Intrapartum care (1st, 2nd, 3rd, and 4th stages): Clinical sciences

Intrapartum care of a pregnant patient encompasses all things related to labor, delivery, and the immediate postpartum period. This period spans the first stage of labor, which begins with the onset of labor and ends with complete cervical dilation; the second stage, which starts with complete cervical dilation and ends with delivery of the neonate; the third stage, which begins with the delivery of the neonate and lasts until delivery of the placenta; and the fourth stage, which is the immediate postpartum period. While it’s important to recognize when interventions are needed during the normal, physiologic processes of labor and delivery, it’s equally important to be aware that for the majority of patients, interventions are not essential and therefore, the focus should be on patient-centered care.

Your first step when a laboring patient presents for intrapartum care includes a focused history and physical exam, assessment of fetal presentation, and monitoring of fetal heart rate and uterine contractions. Here, you should identify risk factors relevant to labor and the postpartum period. Next, assess the fetal presentation, either by ultrasound or, if cervical dilation is adequate, by digital palpation of the presenting part, and assess the fetal response to uterine contractions by monitoring the fetal heart rate patterns.

Because each contraction decreases blood flow to the placenta, it temporarily interrupts oxygen delivery to the fetus. So, if the placenta isn’t delivering adequate oxygen to the fetus and nonreassuring fetal status occurs, you should attempt intrauterine resuscitation with position changes, providing an intravenous fluid bolus and supplemental oxygen, discontinuing any uterotonic medications, and maybe administering a tocolytic. You may even need to proceed with an emergent C-section if there’s no improvement with these conservative interventions.

That being said, if initial monitoring is reassuring, low-risk patients may only need intermittent monitoring throughout labor. Finally, evaluate uterine contractions either by tocometry or palpation to determine the adequacy of contractions and to determine if there’s a need to augment labor.

Based on your findings, assess for mode of delivery, meaning whether a trial of labor is appropriate or C-section is indicated. If there are contraindications to labor, such as fetal malpresentation or a non-reassuring fetal heart tracing, or if there’s a maternal request to defer a trial of labor, proceed with a C-section. If there are no contraindications to labor, proceed with a trial of labor. Your next step should be to determine the stage of labor based on cervical dilation.

The first stage of labor starts with the onset of regular painful contractions, or labor, and ends when your patient reaches 10 centimeters dilation. This is further divided into the latent phase, which is less than 6 centimeters dilation, and the active phase, which is dilation of 6 centimeters or more. In the latent phase, regular cervical change isn’t expected, and labor progresses at a variable rate. On the flip side, the active phase is a time of more predictable cervical change, and a failure to progress during this phase should prompt consideration for a C-section.

Now, during the first stage of labor, you may consider expectant management, meaning a watch and wait approach, depending on factors like the phase of labor and your patient’s desire for pain management or augmentation to expedite delivery. A prolonged latent phase isn’t inherently associated with adverse outcomes; in fact, many patients prefer to spend the early portion of labor in the comfort of their home. However, with high-risk pregnancies, admission might be indicated during the latent phase. The active phase carries more risk than the latent phase, so once your patient is in the active phase, inpatient care and active management is recommended. Additionally, if the progression in the active phase is slow, augmenting labor by breaking the amniotic membranes or utilizing oxytocin might be needed.

It’s also appropriate to admit your patient if they desire neuraxial anesthesia, like an epidural. An epidural can be obtained at any point when your patient requests one, although this will limit their mobility. Intravenous opioids are another option, though you should avoid these as your patient nears delivery, since they can cause respiratory suppression in the newborn. Other pain management options to consider include nitrous oxide, which allows your patient to self-administer the gas with a facemask, as needed; as well as non-pharmacological pain management options, such as hypnobirthing, water submersion, patterned breathing, and positioning techniques. Lastly, you should admit your patient if they desire augmentation of their labor. Next, IV fluids can usually be deferred unless your patient can’t adequately take clear fluids by mouth.

Also be sure to monitor both fetal heart rate and uterine contractions, which can be done by external or internal methods. External monitoring can either be continuous or intermittent, depending on your patient’s risk factors. Internal monitoring is indicated only when there’s a clinical reason for more accurate measurement of uterine activity and fetal heart rate patterns. Internal monitoring involves placing a fetal scalp electrode which directly counts the R wave on the fetal ECG, and by inserting an intrauterine pressure catheter, or IUPC, which accurately measures the strength, duration, and frequency of contractions, as well as the uterine resting tone. An IUPC can also be used for amnioinfusion to replace amniotic fluid in situations like umbilical cord compression.

Finally, don't forget to administer antibiotic prophylaxis to patients who are Group B streptococcus or GBS positive; or if their status is unknown and they have additional risk factors.