C.

M PATEL COLLEGE
OF NURSING,
GANDHINAGAR.
Subject: Nursing Education
Topic : Lesson plan on “CONFERENCE – ABOUT
STAGES OF LABOUR AND ITS MANAGEMENT”

Submitted to:
Mrs. Kalai vani submitted by:
associate professor F.y M.sc Nursing
C.M Patel college Batch: 2019-2021
Of nursing. C.M Patel college
Of nursing.

Submitted on: 22nd November 2019

 INTRODUCTION

• Name of students: F.Y. M. Sc nursing students

• Subject: Nursing Education
• Topic: Conference – about stages of Labour and its management
• Date: 22/11/19
• Time: 10:00 to 4:00 am.
• Duration: 4 hrs
• Place: Pre-clinical lab.
• Group: F. Y Post Basic nursing students
• Method of teaching: lecture cum discussion
• A.V aids: power point presentation, leaflet, video
• Name of Mentor : Mrs. Kalai vani
General objectives:
After completion of conference student will be able to understand about various
programmes running in india and the stages of labour.

Specific objectives:
The student will be able to:
• To introduce about the MMR
• To describe the various programmes running in india that facilitate
maternal health.
• To define the stages of labour
• To explain causes of onset of labour
• To elaborate the first stage of labour.
• To enumerate second stage of labour.
• To describe about the third stage of labour.
• To explain the fourth stage of management.
Sr. time Specific- Contain Teachin A.V aids Evaluati
no objectiv g on
e learning
method
1. 25 To INTRODUCTION Explanat Ppt What is
mins. introduce As many as 34 births and 10 deaths are registered in India every minute. The number goes up to ion maternal
about the 2,062 births and 603 deaths per hour, up to 49,481 births and 14,475 deaths per day and further and child
MMR up to 1.5 million births and 0.4 million deaths per month. mortality
This was disclosed during the National Annual Conference of Chief Registrars of Births & and
Deaths which got underway in New Delhi. Despite these numbers, the level of registration in morbidit-
the country is 68 per cent for births and 63 per cent for deaths. Registrar General of India y ratio ?
D.K.Sikri said that National Population Policy 2000 has mandated cent per cent level of
registration of births and deaths by 2010.
Excluding Uttar Pradesh and Bihar, the registration of birth in the country is 82.5 percent and
that of deaths 72 percent. The total number of registration units in the country is 2.55 lakh in
which 18.6 million births and 5.28 million deaths were registered during 2006, it was stated
during the conference.
The recent World Bank data puts the MMR for India reported in 2015 at 174 per 100, 000 live
births, which is a significant decline from the 215 figure that was reported in 2010.
In absolute numbers, nearly 45,000 mothers die due to causes related to childbirth every year
that accounts for 17% of such deaths globally.
The major cause— Post-Partum Haemorrhage is often defined as the loss of more than 500-
1,000 ml of blood within the first 24 hours following childbirth.
The key to the progress of a country lies in reducing its maternal and child mortality and
morbidity. Over the years, Government of India has taken many initiatives, and the improved
health indicators are a result of that. So it is necessary to maintain or preserve the maternal
health.

Objectives:
• To reduce Maternal Mortality Ratio.
• To increase the Early ANC registration.
• To ensure 3 or more than 3 ANCs to all the expectant mothers and special attention to
high risk pregnancies
 • To decrease the incidence and progress of anaemia in pregnant and lactating women.
• Provide adequate opportunities for safe deliveries and to increase institutional deliveries.
• To improve the coverage of post partum care.
• To increase access to Emergency Obstetric Care for complicated deliveries through
strengthening of FRUs.
• To increase access to early and safe abortion services
• To ensure the Maternal Death audit of all Maternal Deaths.
• To ensure JSSK entitlements in all Govt. institutions deliveries.

Improving Maternal Health is one of the Sustainable Development Goal and a vital component
towards achieving Continuum of Care. Gujarat has made considerable progress over the last
decade in Maternal and Child Health by providing accessible qualitative health services
especially for rural areas, out reached areas and the poor. Maternal Mortality Ratio (MMR) of
Gujarat has reduced from 172 per 1 lakh live births in year 2001 – 2003 to 87 per 1 lakh live
births in year 2015 – 2017 (SRS).

This improvement in reduction can be attributed to various Schemes of Government of Gujarat

such as Mamta Diwas, 108 ambulances, Improvement in government facilities and quality,
continuous tracking of pregnant mothers through TeCHO+ / E-Mamta, Chiranjeevi Yojana,
Kasturba Poshan Sahay Yojana, Mamta Ghar, Free drop back to home after institutional delivery
using Khilkhilat etc.
 Currently Gujarat is 6th among the states with lower maternal mortality ratio.

Services to Pregnant women:

▪ All pregnancies are registered by health workers.
▪ All registered pregnant women are provided three antenatal checkup which also include
Blood Pressure measurement and ruling out any complications, high risk factors
▪ The Pregnant Women are given two doses of tetanus toxoid immunisation. The Pregnant
women are also provided Iron Folic Acid tablets and Calcium Supplementation.
▪ Deliveries by trained personnel in safe and hygienic surroundings are encouraged.
▪ Institutional deliveries are encouraged for women having complications.
▪ In case of complication referrals are made to First Referral Units for Management of
obstetric emergencies.
▪ Three postnatal check-up are given to mothers after the delivery
▪ Spacing of at least three years between children is encouraged.

2. 35 To REPRODUCTIVE& CHILD HEALTH PROGRAMME Explanat Ppt The

Mins describe ion cum program
. the Improving maternal and child health has been one of the top health priorities of Government of Discussi es are
various India. In view of this, The Reproductive and Child Health (RCH) 1 Programme was launched on running
program throughout the country on 15th October, 1997. The second phase of RCH program i.e. RCH – in india
mes II was launched on 1st April, 2005. The main objective of the program was to bring about a for
running change in mainly three critical health indicators i.e. reducing total fertility rate, infant mortality promotio
in india rate and maternal mortality rate with a view to realizing the outcomes envisioned in the n of
that Millennium Development Goals. RMCH+A approach has been launches in 2013 and it maternal
facilitate essentially looks to address the major causes of mortality among women and children as well as and child
maternal the delays in accessing and utilizing health care and services. To add to this various programs health.
health. and schemes has been launched by Government of India to achieve reproductive health goals.

Our Vision
Healthy pregnancy, safe delivery, new-born care and child care for all citizen of India.

Our Mission
Provide all information pertaining to reproductive child health provided by Government of India
at one place to all citizen of India.

Maternal and child health (MCH)

This editorial commentary focuses on a review of past, present, and future maternal and child
health (MCH) services in India. MCH was first initiated in the early 1900s, when maternity
services were improved and rural midwives and birth attendants received training. MCH was
voluntary work coordinated by the Maternal and Child Welfare Bureau under the Indian Red
Cross Society. Madras state was the first to establish a separate Maternal Welfare section in the
Office of Director of Health Services in 1931. In 1946, the Bhore Committee recommended the
integration of MCH within General Health Services, but implementation occurred after 1955.
Before 1953, MCH was unevenly distributed and delivered through maternity homes and
midwives. WHO and UNICEF support contributed to the expansion of MCH services. The
Mudaliar Committee in 1962 recommended, for instance, the expansion of MCH centers to
include 1 ANM per 10,000 population. The Child Care Committee in 1960 prepared the first
report on preschool child care and proposed several models of comprehensive child welfare
services. In 1968, the Committee on Child Welfare Programs associated successful family
planning (FP) with good MCH services. The 5-year plan for 1969-74 was the first to integrate
FP with MCH. 1974 was a pivotal year. India established a National Policy for Children and a
Children's Board. The 1983 National Health Policy identified 9 out of 17 goals as child-related.
India today has an extensive set of MCH/FP services. Future child survival will depend upon
increased immunization coverage. Future efforts should focus on establishing the community as
the focus of updated and well-equipped services. Community volunteers will need to spread
awareness and knowledge of FP and MCH. Programs must reduce poverty, expand schooling,
empower women and girls, and treat domestic violence as a health issue. AIDS is another future
challenge.

Objectives:
The MCH Program aims to achieve the following objectives:
• Increase utilization of quality family planning, maternal. neonatal, and child health
services
• Improve nutrition and water, sanitation and hygiene practices
• Strengthen health system to enable sustainability

Main Activities:

• The Family Planning/Reproductive Health (FP/RH) activity seeks to strengthen the

delivery of integrated FP and safe motherhood services to address the unmet need of
poor and hard-to-reach communities, builds networks, and strengthens care in the public
and private sectors through franchising, voucher systems, and community outreach
models.
• The Maternal Newborn and Child Health (MNCH) Services activity supports the
introduction, scale up, and further development of high-impact and evidence-based
MNCH interventions while incorporating birth spacing and family planning services into
public and private sector facilities.
• The Health Communication activity uses commercial marketing techniques and
innovative social and behavior change communications strategies to position products
and services with messages that increase knowledge, create demand, and promote
healthy behaviors.
• The Health Commodities and Supply Chain activity provides technical assistance to
strengthen the government's capacity to estimate its requirement for contraceptive
 commodities and undertake transparent procurement; and also provides technical
assistance to improve and sustain the commodity supply chain management and
distribution systems with an emphasis on the logistics management information system.
• The Health Systems Strengthening activity provides technical assistance to the public
health and population sectors to reform and improve service delivery in a post-devolution
operating environment by addressing governance, workforce, information systems, and
overall financing, while also supporting both supply- and demand-side initiatives and
community financing innovations to reduce financial barriers for the poor.
• Nutrition/ Water, Sanitation, and Hygiene activities seek to decrease stunting by
strengthening programs and policy; supporting community-oriented approaches; and
improving behaviors and practices

National Health Mission (NHM)

The Union Cabinet vide its decision dated 1st May 2013 has approved the launch of National
Urban Health Mission (NUHM) as a Sub-mission of an over-arching National Health Mission
(NHM), with National Health Mission (NHM) being the other Sub-mission of National Health
Mission.
Outcomes for NHM in the 12th Plan are synonymous with those of the 12th Plan, and are part
of the overall vision. The endeavour would be to ensure achievement of those indicators in Box
1. Specific goals for the states will be based on existing levels, capacity and context. State
specific innovations would be encouraged. Process and outcome indicators will be developed to
reflect equity, quality, efficiency and responsiveness. Targets for communicable and non-
communicable disease will be set at state level based on local epidemiological patterns and
taking into account the financing available for each of these conditions.

After the launch of National Rural Health Mission (NRHM) in 2005, significant improvements
have taken place in building the health infrastructure in the country,” said a senior health
ministry official.
The visibility of NRHM, now called National Health Mission, is reflected in progress towards
achieving targets for the reduction of Maternal Mortality Rate (MMR), Infant Mortality Rate
(IMR), Total fertility Rate (TFR) and other indicators.
NHM Framework for Implementation
Continuation of the National Health Mission - with effect from 1st April 2017 to 31st March
2020 has been approved by Cabinet in its meeting dated 21.03.2018.
NHM has six financing components:
(i) NRHM-RCH Flexipool,
(ii) NUHM Flexipool,
(iii) Flexible pool for Communicable disease,
(iv) Flexible pool for Non communicable disease including Injury and Trauma,
(v) Infrastructure Maintenance and
(vi) Family Welfare Central Sector component.

Goals:
➢ Reduce MMR to 1/1000 live births
➢ Reduce IMR to 25/1000 live births
➢ Reduce TFR to 2.1
➢ Prevention and reduction of anaemia in women aged 15–49 years
➢ Prevent and reduce mortality & morbidity from communicable, non- communicable;
injuries and emerging diseases
➢ Reduce household out-of-pocket expenditure on total health care expenditure
➢ Reduce annual incidence and mortality from Tuberculosis by half
➢ Reduce prevalence of Leprosy to <1/10000 population and incidence to zero in all
districts
➢ Annual Malaria Incidence to be <1/1000
➢ Less than 1 per cent microfilaria prevalence in all districts
➢ Kala-azar Elimination by 2015, <1 case per 10000 population in all blocks
A substantial increase in the availability of financial resources for Reproductive and Child
Health (RCH), healthcare infrastructure and workforce as also the expansion of programme
management capacity since the launch of NHM in 2005 provides an important opportunity to
consolidate all our efforts. As we inch closer to 2015, there is an opportunity to further accelerate
 progress towards MDG and redefine the national agenda to come up with a coordinated approach
to maternal and child health in the next five years.

In order to bring greater impact through the RCH programme, it is important to recognise that
reproductive, maternal and child health cannot be addressed in isolation as these are closely
linked to the health status of the population in various stages of life cycle. The health of an
adolescent girl impacts pregnancy while the health of a pregnant woman impacts the health of
the newborn and the child. As such, interventions may be required at various stages of life
cycle,which should be mutually linked. And hence, on the basis of available data and the close
inter-linkages between different stages of life cycle emerged a need to introduce RMNCH + A
strategy.
Programmes Under RMNCH + A
• Maternal Health
• Child Health
• Nutrition
• Family Planning
• Safe Abortions
• Urban RCH
• Rural Health
• ARSH (Adolescent Reproductive and Sexual Health)
• RBSK (Rashtriya Bal Swasthya Karyakram)
• Training & Capacity Building /SIHFW
• Programme Management
• Vulnerable Groups

MAMATA CARD
In the Gujarat Mother and Child Protection card is known as Mamta Card. The Mamta Card has
been developed as a tool for families to learn, understand and follow positive practices for
achieving good health of pregnant women, young mothers and children.
Gujarat has been using Mamta Card since 2005. In the year 2013-14 total 15,00,000 Mamta
Cards has been approved to distribute in whole State to help families to know about various
types of services which they need to access for the health and well-being of women and children.
This card empowers families to make decisions for improved health and nutritional status and
development of young children on a continual basis.
Mamta Card could be used by the following individuals and groups
Family members (Mothers, Fathers, Mother-in-laws, Adolescent Girls and others)
For gaining knowledge related to children’s health, nutrition and development.
For using all available services.
For practicing optimal care behaviors.
For monitoring and promoting growth and development of children.
Village Groups / Women (Mahila Mandal) Groups
ANM / ASHA / AWW
Health & ICDS Supervisor for ensuring

MAMTA GHAR
One of the major determinants in some areas of the State is the ability to bring the necessary
technical skills – economic, geographical, and operational – to the women in need of help.
Access to a continuum of care, including appropriate management of pregnancy, delivery, post
partum care and access to life-saving obstetric care when complications arise are crucial to Safe
Motherhood.

MAMTA SAKHI ( Birth Companion Scheme)

Under this scheme a female family member allow to be at the side of pregnant woman at the
time of delivery in government institutions. The presence of birth companion during childbirth
meant that a woman was never left alone during this intensely stressful and frightening time of
her life.

MAMTA DOLI
Reduction in delay due to transportation to the health facility for Institutional Delivery is of
utmost importance for bringing down the MMR. In view of the above the State Govt. has decided
to implement the Mamta Doli initiative in certain inaccessible areas of Gujarat.
The purpose of the initiative is to bring the pregnant women to the nearest motorable point from
where she can be picked up from ambulance receiving point for further transportation by EMRI
108 vehicle for Institutional Delivery or transportation of the pregnant women directly by the
Mamta Doli service providers.
MAMTA ABHIYAN
Outreach preventive and promotive services for ANC and PNC are designed under MAMTA
Abhiyan. MAMTA Abhiyan has four components including MAMTA Divas (Health &
Nutrition Day), MAMTA Mulakat (PNC Home visit), MAMTA Sandarbh (Referral services)
and MAMTA Nondh.

CHIRANJIVI YOJANA

Chiranjeevi Yojana (CY) was created to significantly reduce maternal and infant mortality by
harnessing the existing private sector and encouraging it to provide delivery and emergency
obstetric care at no cost to families living below the poverty line.

KASTURBA POSHANSAHAYYOJANA

Under this scheme, the financial assistance is given to the pregnant women belonging to
below poverty line (BPL). This scheme has been initiated in order to achieve the goals i.e. to
ensure safe motherhood and institutional deliveries, to reduce the morbidity and mortality.

THE JANANI SURKASHA YOJNA (JSY) SCHEME

It has brought about a surge in institutional deliveries and huge financial uptakes in most
states.
Launch of Janani- Shishu Suraksha Katyakram (JSSK) in 2011 has further strengthened
maternal health initiatives by entitling free deliveries and Caesarean-Sections to every
pregnant woman coming for deliveries at government health facility.
The transport from the health facility, drop back and any referrals between facilities is
also free for pregnant women coming to government health facility.
This ensures nil out of pocket expenditure for the women and their families. Even the
sick newborns are treated free without any expense on diagnostics, drugs, consumables,
diet, transport, etc.
The JSY and JSSK programmes have incentivised pregnant women to access healthcare
in greater numbers.
 Before few year, heath ministry launched an innovate scheme to provide free health
check-ups to pregnant women at government health centres and hospitals by private
doctors under The Pradhan Mantri Surakshit Matritva Abhiyan.
Popularly referred to as ‘I pledge for 9’ that was announced by Prime Minister Narendra
Modi during his monthly radio address Mann Ki Baat on June 9, invites the private sector
to provide free ante-natal services (ANC) on the 9th of every month on a voluntary basis
to pregnant women, especially those living in underserved, semi-urban, poor and rural
areas.
More than 2 lakh high-risk check-ups have happened under the scheme and we expect
to cover many more in future. We are happy with the results as our rate of improvement
is faster than other countries,” said JP Nadda, Union health minister.

RADHAN MANTRI SURAKSHIT MATRUTAVA ABHIYAN (PMSMA)

To reduce Maternal Mortality ratio and to ensure qualitative Maternal Health services,
various programms & schemes is been implimented in State.
Pradhan Mantri Surakshit Matrutava Abhiyan (PMSMA) is been implimented since 09th
June 2016 aross state to ensure early identification & prompt treatment of high risk
pregnant womens of 2nd / 3rd trimesters under guidance of specialist.
Across state 09th of every month \Pradhan Mantri Surakshit Matrutava Abhiyan
(PMSMA) clinic is been organized at every Public Health Institute.
Under this abhiyan essential Anatenatal care & other necessary health services in been
provided by specialist at every Public Health Institute at 09th of every month.
In the 31st July 2016 episode of "Man ki Baat” Honable Prime Minister has appealed to
private sector obstetricians/ physicians to volunteer their services for this programme.
Pradhan Mantri Surakshit Matrutava Abhiyan clinic is been organized at all Community Health
centre, Sub district Hospital, District Hospital & Medical Collge Hospitals.
All essential Antenatal examinations, check up, Hemoglobin, Urine, Routine Blood Sugar,
Malaria, HIV, Blood grouping etc essential laboratory services is also ensured, even if required
USG services also been provided to all pregnant women.
Pradhan Mantri Surakshit Matrutava Abhiyan (PMSMA) ensures essential examination of
pregnant women and early identification of pregnant women with high risk factors and also
ensures necessary medical check up, treatment & laboratory investigations under guidance of
specialist. If it is required than pregnant women is also referred for essential medical check up
 & treatment to higher level public health institutes. All these services is been provided free of
cost to all pregnant women at all public health institutes.
More than 15 lakh pregnant women are examined & out of which total 83,000 High Risk
Pregnancy have been identified and given treatment under the campaign.

SURAKSHIT MATRITVA AASHWASAN (SUMAN) SCHEME

Aiming zero preventable maternal and newborn deaths in India, the central government on
Thursday launched the Surakshit Matritva Aashwasan (SUMAN) scheme, under which pregnant
women, mothers up to 6 months after delivery, and all sick newborns will be able to avail free
healthcare benefits. The scheme will largely help in bringing down maternal and infant mortality
rates in the country

STAGES OF LABOUR AND ITS MANAGEMENT. Explanat Ppt What is

3. 10 To ion cum the
mins define Discussi labour
. the There are four stages of labour. These are: on and how
stages of i) The First Stage (Dilatation of the cervix) many
labour This is from the onset of true labour pain to complete dilatation of the cervix. It comprises a stages of
latent phase and an active phase. The latent phase is from the onset of true labour to 3 cm labour?
dilatation of cervix, and the active phase is from 3 cm dilation to complete dilatation of cervix.
Its average duration is 121.rs in primi gravida & 6 hrs in multipara.’
The Second Stage (Expulsion of foetus)
It begins when the cervix is fully dilated and ends when the baby is born. Its average duration is
2 hrs in primigravida & 30 mins in multipara.
iii) The Third Stage (Separation and expulsion of the placenta and membranes)
It begins at the birth of the baby and ends at the expulsion of the placenta and membranes. Its
average duration is about 15 mins in both primi & multipara.
iv) The Fourth Stage
This begins from the birth of the placenta, till one hour after delivery.

4. Ppt Which
20 To CAUSES OF ONSET OF LABOUR: Explanat are the
mins explain ion cum causes
causes of The onset of labour is said to be multi factorial in origin, i.e. hormonal, mechanical andneuronal Discussi and signs
onset of factors. You will be learning about each of these now. on of onset
labour a) Hormonal Factors: The hormones responsible for the onset of labour are oxytocin, of
progesterone and prostaglandins. The foetal hypothalamus is triggered to produce the releasing labour?
factors. These Releasing factors stimulate the anterior pituitary gland to produce
adrenocorticotropic hormones (ACTH). ACTH stimulates the foetal adrenal glands to secrete
cortisol. Cortisol causes changes in relative levels of placental hormones, i.e. the oestrogen
levels rise and the progesterone levels fall

Foetal hypothalamus
(triggered)

Releasing factors are produced

Stimulation of anterior pituitary gland

Production of adrenocorticotropic hormone

Stimulation of foetal adrenal gland

Secretion of cortisol

Increase in oestrogen level 4 Decrease in progesterone level

Now you will see the role of each of these hormones in the onset of labour.

I) Progesterone: It has a relaxant effect on the uterus. It is first produced by the corpus
lutetium and then by placenta. It inhibits uterine contractility. When the oestrogen level
increases, the progesterone levels decrease. This decreases at the end of pregnancy, (The
increased production of foetal dehydroepiandrosterone sulphate (DHEAS) inhibits the
production of foetal pregnenolone to progesterone).

II) Oxytocin: This hormone is released by the posterior pituitary gland of the mother. It has a
stimulating action on the pregnant uterus. Towards the end of pregnancy, there is an increase
 in the oxytocin receptors in the deciduas vera. The oxytocin released acts directly on the
myometrium and causes the uterus to contract. Further, it acts on the endometrial tissue and
causes the release of prostaglandin.

III) Prostaglandin: The major sites of synthesis of prostaglandins are placenta, foetal
membrane, decidual cells and myometrium. It is thought that the decidua at term releases
prostaglandins from the uterus in response to the release of oestrogen. They act on the uterine
muscles and causes it to contract.

b) Mechanical Factors
This is due to mechanical stimulation of the uterus and cervix:
i) Uterus: As pregnancy advances, its contractility increases and it becomes more susceptible
to stimulation
ii) Cervix: The presence of the presenting part on the nerve ending of the cervix causes onset
of labour.

c) Neuronal Factors
and B adrenergic receptors are present in the myometrium. When progesterone gets
withdrawn, onset of Labour takes place.

PREMONITORY SIGNS OF LABOUR:

During the three weeks prior to the onset of labour, some changes take place. These are
useful to determine the approach of labour.
• Lightening or sinking of the uterus: Takes place 2-3 weeks before the onset of
• Inbour This is because the symphysis pubis widens and softens; the pelvic floor descends
into the true pelvis.
• Frequency of micturition: Due to pressure of the foetal head on the bladder.
• Presence of false pain: These are erratic and irregular, causing the uterus to contract
and relax
• Taking up of the cervix: It gradually merges into the lower uterine segment.
5. 45 To MANAGEMENT OF FIRST STAGE OF LABOUR: Explanat Ppt What is
mins elaborate ion cum the
. the first This is from the onset of true labour pain to complete dilatation of the cervix. It comprises a Discussi manage
stage of latent phase and an active phase. The latent phase is from the onset of true labour to 3 cm on ment for
labour dilatation of cervix, and the active phase is from 3 cm dilation to complete dilatation of 1st stage
cervix. of
Its average duration is 12 hrs in primigravida & 6 hrs in multipara. labour?

Physiological Changes:
It is important for you to make observation and determine deviation from normal while caring
for women in labour. This knowledge about physiology is needed for effective management
The physiological changes of the first stage of labour is described as follows:

i) Contraction and retraction of the uterine muscle

Uterine contractions are involuntary, regular and rhythmic. The intensity increases
progressively. The intervals between them gradually diminish from around 15 minutes at the
beginning of the first stage to two or three minutes at the end of the second stage.

ii) Retraction
It is the quality of the uterine muscle whereby the contraction does not pass off entirely.
Instead of becoming completely relaxed after the contraction, the muscle fibers retain some
of the contraction. Thus the upper segment of the uterus becomes shorter and thicker and its
cavity diminishes, helping in the progressive expulsion of the foetus
The other characteristics of uterine contractions are fundal dominance and polarity.

iii) Fundal dominance

Each contraction starts in the fundal region and spread downward being stronger and persisting
longer in the upper region. This makes the fundus and midzone remain hard throughout the
period of contraction, while the wave of contraction weakens in the lower uterine segment.

iv) Polarity
This is the neuromuscular harmony between the two poles or segments of the uterus throughout
labour. The upper pole contracts strongly and retracts to expel the foetus, while the lower pole
contracts slightly and dilates to allow expulsion of the foetus.
v) Formation of the upper and lower uterine segment
Functionally, the uterus is divided into two segments, by the end of pregnancy i.e. the upper
uterine segment and the lower uterine segment. The upper uterine segment is the thick muscular
contractile part. The lower uterine segment develops from the isthmus of the uterus and extends
to the cervix. It is thin and distensible and measures 7,5 to 10 cm in length When labour begins
the lower uterine segment stretches because there is a pull on it by the retracted longitudinal
fibers in the upper segment.
vi) Development of the retraction ring
The refraction ring is a ridge that forms at the lower border of the thick segment where it meets
the lower segment. It is normal if it is not visible over the symphysis pubis. If it is visible as a
depressed ride running transversely or slightly obliquely across the abdomen above the
symphysis pubis, it is called Bandl's ring. It appears in obstructed labour because marine
segment stretches. Thus the greater the distension of the lower segment, the higher will be the
retraction ring rise, causing danger of rupture of uterus.
vii) Taking up of the cervix:
the muscle fibers surrounding the internal os are drawn upwards by the retracted upper segment
causing the cervix to shorten It then merge into and becomes part of the lower uterine segment.
Gradually cervical effacement also takes place.
vii) Show
It is the operculum that is formed during pregnancy and expelled in the form of bloodstained
mucoid discharge, a few hours before within or after labour has started. The blood is from the
ruptured capillaries where the chorion is detached and from the dilating cervix.
ix) Formation of the bag membrane
With the dilatation of the lower uterine segment, the chorion gets detached from it. This loosened
part of the fluid, bulge downward into the dilating internal os. The amniotic fluid in front of the
head that fits into the cervix is called fore water, The fluid behind the head is the hind water.
Thus with contraction, the pressure is not exerted on the fore waters. There is a general fluid
pressure, i.e. the pressure of the uterine contractions is exerted on the fluid when the membranes
are intact. Thus the pressure is equalised throughout the uterus.
x) Rupture of the membranes
When extensive cervical dilation has taken place towards the end of the first stage, the bag of
membranes receives very little support. Along with this, there is increased force of the strong
uterine contractions. This causes the membranes to rupture.

Nursing Management Of First Stage Of Labour:

The basic principles in the management of women in the first stage of labour includes
understanding and meeting the woman's need and providing efficient care, i.e. giving comfort,
relieving pain, and conserving woman's strength. One also needs to maintain asepsis throughout
labour and exercise vigilant observation of both maternal and foetal status and coping with
emergencies that may arise.
Recognition of First Stage of Labour by Nursing Personnel
The following signs will enable the nurse to know that the woman is in first stage of labour
On Abdominal Examination
• The uterine contractions will recur with rhythmic regularly and will not exceed 60 minutes
• Presence of abdominal tightening, discomforts or pain
• Presence of backache with contraction

On Vaginal Examination

❖ The cervix is shortened

❖ The membranes feel tense during a contraction
❖ The os dilate progressively Show is present

Admission and Initial Assessment of a Woman in Labour

When the woman is admitted, the nurse has two priorities
Establishing a Therapeutic Relationship
This is done by making the woman and family feels comfortable, thus strengthening the
confidence in the woman's ability to give birth and by using communication skills. The woman
m labour needs to be reassured that she is accepted and will be taken care of. From time to time
the family members must be informed about the progress condition of the woman.
Assessing the Condition of the Mother and the Foetus
This includes an initial interview and nursing history, a physical examination, psychosocial
assessment and review of laboratory tests. The prenatal records need to be reviewed by the
admitting nurse to assist in the assessment of the woman
Nursing History
This includes:
Identification data: Name, age, occupation et
Chief complaints: Reason for seeking care
History of labour Uterine contractions: onset, duration, frequency, intensity discomfort
and pain
Show and/or bleeding Presence of show (blood and mucus). bleeding time and quantity
Amniotic membrane: Rupture or intact; gush or trickling of fluid time of occurrence.
Sleep, rest and food
Any deprivation of sleep and rest
Time when food and fluids was taken and amount

1) Obstetric History
Booked or un booked case
▪ Gravida, parity, abortion
▪ Last menstrual period and expected date of confinement
▪ Past obstetrical history
▪ Any complications present during previous and present pregnancy

i) Medical History
Presence of any medical problems that can influence labour and birth.
• Allergies of food and medication

ii) Psychosocial History

• Prenatal education received
• Response to labour
• Support system

iv) Physical examination

This includes abdominal examination, vulval examination, vaginal examination and
general examination

v) Abdominal Examination
✓ Uterine contraction: characteristics-palpation to assess frequency, duration and Intensity
✓ Assessment of fundal height (in weeks and cm)
✓ Abdominal inspection: ship, size and obvious fetus movement, any surgery scar strial
gravida, rum etc.
✓ Abdominal palpation (Leopold manoeuver) ie. position, presentation, attitude anddegree
of engagement.
✓ Auscultation of foetal heart rate before, during and after contraction for rate and rhythm.

vi) Vulval examination

• For gaping of vaginal orifice or anus and bulging of perineum (suggestive signs
ofsecond stage of labour)
• Presence of bleeding; colour and odour of amniotic fluid.
• Oedema of labia.

vii) Vaginal Examination

This is done to assess:
• Cervical dilatation, firmness and effacement
• Amniotic membrane status intact or ruptured
• Presentation
• Position
• Station of the presenting part
• Any abnormalities: cord prolapse anencephaly, hydrocephalus or compound
presentation
vii) General Examination
• General appearance: Build und stature, conveys impression about health, nutrition and
psychological condition
• Temperature, pulse and respiration: Any clevation needs to be reported immediately
• Blood pressure: If over 140/90 mm of Hg and needs physician's attention.
• Head to toe examination Observe for pallor, respiratory difficulty. Edema -presence
and location, signs of infection

ix) Laboratory Tests

• Complete blood count
• Blood group and Rh type
• Blood glucose und VDRL
• Urine analysis. Protein, glucose and ketones

Preparation for Delivery

Now you will learn bow to prepare for a delivery Details of these will be presented in the
practical section
The preparation for delivery includes
• Physical and psychological preparation of the woman
• Preparation of the environment ie. the delivery room

a) Physical Preparation
b) Vulval and Perineal Preparation
Shaving or clipping of the perineal hair is done. In some institutions ,this practice is discontinued
because research does not show that there is decrease in rates of infections by performing this
procedure.
Cleansing of the vulval area is done with soap and water and then with a non irritating detergent
preparation like 10% dettol solution or hibitane (chlorhexidine) 1 in 2000.
General care
The women needs to have a bath and wear clean clothes if delivery is imminent, the area from
umbilicus to knees can be washed.
• The hair is to be combed
• Finger and toe nails are to be trimmed.
• Nail polish and lipstick are to be removed

c) Psychological Preparation
Emotions of the woman in labour profoundly influences her reaction to discomfort and pain
The woman should be explained the birth process. Emotional support should be given by the
Nurse. Emotional support consists of helping the mother to feel in control of herself and to feel
Accepted The nurse can give practical advice to the woman, as to what is expected of her and
how she can help during Labour. If a companion will be present the nurse can give advice to
her/him about the role in labour.

d) Preparation of Environment i.e. the Delivery Area/Room

High standards of cleanliness need to be maintained at all time. The midwife needs to Prepare
the delivery room: warm, well-lit, sterile delivery kit and keep oxytocin syntrometrine Set up
for the delivery Provide warm environment for the new born Ensure that the new born
resuscitation equipment is present and functioning. Ensure that adult emergency equipment is
available.

Observation of women during first stage of labour: use of partograph

During the first stage, the midwife needs to constantly observe the women to safeguard her and
the foetus and notify the progress of labour.
a) Observation of the Mother
• Reaction to labour: observation of psychological attitude during labour
• Vital signs:
- Pulse rate: Steady pulse rate indicates that the woman is in good condition. A pulse
Rate more than 100 beats per minute is indicative of infection, ketosis or hemorrhage
Record it every one-hour or 2 hours during early labour and every 15-30 minutes
when labour progresses.
- Temperature: should be recorded every 4 hours. It should remain within normal
range. Pyrexia indicates Ketosis or infection.
- Blood pressure: should be recorded every 4 hours. If it is abnormal, it is to be
recorded more frequently

b) Progress of Labour
The woman usually recognises the first stage of labour by the following signs:
➢ Show: a Jelly-like pink, red or brown discharge is experienced by the woman. This is the
bloodstained mucus.
 ➢ Contractions: this exhibits a pattern of rhythm and regularity, usually increasing in
length, strength and frequency as the time goes on. She will experience backache. If she
places her hand on the abdomen , she will feel simultaneous hardening of the uterus.
➢ Rupture of the membranes : she will experience a sudden gush of fluid as rupture of
membranes of there may be dribble of amniotic fluid.
➢ Abdominal examination
➢ Contractions
➢ The frequency, duration and intensity of the contractions should be assessed. The
frequency
➢ of contractions is timed from the beginning of one contraction to the beginning of the
next
➢ The duration of contractions is timed from the moment the uterus first begins to tighten
until
➢ it relaxes again.
➢ The intensity of a contractions may be mild, moderate or strong at its acme.
➢ This is assessed by palpating the fundus of the uterus.
➢ Descent of the Presenting Part
➢ If there is no undue bony or soft tissue obstruction with passage descent is a continuous
➢ process. It is slow or insignificant in first stage of labour but is pronounced during second
➢ stage of labour and descent is completed with the birth of the baby. In primigravida, with
➢ prior engagement of the head, practically no descent takes place in first stage of labour,
while in multiparae, descent stars with engagement. Head is expected to reach the pelvic
floor by the time the cervix is fully dilated. Descent is measured by abdominal palpation.
➢ Factors that facilitate descent are:
➢ uterine contractions and retraction.
➢ Bearing down efforts of the woman
➢ Straightening of the fetal avoid, specially after the rupture of membranes

c) Vaginal Examination
Effacement and dilatation of the cervix, descent flexion and rotation of the foetal head need to
be assessed.

d) Observation of Foetal Condition

The fetal condition during labour can be assessed by assessing the foetal heart rate pattern, status
of membranes and liquor and the pH of the foetal blood.

e) Observation of Signs of Distress

f) Use of Partograph
This is a graphic method of recording the salient features of labour. This is a tool for managing
labour only
The observation chart on the partograph are
Progress of Labour
• Latent and active phases of labour
• Cervical dilation
• Descent of foetal head
• Uterine contractions

The Fetal Condition

• heart rate Foetal
• Membranes, liquor
• Molding of the foetal skull bones fetal deceleration related to uterine contraction
• Passage of meconium stained amniotic fluid

Normal labour and nursing

Management
The maternal condition
• Pulse , blood pressure and temperature
• Urine: volume, protein and acetone
• Drugs and IV fluids
• Oxytocin regime.
The method of using the partograph will be discussed in practical.

General Care of Woman during First Stage of Labour

 Providing general care to a woman in labour is an essential function of the nurse. The care
to be given is:
• General Hygiene
• Fluid Oral
• Intravenous
• Nutrition
• Elimination Voiding
• Position and mobility
• Pain relief
• Psychological care
How to
Explanat Ppt
manage
6. 45 To MANAGEMENT OF SECOND STAGE OF LABOUR: ion cum the 2nd
mins enumerat The basic principles in the management of the woman in the second stage of labour are to prevent Discussi Stage of
. e second injury to the mother and the fetus. The duration of second stage varies. In multigravida it may on labour?
stage of last a little as 5 minutes. In primigravida, it may take two hours. This stage has two phases, that
labour is the latent phase and the latent phase is from the onset of labour until the cervix reaches 3 cm
dilatation, and the active phase is from 3cm dilatation to complete dilatation of the cervix, i,e,
10 cm.
Physiological Changes:
Knowledge about physiological processes will help the midwife in managing women in second
stage of labour. You will now see what the changes are.
I. Stronger and More Frequent Contractions:
The contractile power of the uterus is intensified because the fetus is closely applied to
the uterus, as some of the fluid has escaped. The upper uterine segment becomes short
and thick because of the retraction of uterine muscle fibers. During each contraction, its
farce is transmitted through the long axis of the fetus, directing it through the birth canal
This is known as the fetal axis pressure.
II. Expulsive Action of the Abdominal Muscles and Diaphragm:
The abdominal muscles and diaphragm contracts, known as bearing down or pushing
Initially it is reflex but can be side by voluntary effort with the distension of the pelvis
An by the pretender part, the expulsive action becomes involuntary.
III. Displacement of the Pelvic Floor:
The bladder is draw up into the abdomen, the vagina is dilated by the advancing head,
the Posterior of the pelvic floor is pushed downwards into the front of the presenting
part and the reaction 1s compressed by the advancing head. A further change that takes
place is out pouching of the anus, thinning out of the perineum lengthening of the
posterior wall of the birth canal.
IV. Expulsion of the Fetus:
The head is visible at the vulva. With each contraction it advances and recedes till
crowing takes place. The head is born by extension, after which the shoulders and body
is born, with the remaining amniotic fluid

Nursing Management of Women in Second Stage of Labour:

Recognition of the Commencement of the Second Stage of Labour by the Nursing

Personnel:
It is very important for the nursing personnel to recognize the commencement of the second
stage. You will be able to do it if you look for the following signs that show that the second
stage is approaching. There are many probable signs that indicate the transition from first to
second stage. There is only one positive sign. You will be able to understand this if you read the
following..
➢ Positive Signs:
• On vaginal examination
• No cervix is felt
➢ Probable signs:
• Expulsive uterine contraction. The woman has a strong inclination to bear down.
• Trickling of blood: It is due to mild laceration of the cervix that takes place when
it is stretched and laceration of the vaginal mucous when the head descends
down.
• Rupture of the membranes may take place.
• Pouting and gaping of the anus: This occurs when the head bas reached the pelvic
floor. When the anus apes and faces are expelled, the cervix is usually dilated
 • Tenseness between anus and coccyx: This can be assessed by applying pressure
with the sidle finger between the anus and the coccyx. This terseness is because
of the pressure exerted by the descending head on the rectum and pelvic floor.
• Congestion and gaping of the vulva.
• Presenting part appears. This is considered as the probable sign because in some
cases like footling breech presentation, the foot may appear, although the cervix
is not dilated completely are if excessive molding of head is present.
• A caput may appear
Observation: Maternal and Fetal Condition:
The factors that determine the safety of the second stage and must be carefully observed as
Uterine Contractions:
The strength, length and frequency of contractions should be assessed continuously, In
comparison to the first stage, it is stronger, the duration is longer (I minute), with a longer resting
place.
The Descent:
The progress is observed by noting the descent. It accelerates during the active phase. If there is
delay, a vaginal examination should be performed to note whether internal rotation of head us
take place to note the station of the presenting part and for presence of caput succedaneum.
Fetus Condition:
Observation of color of liquor amine (for meconium staining) Changes in fetal heart pattern.
Maternal Conditions:
Physical ability Coping ability Pulse rate every 15 minutes Blood pressure half hourly.
General Care of Woman:
Women in the second stage of labour will feel exhausted, and may not have the ability to care
for self. You a re will have to give best possible care to the woman and help her to cope with
this stage of labour. The care includes…
• Maternal comfort and hygiene.
• Sponge the face and neck of the mother with a wet towel.
• Provide ice-chips or sips of water.
• Apply moisturizing cream to lips to prevent dryness under skin.
Bladder Care:
Encourage to pass urine at the planning of the second stage if hasn't done it during the late test
stage.
Pain Relief:
Apply measures like massaging, encourage deep breathing, distraction, etc, to relieve pain
Psychological Care:
Reassure the woman. Encourage her to bear down only when instructed to
Pre-birth Considerations Maternal Position and Bearing down Effort:
Maternal position
You will have to give the woman an appropriate position, enable the birth process to be
completed smoothly. There are several factors that will affect the decision for adopting a specific
position, i.e., the maternal and fetal condition, the need for frequent monitoring the woman's
personal choice, the comment is it safe? Is privacy provided and the midwives confidence in her
skills to assist in the delivery process Some of the positions that Can be adopted are:
Semi-recumbent or supported sitting
This increase the efficiency of the uterine contractions and prevents hypotension and reduced
placental perfusion
Squatting, kneeling or standing
The squatting position increase the transverse diameter by 1 cm and the anteroposterior diameter
by 2 cm, thereby resulting in easy delivery. The kneeling and standing position also contributes
to easy delivery
Left lateral position
The midwife can view the perineum clearly. This position is useful for women who cannot
abduct their hips.
Bearing down Effort
The woman should be helped to avoid active pushing before the vertex is visible at the vulva.
This will allow the mother to conserve her effort and will permit the vaginal tissues to stretch
passively, Once the head becomes visible, the mother should be encouraged to follow her own
inclinations in relation to expulsive efforts
Conducting the Delivery (For more details, refer practical)
To avoid complications in the mother as well as the newborn, one must conduct the delivery
very skillfully. You will now team about the conduct of delivery in a vertex presentation. The
two phases of delivery of the fetus in a vertex presentation are
i. delivery of the head, and
ii. delivery of the shoulders and body
The principles to be kept in mind while conducting the delivery is to minimize maternal and
fetal trauma and ensure a safe delivery for the baby. Principle of asepsis must be maintained.
Delivery of the head (For details, refer practical)
The perineum is swabbed and the woman is draped with sterile towels. A pad le to cover the
anus. With each contraction the head descends and the superficial muscles of the pelvic floor
especially the transverse perineal muscles are visible. During the resting phase the head resident,
therein the muscle thins gradually. The midwife places her fingers on the advancing head to
monitor descent and prevent expulsive crowning. Once crowned, and episiotomy is given, the
head is born by extension. The baby's neck i checked for cord around it. If it is loose, it is passed
through the head, of it, it is cut
Delivery of the shoulders and the body
When external rotation of the head occurs, it shows that the shoulders we rotting internally into
the anteroposterior diameter of the pelvic outlet. While waiting for this to occur, mucus from
the baby's mouth and nostrils may be wiped with gauze swab. Placing the hand n each side of
the baby's head, over the ear, and applying downward traction the anterior shoulder is born. The
anterior shoulder slips below the symphysis pubis the head is then guided in an upward direction
towards the mother's abdomen so that the posterior shoulder can escape over the perineum As
soon as the baby is born the cord is cat, eyes are cleaned, airway is cleared and the Apgar.som
is noted
EPISIOTOMY:
It is an incision made into the died out perineal body to enlarge the vaginal orifice delivery
Types of Episiotomy
1. Median:
The incision begins in the centre of the fourchette and is directed posteriorly for
approximately 2.cms in the midline of the perineum
2. Medio-lateral:
The incision begins in the centre of the fourchette and is directed posteriorly, le
diagonally in a straight line 23 cm away from the , o duck position, if de is considered to
be at 6 o'clock position
3. J- Shaped:
he incision is made in the centre of the fourchette and directed posteriorly in the midline
about 2 cm and then directed towards 7 o'clock position
4. Lateral
 The incision is begum one or more cm distant from the centre of the fourchette
Indications
Maternal: Rigid perineum disproportion between fetus and vaginal orifice
Fetus: Card plans in second stage, preterm baby.
Others: For vaginal or intrauterine manipulation, et forceps and brooch delivery
Advantages:
• Reduction of fetus hypoxia and acidosis
• Reduction in overstretching of the perineum
• Bruising of urethra is avoided
• Reduction in bearing down effort in conditions like preeclampsia and candies
desires
• Prevention of third degree tear, in case of presence of scar tissue, which does not
stretch well.
Perineal Lacerations:
Perineal laceration usually occurs as the head is being born. The perineum elongates thins out
and is liable to tear. The extent of the laceration is defined on the basis of the depth
First degree:
Laceration extends through the skin and structures superficial to muscles the fourchette only is
tom.
Second degree:
Laceration extends through muscles of perineal body, it is beyond the
Fourchette, but does not involve rectum or anus
Third degree:
Laceration continues the anal sphincter muscle
Fourth degree:
Laceration also involves the anterior rectal wall
Signs that the perineum is liable to tear:
Perineum does not stretch resists the pressure of the descending head A long perineum; appears
edematous Trickling of blood from the vagina (due to laceration of the vaginal mucus on the
inner surface) when the head is on the perineum. Bluish appearance in the midline of the
perineum, which later becomes white, shiny and transparent.
Prevention of Perineal Tears
How can you prevent perineal tears?
 • Principle of management of the second stage of labour should be that the smallest
possible diameter of the head and shoulders should be permitted to emerge and distend
the vulva.
• Encourage women to take deliberate breathes through her mouth without accentuating
expiration This inhibits the desire to our when the head is distending the perineum.
• Midwife to have control of the advancing head, by placing finger tips on er near the head
to restrain it.
• Maintain flexion and controlling rapid Extension of the head in vertex presentation
• Preventive son before cowing, prevent incipit from gliding over the perineum until the
occipital prominence and if possible the parent eminence have been born
• Keep hands off the perineum: Pressure of the fingers on the perineum further thin the
perineum and causes bruising which favors tearing
• Deliver the head at the end of or between contractions.
• Allow the women to be the head out
• While delivering the shoulders ensure that they have. rotated internally, df not they will
route white passing through the vulva, causing strain on the perineum
Immediate Care of the New born:
Cure immediately after birth focuses on assessing and stabilizing the new born. You must be
vigilant. If there are any sign of distress, appropriate interventions need to be implemented
A brief physical examination of the new born in performed immediately after birth.
a. Clear their pare:
As soon as the head is born, suction the oral pharynx with a small bulge mucus extractor
is used, direct it over the dorsum of the tongue into the pharynx not more than 5 cm
tubing being inside.
• Suction
• Avoid deep suctioning with catheter
• Hold baby with head lowered (10 to 15 degrees)
• Avoid holding baby by ankles upside down.
b. Clamping and cutting of cord:
• Immediately after birth, place the neonate at the same level as uterus till the
endless stopped pulsating or the
• cord is clamped
 • If neonate appears normal and mature, clamp cord close to the umbilicus,
approximately 30 seconds after birth
• without stripping' or 'milking it
• Ligature cord, 2.5 cm from the umbilicus and place the second ligature 5 cm on
the outer side, if there is a need for exchange transfusion, place ligature not closer
than 4 cm from umbilicus
• Examine the cord, for two arteries and one vein.
c. Apgar score:
Appraise neonate at one minute and again at five minutes using Apgar scoring method.
d. Care of the eyes:
Prophylactic agents are to be instilled in the eyes as per institutional policy
e. Attachment and warmth (Bonding):
If immediate intervention is not required, dry the infant and place on mother's abdomen,
covering both. The body may be covered in warm blanket first or in some cases, the baby
is placed on the mother's abdomen, soon after birth, having skin-to skin contact Allow
mother to caress and cuddle the baby and talk in a soothing tone of voice. Caution parents
to keep the new born's head covered. Encourage mother to feed the baby as soon as
possible.
Apgar Scoring:
This is a means of standardizing the method of evaluating and recording the conditions of the
baby, in numerical terms at one minute after birth and if necessary at 5 minutes. Five vital signs
are each given a score of 0, 1 or 2 points, i.e. colour, respiratory effort, heart beat, muscle tone,
reflex response. Heart beat is the most important observation. "High risk pregnancy and labour
potentiates the incidence of a low Apgar score.

7. 30 To MANAGEMENT OF THIRD STAGE OF LABOUR: Explanat Ppt Which

mins describe The third stage of labour is that of separation and expulsion of the placenta and membrane. It ion cum are the
. about the lasts from the birth of the baby until the placenta is expelled. You will now learn about the Discussi changes
third physiological changes that take place in this stage of labour. on are
stage of Physiological Changes happen
labour The physiological changes that take place during this stage, comprises two phases, i.e. in the 3rd
i) The phase of placental separation and ii) the mechanism of placental expulsion. The control stage of
of bleeding also takes place during this period. It will be discussed here. labour?
Mechanism of Placental Separation
During this phase, the placenta separates from the uterine wall and descends. There are some
signs which enables one to know that it has taken place. The uterine wall contracts and retracts.
The upper uterine segment thickens and its capacity reduces. The area of the placental site is
diminished; the cotyledons of the placenta becomes compact. Separation begins in the centre or
the lower edge of the placenta, at the level of the deep spongy level or the decidua. The process
is like the detachment of postage stamps at the perforation between them. The blood sinuses are
for; a retroplacental clot is formed; the placenta gets detached from the uterus; descends from
the lower upper uterine segment into the uterine segment. With the traction, the membranes are
peeled off the deciduas
Signs of Placental Separation
• The uterus becomes globular and contracts firmly
• The uterus rises upward in the abdomen. Changes from discoid to a globular ovoid shape
• The umbilical cord descends 3 inches or more further out of the vagina
• A sudden gush of dark blood from the introitus.

Control of Bleeding
The uterine fibres contracts and retracts as the contraction and retraction of the uterus takes
place. They are arranged in three layers, i.e. the outer longitudinal, inner circular and the
intermediate, which is the thickest and strongest layer arranged in criss-cross fashion through
which the blood vessels run. When the uterus contracts, the blood vessels running through the
fibres are occluded, thus controlling haemorrhage. They are also called 'living ligatures
Nature's Method of Expulsion of Placenta
Nature has two methods of expelling the placenta, described as Schultze and Mathews Duncan.

The Schulze Method

Is common; occurs in 80% of cases
• Placenta slips into the vagina through the hole in the amniotic sac, like and inverted
umbrella.
• Foetal surface appears at the vulva.
 • Placental surface is not seen.
• Blood clot is inside the inverted sac

The Mathews Duncan Method

Occurs in about 20% of deliveries
• Placenta slides down sideways and comes through the vulva with the lateral border first.
This is like button slipping through a button -hole. The maternal surface is seen and
blood escapes.

Nursing Management of Third Stage of Labour

Position of the Woman
This will vary according to the mother's personal choice, normality of progress and experience
of the midwife and the need for monitoring the uterine contractions and blood loss. The positions
are described below:
Dorsal position: It enables the mother to cuddle her baby and allow easy palpation of the uterus
fundus. The disadvantage is that blood will pool in the vagina.
Upright/kneeling/squatting position: These positions may be used when the third stage is to
be managed passively, but contraindicated following an epidural block. It is of advantage
because it will hasten expulsion of the placenta due to gravity and increased intra-abdominal
pressure; aids in observation of blood loss. However, the mother will need support to cuddle her
baby.
Observation
You will now learn about the observations to be made in the mother during this stage of labour.
The maternal status needs to be observed. The following observations need to be made by the
nurse.

B.P. and Pulse

Blood pressure should be checked periodically. The systolic should be over 110 mm Hg. The
pulse is the best guide to the loss of blood. A pulse rate over 90/mt and rising with pallor indicate
haemorrhage.
Consistency of the Uterus
The uterus must have the consistency of a firm tennis ball and its shape must be broader laterally
than antero-posteriorly. It will feel like a cricket ball when a contraction occurs and between
contraction its firm distinct outline should be clearly defined.
Size of the Uterus
After the birth of the baby, the fundus is 2.5 cm above the umbilicus. If it is more than this one
should suspect that there is another baby, the placenta is unduly large, blood clots are present in
the uterus, or the bladder is full.
Amount of the Blood Loss
The vulva is to be observed for loss of blood. Average amount of blood loss is 120 mi to 240
ml. At times blood loss may not be visible, because clots may form. An increasing pulse rate is
indicative of blood loss.
• Level of consciousness
• Respiration: Rate and rhythm

Delivery of Placenta and Membranes (Refer Practical Manual also)

This is done either by active management or by passive physiological management. You will
now learn about this management.
Active Management by Controlled Cord Traction
Delivering the placenta by controlled cord traction following the administration or
syntometrine 1 ml, at the appearance of the anterior shoulder or after the birth of the head
shortens the third stage of labour and reduces blood loss.
Timing of Controlled Cord Traction
After the birth of the baby, usually the placenta should be delivered with the first uterine
contraction within 4-5 minutes.
Method of Controlled Cord Traction
• Wait for a strong uterine contraction when it is palpably contracting. Place palm of
the left hand on the lower abdomen, at the symphysis pubis.
• With the palmer surface, apply counter traction, i.e. biace back the upper uterine
segment, the fingers stretching the lower uterine segment, upwards towards the
umbilicus to prevent inversion of the uterus.
• With the right hand, grasp the cord.
 • Apply traction on the cord in a downward and backward direction, following the line
of the birth canal.
• Avoid jerky movements and force.
• Some resistance is felt, but it is important to apply steady tension by pulling the cord
firmly and maintaining the pressure.
• If the uterus relaxes, stop traction temporarily. First release the downward traction
on the uterus and then the counter traction.
• Then start the same procedure again.
• once the placenta is visible, cup it in the hand to ease pressure on the membranes.
• Apply gentle upward and downward movement, or twist the placenta. This helps in
delivering the membranes intact.

Passive Physiological Management

Before making an attempt to expel the placenta, you ensure that the placenta has
separated and is lying in the lower uterine segment.
There are two ways of passively delivering the placenta and membranes. They are :
✓ fundal pressure
✓ bearing down by the woman

Fundal Pressure
The firmly contracted fundus of the uterus is used as a piston to push out the placenta Method
✓ Ask the woman to open her mouth and breathe through it slowly and quietly.
This helps in relaxation of the muscles.
✓ 240 ml. At times blood loss may not be visible, because clots may form. An
increasing pulse rate is indicative of blood loss.
✓ Level of consciousness
✓ Respiration: Rate and rhythm

Delivery of Placenta and Membranes (Refer Practical Manual also)

This is done either by active management or by passive physiological management. You
will now learn about this management.
 Active Management by Controlled Cord Traction
Delivering the placenta by controlled cord traction following the administration or
syntometrine 1 ml, at the appearance of the anterior shoulder or after the birth of the head
shortens the third stage of labour and reduces blood loss.
Timing of Controlled Cord Traction
After the birth of the baby, usually the placenta should be delivered with the first uterine
contraction within 4-5 minutes.
Method of Controlled Cord Traction
✓ Wait for a strong uterine contraction when it is palpably contracting. Place palm
of the left hand on the lower abdomen, at the symphysis pubis.
✓ With the palmer surface, apply counter traction, i.e. biace back the upper uterine
segment, the fingers stretching the lower uterine segment, upwards towards the
umbilicus to prevent inversion of the uterus.
✓ With the right hand, grasp the cord.
✓ Apply traction on the cord in a downward and backward direction, following the
line of the birth canal.
✓ Avoid jerky movements and force.
✓ Some resistance is felt, but it is important to apply steady tension by pulling the
cord firmly and maintaining the pressure.
✓ If the uterus relaxes, stop traction temporarily. First release the downward
traction on the uterus and then the counter traction.
✓ Then start the same procedure again.
✓ once the placenta is visible, cup it in the hand to ease pressure on the membranes.
✓ Apply gentle upward and downward movement, or twist the placenta. This helps
in delivering the membranes intact.

Passive Physiological Management

Before making an attempt to expel the placenta, you ensure that the placenta has separated and
is lying in the lower uterine segment.
There are two ways of passively delivering the placenta and membranes. They are :
✓ fundal pressure
 ✓ bearing down by the woman

Fundal Pressure
The firmly contracted fundus of the uterus is used as a piston to push out the placenta. Method
❖ Ask the woman to open her mouth and breathe through it slowly and quietly.
This helps in relaxation of the muscles.
❖ Initiate breast feeding as early as possible.
❖ Observe general skin colour , respiration and temperature

The
8. 30 To MANAGEMENT OF FOURTH STAGE OF LABOUR: Explanat Ppt stage of
mins explain The fourth stage of labour, the stage of recovery, is a critical period for the mother and the ion cum recovery
. the new born, because they are recovering from the physical process of birth end are initiating new Discussi that the
fourth relationships, careful management of this stage is essential to promote the best possible out come on 4th stage
stage of for the mother and baby. The management includes observation and care of the mother and the of
manage baby as given in table. labour.
ment. Observation and Care
• Vital signs (pulse, respiration, BP, Temperature
• Uterus (uterine tone, fundal position and height)
• Bladder
• Lochia
• Perineum

General Instructions for Care

➢ A brief physical assessment of the neonate will include:
- External Inspection for skin colour; staining creases on soles palm and feet, nasal
potency meconium staining of curd, skin, finger nails.
- Chest Auscultation for rate and quality of heart beat, murmurs; for rales or
rhonchi.
- Abdomen Inspection for anomalies and umbilical cord condition. Neurological
Checks muscle tone, reflex action, moros reflex; palpation fontanelle; notes,
presence and size of sutures and fontanelles.
 ➢ others Weight, length, head circumference and gestational age. Gross structural
malformations.

While caring for the mother you need to follow the following principles
Prevention of Haemorrhage
Palpate uterus at frequent intervals, check pads, observe for haemotoma under the vaginal
mucous.
Careful monitoring of the perineum and blood loss, maintenance of intravenous fluids, if
prescribed, monitoring vital signs are important.

Prevention of Bladder Distension

Palpate to determine bladder distension. Encourage the woman to void naturally; use nursing
measures : placing a bed pan, pour warm water over the perineum, help to walk to the bathroom.
Maintenance of Safety
Ambulate woman only after considering baseline BP, amount of blood loss, type and amount
of analgesic or anesthetic medications, administered during labour, amount of pain and desire
of women to ambulate.
Assist in ambulation; observe for orthostatic hypotension.

Maintenance of Comfort
The woman may have uterine contractions, which may result in discomfort known as after pain.
This can be taken care of by helping the woman to keep her urinary bladder empty, placing a
warm blanket on the woman's abdomen, administering analgesics that are ordered, encouraging
relaxation and breathing exercises.
Maintenance of Cleanliness
The perineum is cleaned, the buttocks are dried and a clean perineal pad is placed. She is
instructed to wash hands and then cleanse the vulval area
Maintenance of Fluid Balance and Nutrition
The woman is encouraged to take small amounts of fluid, as large amounts can lead to nausea
and possibly vomiting. If the woman has severe bleeding, nothing is given by mouth and
intravenous fluids containing dextrose is given. If the woman tolerates oral fluids, the type,
amount and tolerance is noted.
Psychosocial Needs
 The nurse reassures the mother that her behaviour during the delivery was normal. Some
women may want to rest, because of the exhaustion during labour. The nurse assists in the
bonding process by:
• encouraging the parents to hold the new born face
• encouraging skin contact
• assisting the woman to breast feed the baby
Summary:
Today we discuss about:
• Introduce about the maternal and child mortality and morbidity ratio
• The various programmes running in india.
• The stages of labour
• Causes of onset of labour
• The first stage of labour.
• The second stage of labour.
• The third stage of labour.
• The fourth stage of management.

Conclusion:
The various programmes are running in india for the promotion of the maternal and child health
like reproductive and child health programmes, national health mission, The Janani surkasha
yojana scheme. The four stages of labour and its management.
 Bibliography

1. Annama Jacob “A TEXTBOOK OF MIDWIFERY AND OBSTETRICS FOR

NURSING” reprinted 2011,published by Elsevier.
2. Basvanthapa B T; “COMMUNITY HEALTH NURSING”;1st edition, New Delhi, Jaypee
Brothers publications, 1998.
3. D.C Dutta’s “ TEXT BOOK OF OBSTETRICS” hiralal konarkar, 8th edition, jaypee
brothers medical publisher Ltd, enlarged revised reprint of 7th edition, 2013.
4. Kamini rao “ A TEXTBOOK OF MIDWIFERY AND OBSTETRICS FOR NURSING”,
repainted 2011, published by Elsevier.
5. K.K. Gulani, “COMMUNITY HEALTH NURSING”,2nd edition, kumar publishing house,
2013.
6. Myle’s “TEXT BOOK FOR MIDWIVES”, 5th edition, 1953 reprinted 2009-2010.
7. www.google.com
8. www.youtube.com
9. www.wikipedia.com
10. www.pubmed.com