defined as cumulative blood loss of ≥ 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after birth, regardless of the route of delivery.
The Four Ts of PPH Etiology
- Tone: Uterine Atony is the failure of the uterus to contract down to compress spiral arteries. It accounts for 80% of PPH cases. Risk factors include uterine overdistension (macrosomia, multiples, polyhydramnios), prolonged or rapid labor, high parity, and chorioamnionitis.
- Tissue: Retained placenta or membranes, which prevents the uterus from contracting fully.
- Trauma: Vaginal, cervical, or perineal lacerations, or uterine rupture/inversion.
- Thrombin: Coagulopathies (e.g., DIC, preeclampsia, placental abruption).
Clinical Management of Uterine Atony
The immediate nursing action is to massage the fundus until it is firm. The nurse must also assess for bladder distension; a full bladder displaces the uterus upward and to the right, preventing effective contraction. If the bladder is full, assist the patient to void or perform catheterization.
- Pharmacological Interventions:
- Oxytocin (Pitocin): First-line treatment. Administered IV or IM to stimulate uterine contractions.
- Methylergonovine (Methergine): Administered IM. Contraindicated in patients with hypertension or preeclampsia due to the risk of severe vasoconstriction and stroke.
- Carboprost Tromethamine (Hemabate): Administered IM. Contraindicated in patients with asthma because it causes severe bronchoconstriction.
- Misoprostol (Cytotec): Administered rectally or sublingually. Useful in resource-limited settings.
Lactation & Postpartum Breast Care
Lactation is mediated by endocrine reflexes. Delivery of the placenta triggers a sharp drop in estrogen and progesterone, allowing prolactin to stimulate milk production. Infant suckling stimulates the posterior pituitary to release oxytocin, which drives the let-down (milk ejection) reflex.
Breastfeeding Assessments & Complications
Nurses must assess the mother-infant dyad for proper latch and positioning:
- Signs of a Correct Latch: The baby's mouth is wide open with flanged lips, the chin touches the breast, more of the areola is visible above the upper lip than below, and swallowing is audible. The mother should feel a tugging sensation but no sharp pain.
- Breast Engorgement: Vascular congestion and accumulation of milk, occurring 3–5 days postpartum. Managed with frequent feedings, warm compresses before feeds (to facilitate let-down), cold compresses between feeds (to reduce swelling), and mild analgesics.
- Plugged Ducts: Tender, localized, hard lumps in one breast without systemic symptoms. Managed with frequent nursing, massaging the lump toward the nipple during feeds, and warm moist heat.
- Mastitis: An infection of the breast tissue (commonly Staphylococcus aureus), presenting with localized breast pain, erythema, warmth, and systemic symptoms (fever ≥ 38.5°C, chills, flu-like body aches).
- Management: Requires oral antibiotics. The nurse must instruct the mother to continue breastfeeding or pumping frequently from both breasts. Emptying the breast prevents abscess formation and does not harm the infant.
Clinical Traps & Exam Tips
- Methergine Contraindication: A common DHA exam question presents a patient with a blood pressure of 150/95 mmHg who is experiencing postpartum hemorrhage due to uterine atony. The question asks which medication is contraindicated. The answer is Methylergonovine (Methergine).
- Mastitis Management: Candidates often mistakenly choose to stop breastfeeding on the affected side when a patient has mastitis. Breastfeeding should never be suspended; maintaining milk flow is essential to resolve the infection and prevent abscesses.
- Uterine Displacement: If the fundus is soft, boggy, and displaced to the right of the midline, the priority action is not oxytocin administration or further massage—it is to assist the patient to empty their bladder. A full bladder prevents uterine contraction.
A nurse is caring for a patient in the active phase of labor. The cardiotocograph (CTG) monitors show a baseline fetal heart rate of 145 bpm with moderate variability, but there are repetitive, gradual decelerations that begin after the peak of each contraction and return to baseline well after the contraction ends. Which action should the nurse perform first?
A client who delivered a healthy term infant 30 minutes ago is experiencing excessive vaginal bleeding. The nurse notes that the patient's fundus is boggy, soft, and displaced upward and to the right of the midline. Which intervention should the nurse perform first?
A breastfeeding mother who is 2 weeks postpartum contacts the clinic complaining of a sudden onset of fever, severe chills, body aches, and a painful, red, warm area on her right breast. What instruction should the nurse provide to this patient?