Prepared by: Angeli Joy V.

Monton

SKILLS BUILDING
MATERNAL AND
CHILD CARE
Labor
 Series of physiologic and mechanical
processes by which all products of
conception (fetus, placenta and embryonic
sac) are expelled from the birth canal.

 Preterm labor – before 37 weeks

 Full term labor – between 37 and 41
weeks
 Post term labor – above 42 weeks
Premonitory Signs of Labor
 Lightening
The descent/ settling/ “dropping” of the
presenting part into the pelvic inlet
Happens 10 to 14 days before labor in
primigravida
Occurs one day before or on the day of
labor in multipara
Other signs brought about by Lightening

○ Relief of dyspnea
○ Relief of abdominal tightness
○ Increased frequency of voiding
○ Increased varicosities and pedal edema
○ Shooting pains down the legs / leg cramps
Engagement

○ The largest diameter of the presenting part

passes the pelvic inlet or pelvic brim
b. Increased Braxton Hick’s
contractions 3 to 4 weeks before labor

 Braxton Hick’s contractions – false labor

contractions confined to the abdomen and
are painless, irregular and relieved by
walking.
 May disturb, annoy and confuse the woman
but they do not cause cervical dilatation
 For relief of discomfort, encourage the
woman to walk
Increased maternal activity
Due to epinephrine, there is sudden
burst of maternal energy before labor

Nesting behavior is a psychosocial sign

of approaching labor

Advise woman to have moderation in

activity and conserve energy for the labor
b. Slight decrease in maternal weight

 2 to 3 pound weight loss due to drop in

blood level of the water retaining hormone
progesterone
e. Bloody show
Blood tinged secretions which is a
mixture of the cervical mucus plug
and small amount of blood from torn
capillaries of the cervix, which gives it
a pink tint.
Occurs a few hours to a few days before
onset of the labor
○ Show is not bleeding and if bleeding is
present, no matter how slight, is a danger sign
that needs immediate reporting
f. Softening / “ripening” of the cervix
 Cervical dilatation – cervix being stretched
beyond the normal dimensions
 Cervical effacement – shortening the cervix and
thinning of cervical walls

 Cervical consistencies
 As soft as the nose tip: non pregnant cervix
 As soft as the ear lobe: pregnant cervix
(Goodell’s sign)
 As soft as whipped butter: cervix ripe for labor
g. Rupture of bag of water (BOW)
 Preterm rupture of the BOW (PROM) – when
the bag ruptures before 37 weeks gestation
 Premature rupture of the BOW (PROM) –
when the bag ruptures before labor
 Early rupture of the BOW (EROM) – when the
bag ruptures during the early first stage of
labor, usually before the active phase
The most common time for the BOW to rupture is
the early second stage of labor, when the cervix is
fully dilated.
 The spontaneous rupture of the BOW is
always an indication for hospitalization.
First action after the rupture of the BOW
is to check the fetal heart tones.
h. GI disturbances
 Nausea
 Heartburn
Station
 refers to the descent of the fetal
presenting part through the maternal
pelvis
 Measurement of station is in centimeters
relative to the level of the maternal
ischial spines
Station
0 station:
level of ischial
spines
-1, -2, -3:
above the
ischial spines
+1, +2, +3:
below the
ischial spines to
the perineum
Monitoring Uterine Contractions
 Uterine contractions
 involuntary, rhythmical, intermittent, regular
and painful
Upper uterine segment contracts, retracts
and expels the fetus while the lower uterine
segment and the cervix dilate and thereby
form a greatly expanded, thinned – out
muscular and fibromuscular tube
Phases of uterine contraction
 Increment – building up of contractions
and is the longest phase
 Acme – peak of contraction and most
painful period
 Decrement – period of letting up or
decreasing contraction
Characteristics of uterine contractions
1. Duration – length of time a contraction lasts;
the time from the start of increment of one
contraction to the end of decrement; duration
is expressed in seconds
2. Frequency – time interval between the start of
one contraction to the start of the next
contraction; frequency is expressed in “every
_____ minutes”
Characteristics of uterine contractions

3. Interval or resting period – denotes the time

from the end of one contraction to the start of
the next contraction; it is expressed in minutes.
the interval of contractions is the best time to
1. Auscultate the FHT
2. Check maternal blood pressure
3. Deliver the fetal head in extension

4. Intensity – refers to the strength of a

contraction at acme usually estimated by
palpating the contraction; identified as mild,
moderate or strong
Stages of labor
First stage
Latent Active Transition

Duration 15 – 30 30 – 45 45 – 90
seconds seconds seconds
average of 60
seconds
Frequency Every 5- 8 Every 3 – 5 Every 2 – 3
minutes minutes minutes
Intensity Mild Moderate Strong

Cervical cervix 0 – 3 cm cervix 4 -7 cm cervix 8 – 10

Dilation cm
Latent phase of labor lasts

 Primigravida: up to 20 hours
 Multiparas: up to 14 hours
Second stage of Labor
 Contractions are strong, occurring every
2 to 3 minutes and lasting for 60 to 90
seconds

 Full dilatation signifies the beginning of

delivery, the mother bears down to help
expel the baby
Third stage of Labor
 Concerned with the expulsion of the
placenta once the baby is delivered
 The placenta becomes detached from
the uterine wall and is expelled normally
within a few minutes
Induction of labor
 Amniotomy – rupturing of the amniotic
membrane – unless the membranes have
ruptured prematurely – by passing a long,
sharp – tipped instrument in through the
vagina and cervix to nick the amniotic
membrane, releasing fluid.
 It is painless and sometimes sufficient to set
labor in motion.
Oxytocin
 Oxytocin is a naturally occurring
hormone available in synthetic form
given through small controlled doses by
intravenous infusion in order to promote
healthy contractions leading to normal
spontaneous delivery.
Oxytocin
 Possible complications with the use of
oxytocin therapy include overstimulation
that can lead to respiratory distress in
the baby or uterine rupture; water
intoxication in the mother due to fluid
retaining effect; and increased likelihood
of jaundice in the baby.
Perineal cleansing before delivery
 Also called “perineal prep” or “sterile prep”

 Done primarily to prevent infection and

secondarily to increase the visibility of the
area by removing bloody discharge that is
present prior to delivery

 In lithotomy position, the health care provider

cleanses the vulva and perineal areas
observing strict aseptic techniques
 Shaving is no longer recommended and
universally accepted, as it predisposes
the woman more skin injuries and
potential infections
Internal / Vaginal Examination
 Refers to the feeling the inside of the vagina using
examining fingers
 Purposes
During the first clinic visit, the physician performs IE to confirm
pregnancy and gestation
Determines cervical dilatation and presentation of the baby
during labor
Provides information that will guide you in the management of
the woman in labor
Evaluates the adequacy of the pelvic canal
Rules out prolapsed cord
Confirms malpresentation
To know progress of labor
○ The midwife can perform IE only during labor.
Maternal pushing in Labor
 Maternal pushing or “bearing down”, is
an involuntary response, a reflex
stimulated by the increasing pressure of
the presenting part on the stretch
receptors of the pelvic floor muscles
Positions for labor
 Dorsal recumbent - on the back with
knees up and separated
 Lateral – lying on the side with knees
towards the chest
 Lithotomy – on the back with legs
supported in stirrups
 Semiupright
 Upright – squatting and tailor sitting
 At the start of contraction, the woman takes
a deep breath and blows it all out, takes a
second breath and holds as she closes her
mouth, puts her chin on her chest and bears
down.
 When helping a woman to push, the nurse
or midwife encourages her to push as she
feels like straining a stool
 When the woman runs out of air before
contraction ends, she should take another
deep breath and continue pushing
 Short pushes are ineffective and prolonged
pushing, in which a woman is holding her breath
for more than 5 to 6 seconds, is not
recommended.
 Holding breath for more than 5 to 6 seconds can
result in
Valsalva maneuver – hazardous for mother with cardiac
problems
Diminished feto – placental gas exchange
Diminished perfusion of oxygen across placenta
 A woman in labor should push in the second
stage of labor or from the moment the cervix is
fully dilated (10 cm)
 The woman should not push during the first
stage of labor as this can result in the
following:
Greater maternal fatigue
Added fetal strain
Possible injury to the fetal presenting part – caput
succedaneum
Possible injury to the cervix
Cervical edema due to chronic passive congestion
which can further delay cervical dilatation and may
predispose to cervical laceration
Cervical bruising or trauma
 The woman should also not push at intervals of
contraction because this can result to added maternal
fatigue, added fetal strain and overstretching of the
transverse cervical uterine ligaments, which can
predispose to uterine prolapse
 The woman should not push during crowning – the
encirclement of the widest diameter of the fetal head by
the vulvar ring – because it causes sudden extension of
the fetal head, a factor to perineal lacerations. Instead of
pushing in this stage, the mother is encouraged to pant
or exhale slowly through pursed lips, simulating candle
blowing
 When a woman in labor has cardiac problems, pushing
is also not encouraged to avoid further strain to the
diseased heart.
Seven Cardinal movements of labor
1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. External rotation
7. Expulsion
 Ritgen’s Maneuver
 Insertion of a hand
and application of
upward pressure on
the fetal chin and as
the other hand applies
gentle downward
pressure on the fetal
occiput to allow
controlled delivery of
the fetal head.
Perineal lacerations
 Are injuries in the soft tissues of the birth
canal occurring during the delivery of the
baby.
 Caused by the propulsive effects of
uterine contractions that can lead to
postpartal hemorrhage, the leading
cause of maternal mortality
 The areas commonly affected are the
fourchette, perineum, posterior vaginal
walls and anteriorly, the area near the
clitoris
 If not properly repaired, perineal
lacerations can lead to chronic perineal
pain, painful sexual intercourse and
fecal and urinary incontinence.
 Perineal lacerations are most likely to
happen in the following conditions
○ Face presentation
○ Precipitate labor – labor is very fast (about
an hour only)
○ Rapid breech extraction – increased
degree of forceful distention of the
perinuem
○ Large baby – greater distention of the
perineum
Degree of Perineal Lacerations
 First degree – involves fourchette, perineal skin and
vaginal mucuous membrane

 Second degree - involves fourchette, perineal skin,

vaginal mucuous membrane including the fascia and
muscles of the perineal body

 Third degree – involves damage to the above mentioned

parts and anal sphincter

 Fourth degree – involves massive trauma which extends

into the rectal mucosa exposing the lumen of the rectum
Episiotomy
 Incision made with surgical scissors in the
perineum during childbirth to widen the
opening of the birth outlet and prevent
perineal tearing
 It may be necessary, especially for a
mother delivering the first baby done at the
second stage of labor, usually at the height
of contraction, as the largest part of the
baby’s head begins to emerge from the
birth canal
Benefits of Episiotomy
 prevention of tearing which is painful and takes
much longer to repair than straightforward
incision.
 minimize the pressure of the baby’s head on
pelvic structures, such as the bladder and
urethra, and reducing the risk of damage to
them.
 helps decrease the likelihood of permanent
injury to the tissues of the pelvic floor and
reduces the chances of eventually developing a
cystocele or rectocele.
Disadvantages of Episiotomy
 The mother is more likely to acquire an
infection
 More painful post partum healing
Episiorrhaphy – repair of episiotomy
Basic instruments and supplies
 1 Needle holder
 1 Tissue forceps
 1 pair of suturing scissors
 Hemostats / allis clamps
 Suture materials with
needle
 2 pairs of correctly – sized  Chromic catgut (2-0 and 3-
sterile gloves 0) – material of choice for
 Sterile drapes many years
 1 disposable 10 ml syringe  Polyglycolic derivatives
with needle, 22 gauge,1 ½  Round needle for soft
- inch (3 cm) needle tissues
 Cutting needle – for tougher
 1 % lidocaine
tissues like skin or fascia
 Gauze sponges  Adequate lighting (drop
 Irrigation solution light or flash light)
TPH – DR instruments
Primigravida  Chromic 2 – 0
 1 Needle holder Multigravida
 1 surgical scissors /  1 surgical scissors /
mayo mayo
 2 kelly (Straight or  2 kelly (Scissors or
curved) curved)
 1 tissue forceps  Cotton balls with
 1 3cc syringe betadine
 Cotton balls with  Sterile gauze / OS
betadine
 Sterile gauze / OS
 Lidocaine
Principles of repair
 Adequate hemostasis – identify and
apply pressure on small bleeding areas
 Anatomic restoration – put together the
anatomic structures that have been
injured (muscle to muscle, skin to skin)
 Minimum suture materials
 Asepsis
Providing Local Anesthesia
 Lidocaine is used to numb sensation on
the site of repair
Care of the wound
 Antibiotics and pain relievers are given post
partum in anticipation of infection and pain.
 Inspection of wound is advised
 Povidone – iodine swab on the area of the wound
before and after repair may also help prevent
infection.
 Application of ice cap over the area of repair may
also give significant amount of comfort.
 Advise the patient to take plenty of oral fluids and
increase bulk in the diet to prevent constipation
 Perilight
Complications of Wound Repair and
Management
 Wound infection
 Hematoma – collection of blood into
surrounding tissues following injury to
blood vessels. Small hematomas of
up to 3 cm needs observation only
Apply ice pack (cold compress) on area
Prevent infection
Observe closely
Stages of Placental delivery
 Separation of the placenta from the
uterine wall
 Expulsion from the vagina
Signs of placental separation
 Uterus becomes firm and globular
 Sudden gush of blood from the vagina
 Umbilical cord length
 Uterine fundus rises in the abdomen
Placenta
 Formed by the union of chorionic villi
and deciduas basalis
 Discoid in shape, average weight is 500
gm at term
 Parts
Maternal side – rough, reddish with
cotyledons and with chorion
Fetal side – smooth, shiny, bluish with blood
vessels and with membrane nearest to it
 Umbilical cord
 Length – 55 cm at term
 Parts
1 vein – carries oxygenated blood to
the fetus
2 arteries – carry deoxygenated
blood from the fetus to placenta
Wharton’s jelly – gelatinous
substance
 The cord extends from the fetal
surface of the placenta to the fetal
umbilicus
Amniotic fluid
 500 to 1000 ml at term
Polyhydramnios – excessive amount of
amniotic fluid greater than 1,000 – 1500 ml
Oligohydramnios – amount less than 300 – 500
ml
 pH is neutral to alkaline (7-7.25)
 abnormal colors – green tinged in a non –
breech presentation is a sign of fetal
distress; golden color fluid may be found in
hemolytic disease