1. Introduction to Intranatal Care

Intranatal care refers to the care provided to a woman and her fetus during labor and delivery. As community health nurses, we play a crucial role in ensuring safe childbirth experiences, especially in settings where access to specialized obstetric care may be limited. This comprehensive guide focuses on the early identification, primary management, referral, and follow-up of common complications during labor and delivery.

The World Health Organization estimates that approximately 295,000 women die annually during pregnancy and childbirth, with 94% of these deaths occurring in low-resource settings. Most maternal deaths are preventable with proper intranatal care and timely interventions. Community health nurses are often the first line of defense in recognizing potential complications and initiating appropriate management.

2. Normal Labor and Delivery

Before exploring complications, it’s essential to understand the normal labor process. Normal labor progresses through three main stages and follows predictable patterns. Recognizing deviations from normal patterns is crucial for identifying complications early.

3. Preterm Labor

Preterm labor refers to the onset of labor before 37 completed weeks of gestation. It is one of the leading causes of neonatal morbidity and mortality worldwide. Community health nurses must be skilled in early identification and appropriate management of preterm labor to improve outcomes.

3.1 Early Identification

3.2 Primary Management

When preterm labor is suspected, the community health nurse should initiate the following interventions:

3.3 Referral and Follow-up

Preterm labor often requires higher-level care. The community health nurse should:

Referral Process:

1. Contact the receiving facility to notify them of the transfer and provide clinical information
2. Document all assessments, interventions, and maternal/fetal responses
3. Arrange appropriate transportation (ambulance if available)
4. If time permits and available in your setting, consider administering first dose of:
   • Corticosteroids (if 24-34 weeks gestation) to accelerate fetal lung maturity
   • Magnesium sulfate (if less than 32 weeks) for neuroprotection
5. Accompany the mother if possible, continuing monitoring during transport

Follow-up After Resolution:

• Women who experience preterm labor that resolves should receive weekly follow-up
• Educate about warning signs that necessitate immediate return
• Teach self-monitoring of fetal movement and contraction patterns
• Provide guidance on activity modification and stress reduction
• Connect with social supports and community resources as needed

4. Fetal Distress

Fetal distress (now often termed “non-reassuring fetal status”) refers to signs indicating that the fetus is not receiving adequate oxygen, potentially leading to hypoxia and adverse outcomes. Early identification and intervention are critical for preventing fetal morbidity and mortality.

4.1 Early Identification

Community health nurses should monitor for the following signs of fetal distress:

4.2 Primary Management

When fetal distress is suspected, prompt interventions are necessary:

1. Position change: Place mother in left lateral position to improve placental perfusion and relieve cord compression
2. Oxygen administration: If available, provide supplemental oxygen via face mask at 8-10 L/min
3. Hydration: Ensure adequate maternal hydration (oral or IV if available)
4. Discontinue oxytocin: If being administered for augmentation
5. Assess for underlying causes:
   • Maternal hypotension
   • Uterine hyperstimulation
   • Cord prolapse or compression
   • Placental abruption
   • Maternal fever/infection
6. Continuous monitoring: Increase frequency of FHR assessment to every 5 minutes

4.3 Referral and Follow-up

Fetal distress generally requires immediate referral to a facility capable of emergency cesarean delivery:

• Expedite transfer: Minimize delays, as outcomes are time-sensitive
• Communication: Clearly convey concerns, assessments, and interventions to receiving facility
• Documentation: Record all findings, interventions, and responses in detail
• Continuous monitoring: Maintain FHR assessment during transport if possible
• Maternal support: Provide explanation and emotional support throughout process

Post-event follow-up:

• Review outcomes and care provided for quality improvement
• Provide debriefing for staff involved
• Ensure continued monitoring of neonate for hypoxic-ischemic sequelae
• Follow up with mother to address questions and provide psychological support

5. Prolonged and Obstructed Labor

Prolonged labor refers to abnormally slow progress, while obstructed labor occurs when the fetus cannot pass through the pelvis despite strong contractions. Both conditions increase risk for maternal and fetal complications and require timely identification and management.

5.1 Early Identification

5.2 Primary Management

Community health nurses should implement the following measures when prolonged or obstructed labor is suspected:

1. Assessment:
   • Confirm diagnosis using partograph (if available)
   • Assess maternal vital signs, hydration, and ketosis
   • Monitor fetal heart rate more frequently
   • Evaluate contraction pattern
2. Supportive Care:
   • Hydration (oral or IV if available)
   • Position changes to facilitate fetal descent
   • Emptying bladder
   • Pain relief measures
   • Emotional support
3. Non-pharmacological Interventions:
   • Walking and upright positions (if not contraindicated)
   • Warm shower or bath
   • Counter-pressure on lower back
   • Guided breathing techniques

5.3 Referral and Follow-up

Prolonged and obstructed labor require prompt referral to a facility capable of operative delivery:

During transfer:

• Position mother on her left side
• Continue hydration
• Monitor vital signs and fetal heart rate
• Do not administer oxytocin in suspected obstructed labor
• If obstructed labor is suspected, insert urinary catheter if trained to do so

Follow-up:

• After resolution, monitor for postpartum hemorrhage (risk is increased)
• Observe for signs of infection
• Assess for genital tract trauma
• Monitor for urinary retention (prolonged pressure can damage bladder)
• Provide education on rest, nutrition, and danger signs

6. Vaginal and Perineal Tears

Vaginal and perineal tears occur in approximately 85% of vaginal deliveries. These injuries range from minor superficial tears to severe lacerations involving the anal sphincter. Community health nurses should be skilled in identifying, classifying, and managing these injuries.

6.1 Early Identification

Assessment for tears:

• Visual inspection of perineum, vagina, and labia
• Assessment of bleeding (active or controlled)
• Gentle palpation with gloved hand to assess depth and extent
• Rectal examination to identify third and fourth-degree tears

6.2 Primary Management

Management depends on the degree of tear and available resources:

Basic principles for managing tears:

1. Ensure adequate lighting and positioning
2. Maintain aseptic technique
3. Provide adequate pain relief
4. Identify the full extent of the tear before repair
5. Repair from apex downward
6. Ensure anatomical alignment
7. Avoid excessive tension on sutures
8. Check for hemostasis after repair

6.3 Referral and Follow-up

During referral:

• Apply sterile pad with gentle pressure to control bleeding
• Monitor vital signs for signs of hemorrhage
• Maintain patient in comfortable position (side-lying often best)
• Provide pain relief
• Keep patient warm and maintain dignity

Follow-up care after repair:

• Perineal hygiene education
• Pain management (cooling pads, analgesics)
• Sitz baths 2-3 times daily
• Pelvic floor exercises after healing
• Monitoring for signs of infection
• Dietary advice to prevent constipation
• Follow-up assessment at 1-2 weeks

7. Ruptured Uterus

Uterine rupture is a catastrophic obstetric complication where the integrity of the myometrial wall is breached. It is a life-threatening emergency for both mother and fetus, requiring immediate recognition and management.

7.1 Early Identification

Clinical presentation:

7.2 Primary Management

Uterine rupture is a medical emergency requiring immediate referral. While preparing for transfer, the community health nurse should:

1. Stabilize the mother:
   • Establish IV access with large-bore catheter if available
   • Position flat with legs elevated (unless difficulty breathing)
   • Administer oxygen if available
   • Keep warm
2. Monitor vital signs:
   • Check pulse, blood pressure, and respiratory rate every 5-15 minutes
   • Monitor for worsening signs of shock
3. Control bleeding:
   • Apply external uterine massage if bleeding is evident
   • Do not perform internal examinations if rupture is suspected
4. Prepare for transfer:
   • Arrange fastest possible transport to surgical facility
   • Send someone ahead to alert facility if possible
   • Collect and send any available documentation

7.3 Referral and Follow-up

Uterine rupture requires immediate surgical intervention at a facility capable of performing emergency laparotomy, hysterectomy if necessary, and blood transfusion.

During transfer:

• Continue monitoring vital signs
• Maintain IV fluids if available
• Position to maximize perfusion (left lateral if no hypotension)
• Keep NPO (nothing by mouth)
• Document all assessments and interventions
• If trained personnel available, consider starting antibiotics

Communication with receiving facility:

• Estimated time of arrival
• Patient’s condition and vital signs
• Interventions performed
• Risk factors and history
• Suspected diagnosis and supporting signs

Follow-up after surgical management:

• Counseling regarding future pregnancies
• Psychological support for trauma and potential loss
• Family planning services
• Documentation in maternal health record
• Ensure understanding of warning signs in future pregnancies

8. Immediate Newborn Care

Providing appropriate care immediately after birth is crucial for newborn survival and adaptation to extrauterine life. The first 24 hours are the most critical, with the first “golden minute” being especially important for establishing breathing.

8.1 Immediate Assessment

Apgar Score: A standardized assessment performed at 1 and 5 minutes after birth.

8.2 Routine Care Procedures

The following steps should be performed systematically for all newborns:

Temperature regulation:

• Maintain warm chain: warm room, dry immediately, skin-to-skin contact, delayed bathing
• Cover head with cap (significant heat loss occurs through head)
• Use pre-warmed blankets if available
• Check temperature at 1-2 hours after birth (normal: 36.5-37.5°C)

Umbilical cord care:

• Clean, dry cord care with no topical applications unless antiseptic specifically indicated
• Apply chlorhexidine to cord if home birth in high-risk settings (where recommended)
• Leave cord uncovered, keep clean and dry
• Educate mother on signs of infection (redness, discharge, swelling)

Early initiation of breastfeeding:

• Support breastfeeding within first hour of life
• Assist with proper positioning and attachment
• Observe first feeding for effectiveness
• Educate on feeding cues and frequency
• Avoid formula, water, or other supplementation unless medically indicated

8.3 Managing Common Complications

Management of hypothermia:

• Immediately place in skin-to-skin contact with mother
• Cover both mother and baby with warm blankets
• Ensure room is warm and free from drafts
• If severe hypothermia (<35°C), gradually rewarm with external heat source if available
• Monitor temperature every 15-30 minutes during rewarming
• Initiate breastfeeding to provide calories

Management of hypoglycemia:

• Recognize at-risk newborns: preterm, small-for-gestational age, large-for-gestational age, infants of diabetic mothers
• Ensure early and frequent breastfeeding
• Monitor for signs: jitteriness, lethargy, poor feeding, irregular breathing
• If signs present and glucose testing available, check blood glucose
• If <45 mg/dL (2.5 mmol/L) or symptomatic, refer for medical management

9. Community Health Nursing Perspectives

Community health nurses have a unique role in intranatal care, especially in settings where access to specialized obstetric care may be limited. A community health perspective considers the broader context of care delivery and emphasizes preparedness and resource optimization.

Birth Companion Program:

In many communities, implementing a birth companion program can significantly improve outcomes. Trained companions can:

• Provide continuous support during labor
• Recognize danger signs and advocate for timely care
• Support the community health nurse during emergencies
• Facilitate communication between healthcare providers and families
• Provide culturally appropriate emotional support

Community-Based Transport Systems:

Establishing reliable emergency transport systems is essential for timely referrals:

• Community emergency funds for transportation costs
• Designated drivers or transport volunteers
• Mapping of accessible routes to referral facilities
• Communication systems for coordinating transport
• Maternity waiting homes near facilities for high-risk cases

Strategic Collaboration:

Community health nurses should establish relationships with:

• Traditional birth attendants (for appropriate roles and referrals)
• Community leaders (for support and resource mobilization)
• Referral facilities (for smooth transfer processes)
• Other healthcare providers (for coordinated care)
• Local government (for sustainable support systems)

10. Global Best Practices in Intranatal Care

Different regions have developed innovative approaches to improve intranatal care outcomes. These evidence-based practices can be adapted to various settings:

WHO Safe Childbirth Checklist:

The World Health Organization has developed a 29-item checklist addressing major causes of maternal and newborn mortality. It addresses critical points in care:

1. On admission
2. Just before pushing (or before cesarean)
3. Soon after birth (within 1 hour)
4. Before discharge

Implementation of this checklist has been shown to improve adherence to essential practices and can be adapted for community settings.

Respectful Maternity Care:

Growing global recognition of the importance of dignified, respectful care during childbirth has led to the development of respectful maternity care standards. Key principles include:

• Protection of women’s dignity, privacy, and confidentiality
• Freedom from harm and ill treatment
• Informed consent and choice in care
• Continuous support during labor
• Equity in access and quality of care

Community health nurses should advocate for these principles even in resource-limited settings.

11. Conclusion

Effective intranatal care is critical for ensuring positive outcomes for mothers and newborns. As community health nurses, we play a vital role in identifying complications early, providing appropriate primary management, making timely referrals, and delivering quality follow-up care.

The key components of quality intranatal care include:

• Thorough knowledge of normal labor progression and recognition of deviations
• Systematic assessment skills to identify complications early
• Confidence in performing basic emergency interventions
• Clear decision-making regarding when and how to refer
• Effective communication with mothers, families, and other healthcare providers
• Cultural sensitivity and respectful care practices
• Comprehensive documentation and follow-up

By integrating evidence-based practices with community-centered approaches, community health nurses can significantly reduce maternal and neonatal morbidity and mortality, even in resource-limited settings. Continuous learning, quality improvement, and collaboration with other healthcare providers and community members are essential for enhancing the effectiveness of intranatal care services.

Remember that every birth is both a critical health event and a significant life experience for mothers and families. By providing compassionate, skilled care during the intranatal period, community health nurses contribute not only to saving lives but also to promoting positive birth experiences that can have lasting effects on maternal and infant well-being.