Intrapartum nursing care aims for a safe birth for mother and newborn and a positive birth experience. The nurse continuously assesses maternal and fetal well-being, supports physiologic labor, recognizes deviations early, and advocates for the client's informed choices.

Guiding principles

• Physiologic labor is supported with minimal unnecessary intervention (freedom of movement, oral fluids, continuous support)
• Assessment frequency increases as labor advances and with risk factors
• Respect for the client's birth plan, culture, and choices — including alternative approaches — while keeping safety plans in place

Admission assessment

• Prenatal record: gestational age, blood type and Rh, GBS status, HIV/hepatitis B/syphilis results, complications
• Labor status: contraction pattern, membrane status, bleeding, fetal movement
• If membranes have ruptured: check FHR immediately (cord prolapse), then note COAT — Color (clear is normal; green/brown = meconium; bloody), Odor (foul = infection), Amount, Time
• Vital signs, pain, allergies, last oral intake, birth plan, support persons, psychosocial and safety screening
• Leopold maneuvers, FHR baseline, cervical exam (unless bleeding of unknown cause)

Ongoing assessment (typical low-risk frequencies — follow facility policy)

Signs of second stage: urge to push, rectal pressure, increased bloody show, bulging perineum, crowning. A client who says "the baby is coming" should be examined (cervix and perineum) to confirm full dilation before directing pushing.

• Cervical examinations: sterile technique; limit number, especially after rupture of membranes
• Rupture of membranes testing: speculum pooling, nitrazine (blue), ferning, protein assays
• Laboratory: complete blood count, type and screen; HIV and syphilis testing if not documented
• Group B Streptococcus (GBS): screening at 36 0/7–37 6/7 weeks; intrapartum IV penicillin G for positive results, previous infant with GBS disease, GBS bacteriuria this pregnancy, or unknown status with risk factors. Prophylaxis is considered adequate if started at least 4 hours before birth. Penicillin allergy: cefazolin if low risk for anaphylaxis; clindamycin (if susceptible) or vancomycin if high risk

First stage

• Low-risk clients may drink clear liquids; solid food is usually avoided if cesarean risk is high
• Freedom of movement and upright positions; hydrotherapy
• Amniotomy or oxytocin only for specific indications (see Induction topic)

Second stage

• Spontaneous, open-glottis pushing with the urge (short pushes, exhaling) is physiologic; directed, closed-glottis pushing (prolonged breath holding with Valsalva) is used selectively — sustained breath holding may reduce fetal oxygenation and increase fatigue
• Immediate pushing at full dilation is recommended by ACOG for nulliparous clients with neuraxial analgesia (delayed pushing lengthens the second stage without clear benefit)
• Warm compresses and perineal massage during the second stage reduce severe (third- and fourth-degree) lacerations
• Routine episiotomy is not recommended; fundal pressure is not recommended
• Upright or lateral birth positions can shorten the second stage and reduce operative birth; semi-sitting (semi-Fowler's) combines gravity with provider access

Third stage — active management

• Uterotonic immediately after birth — oxytocin 10 units IM or dilute IV infusion (never an undiluted IV push)
• Controlled cord traction by a skilled provider once the uterus contracts
• Delayed cord clamping for at least 30–60 seconds in vigorous term and preterm infants
• Inspect the placenta: completeness of the maternal surface (missing cotyledons → retained tissue → hemorrhage and infection), membranes, and three cord vessels (two arteries, one vein)

Alternative birth approaches

• Water immersion during the first stage may reduce pain and anesthesia use; birth underwater is not recommended by ACOG outside research settings because neonatal benefits are unproven and rare serious complications occur. Tub water should be near body temperature (about 37–38 °C (98.6–100.4 °F)); leave the water for fever, bleeding, or abnormal FHR
• Home or birth-center birth: for low-risk clients with a qualified attendant and a clear emergency transfer plan; hospitals and accredited birth centers are considered the safest settings in the US
• Leboyer ("gentle birth"): dim lights, quiet room, gentle handling, immediate skin-to-skin
• Childbirth education methods: Lamaze (patterned breathing, relaxation), Bradley (partner-coached), hypnobirthing
• The nurse respects choices, provides accurate risk information, and keeps safety monitoring in place

Listed in priority order.

1. Maternal and fetal safety
   • FHR and contraction assessment at required intervals; act on abnormal patterns (reposition, fluids, stop oxytocin, notify)
   • After rupture of membranes: FHR first, then fluid characteristics and temperature
   • Watch for bleeding, hypertension, fever, and signs of infection
2. Promote progress and comfort
   • Position changes every 30–60 minutes; walking; void every 2 hours
   • Heat packs to the lower back and sacral counterpressure for back pain; breathing coaching
   • Calm, continuous presence for the client who is losing control — coach breathing and give simple, direct instructions rather than leaving her alone
3. Second stage
   • Confirm full dilation; support spontaneous pushing and rest between contractions
   • Explain that the head moving back between contractions is normal
   • Prepare the birth area, newborn warmer, and resuscitation equipment
4. Immediate newborn care
   • Dry, stimulate, and place skin-to-skin; assess breathing and tone
   • Suction only if the airway is obstructed or positive-pressure ventilation is needed — bulb syringe mouth before nose (nose suction can trigger a gasp and aspiration)
   • Apgar scores at 1 and 5 minutes (every 5 minutes up to 20 minutes if the score is below 7)
   • Identification bands before separation; vitamin K IM, erythromycin eye ointment, and hepatitis B vaccine within 24 hours (US schedule; plus hepatitis B immune globulin within 12 hours if the mother is HBsAg-positive or of unknown status). A December 2025 federal change to the birth-dose recommendation was stayed by a federal court in March 2026 and is under appeal — check the current CDC/AAP schedule; delay the first bath (no immediate bath)
5. Fourth stage (first 1–2 hours)
   • Fundus and lochia every 15 minutes for the first hour, then every 30 minutes (per policy) with vital signs and bladder check
   • Boggy uterus → fundal massage first; heavy bleeding with a firm uterus → suspect laceration (see laceration degrees in Induction, Operative, and Cesarean Birth)
   • Perineal ice packs; encourage breastfeeding within the first hour
6. Documentation and communication with the team and family

• Explain each procedure and what to expect; involve the support person
• Teach breathing and relaxation between contractions; push with the urge after the nurse confirms full dilation
• Encourage skin-to-skin and early breastfeeding
• For home birth plans: confirm a licensed attendant, low-risk status, and a transport route and plan to the nearest hospital

• After rupture of membranes, check FHR first, then COAT
• A client who feels the baby coming: check the cervix/perineum before directing pushing
• Encourage spontaneous, open-glottis pushing; avoid routine episiotomy and fundal pressure
• Warm compresses reduce severe perineal tears
• Active third-stage management: oxytocin after birth, cord traction, uterine assessment
• Delayed cord clamping 30–60 seconds
• Newborn suction: mouth before nose, only when needed
• Apgar at 1 and 5 minutes
• Fourth stage: fundus/lochia every 15 minutes for 1 hour
• Underwater birth not recommended by ACOG; immersion in the first stage is acceptable