Section 6.2: Intrapartum Care & Essential Intrapartum and Newborn Care (EINC)

The Stages of Labor

Intrapartum care requires acute observation, continuous monitoring, and supportive interventions as the client progresses through the dynamic process of childbirth.

First Stage of Labor: This stage begins with the onset of true labor contractions and ends with full cervical dilation (10 cm) and effacement. It is divided into three phases:

1. Latent Phase (0-3 cm): Contractions are mild, occurring every 5-10 minutes. The client is usually sociable, excited, and cooperative. Nursing care focuses on admission assessment, ambulation if membranes are intact, and providing anticipatory guidance.
2. Active Phase (4-7 cm): Contractions become stronger, longer, and more frequent. The client often becomes more serious, focused, and may request pain relief. Nursing interventions include assisting with breathing techniques, providing comfort measures (massage, hydrotherapy), and administering analgesics as ordered.
3. Transition Phase (8-10 cm): This is the shortest but most intense phase. Contractions are very strong, occurring every 1.5-2 minutes. The client may experience nausea, vomiting, shivering, a feeling of loss of control, and a strong urge to bear down. The nurse must encourage pant-blow breathing to prevent premature pushing, which can cause cervical edema and tearing.

Second Stage of Labor: This is the stage of fetal expulsion, beginning with full dilation and ending with the birth of the neonate. Contractions continue to be strong and expulsive. Nursing care involves coaching the client to push effectively during contractions, monitoring the fetal heart rate (FHR) continuously or intermittently, and preparing for delivery. Episiotomy, if indicated, is performed during this stage.

Third Stage of Labor: This stage begins after the birth of the baby and ends with the delivery of the placenta (placental separation and expulsion). Signs of placental separation include a sudden gush of blood, lengthening of the umbilical cord, and the uterus becoming globular and firmer. The placenta is usually delivered within 5-30 minutes. Active management of the third stage involves administering uterotonics (e.g., oxytocin) to prevent postpartum hemorrhage, controlled cord traction, and uterine massage.

Fourth Stage of Labor: This encompasses the first 1-4 hours postpartum. It is a critical period for maternal stabilization. The primary nursing focus is monitoring for hemorrhage. Assessments include vital signs, uterine tone (fundus should be firm and midline), lochia characteristics, and bladder status. A full bladder can displace the uterus upward and laterally, preventing contraction and increasing the risk of atony.

Fetal Monitoring

Electronic Fetal Monitoring (EFM) evaluates the fetal heart rate relative to uterine activity, providing vital information about fetal oxygenation.

• Baseline FHR: Normal is 110-160 bpm.
• Variability: Fluctuations in the baseline FHR. Moderate variability (6-25 bpm) is the most reassuring sign of fetal well-being and a well-oxygenated central nervous system.
• Accelerations: Abrupt increases in FHR above baseline. Reassuring; indicative of fetal movement and lack of hypoxia.
• Decelerations: Decreases in FHR below baseline. Their significance depends on their timing relative to contractions:
  • Early Decelerations: Symmetrical decreases that mirror the contraction (nadir matches the peak of contraction). Caused by head compression as the fetus descends. Benign; no intervention needed.
  • Variable Decelerations: Abrupt decreases varied in shape (U, V, or W) and timing. Caused by cord compression. Nursing interventions: Change maternal position, administer oxygen, discontinue oxytocin if infusing, and consider amnioinfusion if ordered.
  • Late Decelerations: Symmetrical decreases that begin after the peak of the contraction and return to baseline after the contraction ends. Caused by uteroplacental insufficiency (fetal hypoxia). These are ominous. Immediate interventions (VEAL CHOP acronym is useful for recall, but action requires POISON): Position change (lateral), Oxygen administration (mask at 8-10 L/min), IV fluid bolus, Stop oxytocin, Observe/monitor closely, Notify the physician for potential expedited delivery.

Essential Intrapartum and Newborn Care (EINC) - "Unang Yakap"

The Philippine Department of Health advocates for EINC, a set of evidence-based practices ensuring safe birth and newborn survival. The protocol focuses on four time-bound, step-by-step interventions during the immediate newborn period.

1. Immediate and Thorough Drying (0-3 minutes): As soon as the baby is delivered, the nurse quickly and thoroughly dries the baby for 30 seconds to prevent hypothermia. Do not wipe off the vernix caseosa, as it provides insulation and immune protection. Remove the wet cloth.
2. Early Skin-to-Skin Contact (SSC): Place the naked baby prone on the mother's bare chest or abdomen and cover them with a dry blanket. SSC promotes thermoregulation, stabilizes the newborn's heart rate and breathing, fosters early maternal-infant bonding, and facilitates colonization with maternal protective flora.
3. Properly Timed Cord Clamping (1-3 minutes): Delay clamping the umbilical cord until pulsations cease (usually 1-3 minutes). This allows for placental transfusion, providing the newborn with additional blood volume, increasing iron stores, and reducing the risk of anemia in infancy. Once pulsations stop, clamp and cut the cord.
4. Non-Separation of Newborn from Mother for Early Breastfeeding: Keep the baby in SSC for at least 90 minutes. Observe the baby for feeding cues (rooting, lip smacking, hand-to-mouth movements). The baby will self-attach and initiate breastfeeding when ready. Breastfeeding provides colostrum, which is rich in antibodies, and stimulates maternal oxytocin release, aiding in uterine involution.

Routine procedures such as vitamin K administration, hepatitis B and BCG vaccination, eye prophylaxis, and detailed physical examination should be deferred until after the first breastfeed or at least 90 minutes postpartum to avoid interrupting the initial bonding and feeding process.