GOVERNMENT COLLEGE OF

NURSING, JODHPUR (RAJ.)

INTRA-NATAL ASSESSMENT

Subject-Obstetrics & Gynecology Specialty-II

SUBMITTED TO - SUBMITTED BY-

Mrs. JYOTI BALA JANGID HEMLATA BHANWARIA
NURSING LECTURER M.sc (N) Final year
GCON, Jodhpur GCON, Jodhpur
 MATERNAL ASSESSMENT HISTORY

Obtain a brief oral history when the woman is admitted to the birthing area. Each agency has its own admission
forms, but they usually include the following information:
■ Woman’s name and age
■ Last menstrual period (LMP) and estimated date of birth (EDB)
■ Attending physician or certified nurse-midwife (CNM)
■ Personal data: blood type; Rh factor; results of serology testing; prepregnant and present weight; allergies to
medications, foods, or other substances; prescribed and over-the-counter medications taken during pregnancy;
and history of drug and alcohol use and smoking during the pregnancy
■ History of previous illness, such as tuberculosis, heart disease, diabetes, and so forth
■ Problems in the prenatal period, such as elevated blood pressure, bleeding problems, recurrent urinary tract
infections, other infections
■ Pregnancy data: gravida, para, abortions, and perinatal deaths
■ The method chosen for infant feeding
■ Type of prenatal education classes (childbirth education classes)
■ Woman’s preferences about labor and birth, such as no episiotomy, no analgesics or anesthetics, or the
presence of the father or others at the birth
■ Pediatrician or family practice physician
■ Additional data: history of special tests such as nonstress test (NST), biophysical profile (BPP), or ultrasound;
history of any preterm labor; onset of labor; amniotic fluid membrane status; and brief description of previous
labor and birth
■ Onset of labor
■ Status of amniotic membranes (Are they intact or ruptured? If ruptured, time of rupture, color of fluid, and
odor.)

SIGNS OF LABOR
1. Pre-labor or premonitory signs of labor may begin two to three weeks prior to the onset of true labor in
primigravidaeand a few days before in multipara.
 Lightening—In primigravidae the presenting part sinks into the true pelvis due to active pulling up of
the lower segment of the uterus around the presenting part. This minimizes the fundal height and
hence relieves the pressure on diaphragm making breathing easier for the mother.
 Frequency of micturition and constipation—The mother may experience urinary frequency and
constipation due to pressure from the engaged presenting part.
 Cervical changes—The cervix becomes ripe. A ripe cervix is soft, less than 1.3 cm in length, admits
one finger and is dilatable.
 Taking up of cervix—The cervix becomes shorter as it gets drawn up and merged into the lower
uterine segment.

2. True labor
The features of true labor pains are:
 Painful, rhythmic uterine contractions with hardening of uterus.
 Progressive dilatation and effacement of cervix
 Appearance of “show”—blood stained mucoid discharge
 Formation of the bag of waters.

Features of True and False Labor Pains

True labor pains
False labor pains.
• Pain occurs in the lower abdomen and groin
only and remains stationary in the lower abdomen
• Pain is continuous without any rhythmicity
•There is no hardening of uterus
• No effect on dilatation of cervix and no “show”
• The pain arises in the back, radiates to the front of
abdomen and thighs Intermittent in nature with increase in intensity, frequency and duration Associated with
hardening of uterus due to retraction of muscle fibers Expulsion of “Show” which is the mucus plug mixed
with blood from the ruptured capillaries of the cervix
• Dilatation of internal os and taking up of cervix
• Formation of “bag of waters” due to stretching of the
lower uterine segment and detachment of membranes
from the decidua.
• Pain increases after administration of an enema
• Pain occurs due to uterine contraction
• No dilatation and taking up of cervix
• No formation of bag of waters
• Pain diminishes after enema
• Pain occurs due to a loaded rectum

STAGES OF LABUR AND PHYSIOLOGICAL CHANGES DURING THE DIFFERENT STAGES

1. First Stage—Stage of Dilatation

First stage of labor begins with regular, rhythmic contractions and completes when the cervix is fully dilated.
Average duration is 12 hours in primigravida and 8 hours in multigravida.

Physiological changes
 Contraction and retraction of uterine muscle
 Formation of upper and lower segments
 Development of the retraction ring
 Polarity neuromuscular harmony between the two poles or segments of uterus
 Dilatation and effacement of cervix
 Fetal axis pressure
 Formation of bag of water
 Rupture of membranes.

2. Second Stage—Stage of Expulsion

Second stage of labor begins with the complete dilatation of the cervix and ends with the expulsion of the fetus
through the birth canal. Average duration is 1-11/2 hours in primigravida and 1/2 hour in multigravida.

Physiological changes
 Stronger, frequent contractions
 Voluntary contractions of the abdominal muscles-bearing down efforts
 Expulsive, downward force of uterine contractions
 Displacement of pelvic floor (soft tissue displacement)
 Expulsion of the fetus.

THE MECHANISM OF NORMAL LABOR ASSESSMENT

Definition
The mechanisms of labor are the positional movements that the fetus undergoes to accommodate itself to the
maternal pelvis as it negotiates the birth canal.

Positional movements
There are several basic movements which take place when the fetus is in a cephalic, vertex presentation.
 Engagement
 Descend throughout
 Flexion
 Internal rotation of the head
 Crowning
 Birth of the head by extension
 Restitution
 Internal rotation of the shoulders
 External rotation of the head as the shoulders rotate internally
 Birth of the shoulders and body by lateral flexion.

Principles
The principles are common to all mechanisms.
 Descend occurs throughout
 The part that leads and first meets the resistance of the pelvic floor will rotate forwards until it comes
under thesymphysis pubis.
 The part that escapes under the symphysis pubis will pivot around the pubic bone.
 During the mechanism, the fetus turns slightly to take advantage of the widest available space in each
plane of the pelvis, i.e. transverse at the brim and anteroposterior at the outlet.

Summary of mechanisms in left occipitoanterior position

 The lie is longitudinal
 The presentation is cephalic
 The position is left occipitoanterior
 The attitude is one of flexion
 The denominator is occiput
 The presenting part is the posterior part of the anterior parietal bone

 Engagement takes place with sagittal suture of the fetal head in the right oblique diameter of the pelvic
inlet and the biparietal diameter in the left oblique. The occiput points to the left ileopectineal eminence
and sinciput to the right sacroiliac joint.
 Descend occurs throughout.
 Flexion substitutes the suboccipitobregmatic diameter for the suboccipitofrontal which entered the
pelvic inlet
 Internal rotation takes place as the occiput turns 1/8th of a circle (45 degrees) to the right and sagittal
suture comes
 to the anteroposterior diameter of the pelvis (outlet).
 The occiput escapes under the symphysis pubis and crowning occurs when the head no longer recedes
between
 contractions.
 The head is born by extension, pivoting on the suboccipital-region around the pubic arch
 Restitution-the occiput turns 1/8th of circle (45 degrees) to the left to undo the twist on the neck
 Internal rotation of the shoulders.
The anterior shoulder reaches the pelvic floor and rotates anteriorly to lie under the symphysis pubis. This
movement can be seen as the head turns at the same time of external rotation of the head.
The head turns 1/8th of a circle (45 degrees) to the mother's left. The bisacromial diameter comes into
the anteroposterior diameter of the maternal pelvis. This occurs in the same direction as restitution and at the
same time as internal rotation of shoulders.
The anterior shoulder escapes under the symphysis pubis and the body is born by lateral flexion.

3. Third Stage—Stage of Placental Delivery

Third stage of labor comprises the phase of placental separation, its descend to the lower segment and finally its
expulsion with the membranes. The time begins upon completion of the birth of the baby and ends with the
expulsion of placenta. Average duration of third stage is 30 minutes in both primigravidae and multipara.

Physiological changes
 Contraction and retraction of uterus
 Expulsion of placenta and membranes.

Signs of placental separation:

 Sudden trickle or gush of blood
 Lengthening of the umbilical cord visible on the introitus
 Change in the shape of the uterus from discard to globular
 Change in the position of the uterus as it rises in the abdomen
Method of separation of the placenta may be central (Schultz method) or marginal (Mathews Duncan method).

4. Fourth Stage
Fourth stage of labor begins with the birth of the placenta and ends one hour later. The first postpartal hour is a
critical time of initial recovery from the stress of labor and delivery and requires close observation of the
mother.

Physiological changes
 Uterus becomes firm and retracted (hard to touch)
 When contracted, the entwining muscle fibers of the myometrium serve as ligatures to the open blood
vessels at the placental site and bleeding is controlled naturally.
 Thrombi form in the distal blood vessels in the decidua from where it does not get released into systemic
circulation.

NURSING MANAGEMENT DURING LABOR AND DELIVERY

First Stage of Labor
 Admit the mother in labor room and complete procedures such as changing to hospital gown, applying
identification band, obtaining history and completing chart forms
 Orient patient to labor and delivery rooms
 Explain admission protocol, labor process and management plans
 Carry out perineal shave and administer enema if not contraindicated
 Start an I.V. line if indicated and administer fluids
 Provide bodily care and attend to comfort needs
 Monitor and evaluate maternal well-being, fetal well-being and progress of labor (vital signs of mother,
fetal heart sounds, uterine contractions, cervical dilation and fetal descend)
 Encourage to use coping skills such as breathing, relaxation and positioning
— During latent phase (1-4 cm dilation) review breathing techniques she can use as labor progress and
encourage ambulation and comfortable position.
— During active phase (4-8 cm dilation) provide comfortable position, assist with breathing exercises,
provide
backup and sacral pressure and analgesia.
— During transitional phase (8-10 cm dilation), assist with deep breathing during contractions and
shallow
breathing and relaxation between contractions.
 Provide information about progress of labor, fetal well-being and how she is coping.

Second Stage of Labor

 Continue to monitor maternal well-being including vital signs, bladder care, hydration and analgesia
 Encourage maternal pushing efforts
 Evaluate perineal integrity and perform episiotomy if appropriate
 Deliver the baby and reassure mother about neonate's condition.

Third Stage of Labor

 Encourage patient to maintain position to facilitate delivery of placenta
 Allow mother to hold and feed the baby if she desires
 Deliver placenta and membranes
 Monitor maternal vital signs, bleeding and consistency of uterus
 Administer oxytocin if required
 Examine placenta and membranes for completeness
 Perform episiotomy suturing if one was made.

Fourth Stage of Labor

 Provide clean gown, perineal pads and comfortable position
 Check vital signs regularly
 Palpate fundus of uterus for contractility
 Massage the fundus and express any clots present
 Inspect the perineum, bladder and change pads
 Offer food and fluids if not contraindicated