The Labor Phenomena

Labor and Delivery

• Also known as parturition, childbirth, birthing
• Is the process by which the fetus and the
placenta are expelled from the uterus and the
vagina into the external environment
• A parturient is a woman in labor
• Toco- and toko- (Gr) are combining forms
meaning childbirth
• Eutocia – normal labor
• Dystocia – difficult labor
• The trigger that converts the random,
painless Braxton-Hicks contraction, into
strong coordinated labor contractions is
unknown
• Normally labor begins when the fetus is
sufficiently mature, yet not too large to cause
difficulties in delivery
• In some instances labor begins before the
fetus is mature (premature birth); in others
labor is delayed (postmature birth). It is
unknown why this occurs
 THE LABOR PHENOMENA
Theories proposed why Labor begins:

1. Uterine Stretch Theory. Any hollow body organ when

stretched to capacity will necessarily contract and empty
because of pressure on nerve endings and increased
irritability of the uterine musculature.
2. Oxytocin Stimulation Theory . Because labor is
considered a stressful event, the hypophysis is
stimulated to initiate production of oxytocin by the
posterior pituitary gland. Oxytocin is known to stimulate
uterine contractions.
3. Progesterone Deprivation Theory. Progesterone is
believed to inhibit uterine motility. A decrease in the
amount of the hormone, therefore, results in uterine
contractions.
4. Prostaglandin Theory. The relative progesterone
deprivation and estrogen predominance set off
production of cortical steroids which act on lipid
precursors to release arachidonic acid and, in turn,
increase the synthesis of prostaglandins.
5. Theory of Aging Placenta. The decrease of nutrients and
blood supply in the aging placenta causes uterine
contractions. (By 260 days the placenta began to age; life
span of placenta is 42 weeks. At 36 weeks, degenerates
leading to contraction-onset of labor)
 Factors affecting Labor &
Delivery (5 P’s)
1. Passenger
2. Passageway
3. Power
4. Person (Psyche)
5. Placenta
 1. Passenger
• The passage of the fetus through the birth
canal is influenced by:
-size of the fetal head and shoulder
-dimensions of the pelvic girdle
-fetal presentation
-fetal position
• Fetal head – is the largest presenting part –
common presenting part – ¼ of its length
• Bones – 6 bones
S – sphenoid P – parietal 2x
F – frontal-sinciput T – temporal
E – ethmoid O–
occipital/occiput
Measurement of fetal head:
1. Transverse diameter – 9.25 cm
-biparietal –largest transverse
2. Bimastoid 7 cm – smallest transverse
SUTURES – intermembranous spaces that allow moulding
2. Sagittal suture – connects 2 parietal bones (sagitna)
3. Coronal suture – connect parietal & frontal bone (crown)
4. Lambdoidal suture – connects occipital & parietal bones
MOLDINGS – the overlapping of the sutures of the skull to permit
passage of fetal head during delivery
Fontanels:
1. Anterior fontanel – bregma, diamond shape,
3x4 cm (> 5 cm-hydrocephalus) 12-18 mos.
After birth, close
2. Posterior fontanel or lambda (vertex) –
triangular shape; 1x1 cm; 2-3 months, close
Anteroposterior diameter
suboccipitobregmatic, 9.5 cm, complete flexion,
smallest AP
occipitofrontal 12 cm, partial flexion
occipitomental 13.5 cm hyperextension
submentobregmatic – face presentation
 Shapes of Pelvis
1. Gynecoid – round shape
2. Android – describe as male pelvis; heart shape
3. Anthropoid – apelike pelvis; diamond shape;
narrowed transverse diameter
4. Platypelloid – widen transverse; narrow antero-
posterior; flat in front & back; oval shape/pear
shape
Fetal lie – relationship
of the long axis of the
fetus to the long axis
of the mother
►if the two are parallel,
then the fetus is said
to be longitudinal lie
►if the two are at 90
degree angle to each
other, the fetus is said
to be in transverse lie
 PASSAGES
PELVIS = 4 BONES Linea Terminalis –
2 hip bones (innominate) imaginary line that
1 sacrum; 1 coccyx separates the false &
Pelvic brim – False pelvis; true pelvis
supports the uterus
True pelvis – lower part of the
pelvis
Pelvic Inlet- where the baby passes first
a. Diagonal conjugate – posterior border of
the pubis – anterior portion of sacral
promontory. Ave. 12.5 – 13 cm
a. Conjugate vera (true) – anterior border of
the pubis – anterior portion of sacral
promontory. 11.0 cm. Can be measured
only thru radiographic films
b. Obstetric conjugate – shortest. Estimating
by subtracting 1.5 to 2 cm ˂ the diagonal
conjugate. Measures 10 cm or more
Ex.: DC = 12.5 cm – 1.5 = 11 cm
Transverse diameter – line between the
points farthest from the ileopectineal line
- 13 cm.
Pelvic Outlet
-antero posterior – lower border of the
symphysis pubis to the sacro coccygeal
points. Diameter: 13 cm
-transverse diameter – between the 2 ischial
spines. Diameter: 10-11 cm.
- Narrower diameter is much important than
the wider diameter
PREMONITORY / PRELIMINARY / PRODROMAL SIGNS OF
LABOR
1. Lightening. This is defined as the settling of the fetal
head into the pelvic brim which occurs 2-3 weeks before
labor onset. Lightening causes relief of abdominal
tightness and diaphragmatic pressure so that respiration
becomes easier.

– Lightening should not be confused with engagement,

since engagement is defined as that point when the
biparietal diameter of the fetal head has passed the
pelvic inlet.
2. Loss of weight. There is loss of weight of about 2-3
lbs. one to two days before labor onset, due to loss
of appetite and decrease in progesterone level.
Progesterone is known to cause fluid retention. Its
decrease, therefore is known to cause fluid
excretion, thus causing loss of weight.

3. Increase level of activity (“nesting behavior”). The

sudden burst of energy is believed to be due to
increase in epinephrine in response to the stress
brought about by the approaching delivery. The
pregnant woman should be cautioned not to use this
energy to carry out household chores because it is
meant to prepare the body for the “labor” ahead.
4. Braxton Hicks Contraction – these are painless,
irregular ad intermittent uterine contractions are also
known as practice contractions.

5. Ripening of the cervix- The cervix becomes even

softer, now described as “butter-soft”.

6. Rupture of the membranes- Also known as the bag

of waters, its rupture may be seen as a sudden gush,
or a scanty, slow sleeping, of amniotic fluid from the
vagina. The color of the amniotic fluid should always
be noted.
At term, it is clear, almost colorless, and contains white
specks of vernix caseosa. Green staining means the
amniotic fluid has been contaminated with
meconium, a sign of fetal distress if the fetus is in
non-breech presentation. Yellow staining may mean
blood incompatibility, while pink staining may
indicate bleeding.

7. Show- This is the blood-tinged mucus discharged

from the vagina because of pressure of the
descending fetal part on the cervical capillaries,
causing their rupture.
 SIGNS OF TRUE LABOR

True labor is said to occur when the following signs are observed:
Uterine contractions. The surest sign that labor has begun is the
initiation of effective, productive, and involuntary uterine
contractions.
There are three phases of uterine contractions:
Crescendo / Increment – intensity of the contraction increases. This
phase is longer than the other two phases combined.

Acme / Apex – the height or peak of the contraction .

Decrescendo/Decrement – intensity of the contraction decreases.
Show:

Capillary blood mixes with mucus when operculum is

released, that is why show is no more than a pinkish
vaginal discharge. Show should be distinguished from
bright red vaginal bleeding because the latter is a danger
sign during this phase of pregnancy.
There are several differences between false and true labor pains as
shown in Table 1.

False Labor Pains True Labor Pains

1.Remain irregular 1.May be slightly irregular at first nut

become regular
and predictable within a matter of hours.
2.Generally confined to the
abdomen 2.First felt in the lower back and sweep
around to
the abdomen in a girdle-like fashion.
3.No increase in duration,
frequency and intensity. 3.Increase in duration, frequency and
intensity.
4.Often disappear if the woman
ambulates. 4.Continue no matter what the woman’s
level of activity
5.Absent cervical changes.
5.Accompanied by cervical effacement
and dilatation.
• Dilatation- This is the process by which the external
cervical is enlarges from a few millimeters wide to 10 cm
full dilatation.
• In primigravidas- effacement occurs before
dilatation; in multigravidas, however, dilatation may
precede effacement
• Effacement – thinning/shortening of the cervical
canal
• Cervix = 1 inch thick; during labor, paper thin
½ inch cervix = 50% effaced
¼ inch cervix = 75 % effaced
¾ inch cervix = 25 % effaced
 Uterine Changes

The uterus is gradually differentiated into two distinct portions. These

are distinguished by a ridge formed in the inner uterine surface, the
physiological retraction ring.

1. Upper uterine segment is the portion from the isthmus (or the
physiological retraction ring) up to the fundus.

2. Lower uterine segment is the portion from the isthmus (or the
physiological retraction ring)
down to the cervix.
LENGTH OF LABOR

• In general multigravidas deliver 6 hours earlier than

primigravidas. Labor which is completed in more than 18
hours in primigravidas or more than 12 hours in
multigravidas is called prolonged labor.

• Labor which is completed in less than 3 hours is termed

precipitate delivery.
 Comparison Of Length Of Labor In Primigravidas And
Multigravidas

Stage of Labor Primigravidas Multigravidas

First Stage 12 ½ hours 7 hours, 20 minutes

Second Stage 80 Minutes 30 minutes

Third Stage 10 Minutes 10 minutes

TOTAL 14 hours 8 hours

 STAGES OF LABOR
STAGES DURATION START-END

STAGE I CERVICAL P - 10-14 Hrs TRUE LABOR –

DILATATION M - 6-8 Hrs FULL DILATION

STAGE II FETUS P – 1.5 Hrs FULL DILATION –

M – 30-45 Min. FETAL EXPULSION

STAGE III PLACENTA 5 – 30 Min. FETAL EXPULSION

– PLACENTAL
DELIVERY

STAGE IV RECOVERY/ 1 – 2 Hrs. Watch out for signs

IMMEDIATE of hemorrhage
POSTPARTUM
 PHASES OF THE 1ST STAGE OF LABOR

PHASES DILATION DURATION INTERVAL INTENSITY

A. LATENT 0-4 CM 30-45 SEC. 15 MIN. MILD

B. ACTIVE 4-8 CM 45-60 SEC. 5 MIN. MOD-STRONG

C. TRANSITION 8-10 CM 60-90 SEC. 2-3 MIN. VERY STRONG

THE FIRST STAGE OF LABOR
• The first stage of labor, otherwise
known as the Stage of Dilatation, is a
very important stage
• in so far as assessment of fetal and
maternal well-being is concerned. The
following are discussions of this stage
of labor.
 Phases
• Latent Phase. The phase begins with onset of
regular contraction and ends with complete
effacement (100%) and cervical dilatation of
about 4 cm.
• Mild uterine contractions occur regularly
10-20 minutes apart and are of short duration
(10-30 seconds). The woman usually
experiences low backaches and abdominal
cramps and is generally excited, alert,
talkative, and in control.
• Active or Accelerated Phase. This
begins with complete effacement and
cervical dilatation of
• about 2-3 cm and ends with cervical
dilatation of approximately 8 cm.
Moderate uterine contractions
• occur at 2-5 minute intervals and last
30-45 seconds. The woman
experiences moderately increased
• pain, may be more apprehensive, and
fears losing control.
NURSING MANAGEMENT

Nursing care of the woman in her first stage of labor includes the following considerations:
Hospital Admission. Privacy and reassurance are both very important at this time and throughout
the other stages of labor. Establishing the maintaining rapport with the woman in labor will go a long
way towards alleviating fear and apprehension. Keeping her informed of the progress of labor is the
best way of giving emotional support.

Such important data as the expected date of confinement (EDC), the condition of the membranes,
and the show should be elicited at the onset on order to determine the kind of management to be
given to the particular patient.

Physical Assessment. General physical examination. Leopold’s maneuvers and/or

internal examination are done to determine the following:

Effacement, dilatation, and condition of the membranes.

Lie or presentation – the relation of the long axis of the fetus to the long axis of the mother.
Lie may either be vertical or horizontal.

Location of the fetal heart tone in relation to the presentation.

 Outline of Various Presentation
And Their Presentations Parts
I.VERTICAL LIE
A.Cephalic Presentation – head is the presenting part
1.Vertex – head is sharply flexed, making the parietal bones the presenting part
2.Face
3.Brow
4.Chin
A.Breech Presentation – buttocks are the presenting parts
5.Complete breech – thighs are flexed on the abdomen and legs are on thighs
6.Frank breech – thighs are flexed and legs are extended, resting on the
anterior surface of the body
7.Footling
a.Double – legs unflexed and extended; feet are presenting parts
b.Single – one leg unflexed and extended; one foot is the presenting part
I.HORIZONTAL LIE –Shoulder Presentation

Station the relation of the fetal presenting part to the level of the ischial spines are explained below.
Station 0 – when the fetal presenting part is at the level of the ischial spines. Station 0 is
synonymous to engagement.

Station – 1 or 2 – when the fetal presenting part is above the level of the ischial spines.

Station + 1 or +2 – when the fetal presenting part is 1 cm or 2 cm below the level of the ischial spines.

Station +3 or +4 – is synonymous to crowning. Crowning is defined as the encirclement of the

largest diameter of the fetal head by the vulvar ring.

Station +3 or +4 – is synonymous to crowning. Crowning is defined as the encirclement of the

largest diameter of the fetal head by the vulvar ring.
 Position – the relation of the fetal presenting part of a specific quadrant of the woman’s pelvis.
The woman’s pelvis is divided into four quadrants:

right anterior
right posterior
left anterior
left posterior

Four parts of the fetus have been chosen as points of direction:

occiput – in vertex presentations

chin (mentrum) – in face presentations
sacrum – in breech presentations
scapula (acromion) – in shoulder presentations. The word “dorso” is added to indicate
the position of the fetal back.

An outline of the different possible fetal positions is shown in Table 4. the most common and
favorable position is the loccipito-anterior position. (LOA). In the ROA position, the occiput
of the fetus is the right side of the mother and is directed towards her front; in such position,
the fetus, therefore, is facing the mother’s right buttock.
Outline of Possible Fetal Positions

Vertex Presentation Face Presentation

LOA – left occipitoanterior LMA – left mentoanterior
LOP – left occipitoposterior LMP – left mentoposterior
LOT – left occipitotransverse LMT – left mentotransverse
ROA – right occipitoanterior RMA – right mentoanterior
ROP – right occipitoposterior RMP – right mentoposterior
ROT – right occipitotransverse RMT – right mentotransverse

Breech Presentation Shoulder Presentation

LSA – left sacroanterior LADA – left acromiodorsoanterior
LSP – left sacroposterior LADP – left acromiodorsoposterior
LST – left sacrotransverse RADA – right acromiodorsoabterior
RSA – right sacroanterior RADP – right acromiodorsoposterior
RSP – right sacroposterior
RST – right sacrotransverse

Bath
Bath is advisable if contractions are still tolerable or are not too close to one another.
Bathing will not only ensure cleanliness but will also provide comfort and relaxation.
Perineal Preparation
The perineum is cleansed from front to back using the No. 7 stroke in order
to disinfect the area surrounding the vagina, this procedure helps to prevent contamination of
the birth canal and reduce possibilities of postpartum infection. Perineal shaving is no longer a
routine procedure nowadays but if and when it is ordered, the techniques vary from one hospital
to the other. The basic steps are as follows:

The perineal hair is first lathered well.

The skin from above is stretched and kept taut and with the use of a safety raxor, hair is shaved
downward from the mons veneris, using long single strokes running along the growth of the hair.

The perineum is again washed thoroughly after shaving.

The woman is instructed not to touch the genitals afterwards to keep the area as clean as possible
during labor.

Perineal Skin Prep

Ambulation
Ambulation is advised during the latent phase of labor in order to help shorten the first stage of labor.

Diet
Solid or liquid foods are avoided for the following reasons:

Digestion is delayed during labor.

A full stomach interferes with proper bearing down.

Aspiration may occur during the reflex nausea and vomiting of the transition phase or when
anesthesia is used.

Enema Administration
Enema is not a routine procedure for all women in labor but may be done for the following reasons:

A full bowel hinders labor progress; enema increases the space available for passage of the
fetus and improves frequency and intensity of uterine contractions. The effectiveness of enema
administration is therefore, shown by evaluating the change in uterine tone and the amount of show.

Enema decreases the possibility of fecal contamination of the perineum during the second
stage of labor.

A full bowel can add to the discomfort of the immediate postpartum period.
The procedure of enema a administration during labor consists of the
following considerations:
Soapsudsor Fleet enema is usually given

The optimal temperature of the solution is 105 -115o1 (40.5 -5.46.1oC).

The patient is placed on side –lying position

Voiding
The woman in labor should be encourage to empty her bladder every to 2-3 hours because

full bladder retards fetal descent.

Urinary stasis can lead to urinary tract infection
A full bladder may be traumatized during delivery.

Breathing Technique

The woman in the first stage of labor should be instructed not to push or beat down during
contractions because it will not only lead to maternal exhaustions but, more importantly,
unnecessary bearing down can lad to cervical edema because of the excessive pounding of
the fetal presenting part on the pelvic floor, thus interfering with labor progress. To minimize
bearing down, the patient should be advised to do abdominal breathing during contractions.
 Position

Encourage the woman in labor to assume Sim’s position because the inferior vena cave is
caught between the gravid uterus and the spinal column, causing a drop in arterial blood pressure,
which leads the woman to complain of dizziness.

it favors anterior rotation of the head

it promotes relaxation between contractions.
It prevents Supine Hypotensive Syndrome

Contractions
Uterine contractions are monitored every hour during the latent phase of labor and every
30 minutes during the active phase by spreading the fingers lightly over the fundus.

Duration – from the beginning of one contraction to the end of the same contraction.

Interval- from the end of one contraction to the beginning of the next contraction.

Early in labor interval is 40-45 minutes; late in labor, interval is only 2 minutes.

Frequency – from the beginning of one contraction to the beginning of the next
contraction (A to C of Fig. 3). A woman in labor should seek hospital admission
when her contractions are already occurring every 5-10 minutes. The nurse should time
3-4 contractions at a time to have a good picture of the frequency of contractions.

Intensity – prolonged and sustained uterine contractions can lead not only to
fetal distress but also to rupture of the uterus.
Vital Signs

Blood Pressure (BP) and Fetal Heart Rate (FHR) are taken every hour during the latent phase
and every 30 minutes during the active phase. Definitely, BP and FHR should never be taken
during contraction.

During uterine contractions, no blood goes to the placenta. The blood is pooled to the peripheral
blood vessels which results in increased blood pressure. Therefore, the blood pressure should be
taken in between contractions and whenever the mother in labor complains of a headache.

FHR, on the other hands, tends to decrease during a contraction because of the compression of
the fetal head. When the fetal head is compressed by the contracting uterus, the vagus nerve is
stimulated, thus causing bradycardia, FHR normally 120-160 per minute. It should not be mistaken
for the uterine soufflé the sound which results when the uterine blood vessels refill with blood.
Uterine soufflé synchronizer with maternal heartbeat. For any abnormality in FHR the initial nursing
action is to change the mothers in position because the abdormality may just be due to Supine
Hypotensive Syndrome. If the rate does not change despite positioning the attending physician
should be informed.

Danger Signals
The nurse must be aware of the following danger signals labor and delivery.
Signs fetal and maternal distress are given below.
SIGNS of fetal distress
Tachycardia (FHR more than 180)
Bradycardia (FHR less than 100)

Meconium-stained amniotic fluid in non breech presentation

Fetal thrashing or hyperactivity due to feta struggling fro more oxygen.

Signs of maternal distress

BP over 140 /90, or failing BP associated with clinical signs of shock
(pallor, restlessness or apprehension, increased respiratory and pulse rates)

Bright red vaginal bleeding or hemorrhage (blood loss of more than 500 cc)

Abnormal abdominal contour (may be due to uterine rupture of Band’s pathological ring,
a condition wherein the muscles at the physiological retraction ring become very tense,
gripping the fetus causing possible fetal distress.

Administration of Analgesics
Narcotics are the most commonly used analgesics, specifically Demeerol (meperidine
hydrochloride). Its dosage is based on the patient’s weight the status of labor, and the
size and stage of gestation. Demerol acts to suppress the sensory portion of the cerebral cortex.
A dose of 25-100 mg is given and it takes effect within 20 minutes when the patient experiences
a sense of well-being and euphoria. Demerol, being also an antispasmodic, should not be given
very early in labor because it will retard labor progress. It should not also be given when delivery
is less than an hour away because it can cause respiratory depression in the newborn. It is,
therefore, preferably given when cervical dilatation is around 5-8cm.
Administration of Anesthethics
Regional anesthesia is preferred over any other form because it does not enter maternal
circulation and therefore does not retard labor contractions nor cause respiratory depression
in the newborn. The patient is completely awake and aware of what happening, but since there
is loss of coordination between contractions and pushing, the baby will have to be delivered
with the aid of forceps. One of the more commonly used anesthesia is the low spinal, specially
saddle block. Xylocaine is injected into the 5th lumbar space, causing anesthesia into the parts
of the body that come in contract with a saddle, e.g., the perineum, the upper thighs, and lower
pelvis. Postspinal headaches, however , may occur because of leakage of cerebrospinal fluid
(CSF) or air at the time of needle insertion. The patient should be kept flat on bed for 13 hours
and her fluid intake increased to prevent postspinal headaches.

Local anesthesia in the following forms may also be administered:

Paracervical – transvaginal injection into either side of the cervix.
Pudendal block – injection through the sacrospinous ligament into the posterior areolar
tissues to reduce perception of pain during the second stage of labor.

Transfer of Patients
A sure sign that the baby is about to be born is the bulging of the perineum.
 The Transition Phase of Labor

Nursing Management

Breathing Technique
The patient should be assisted in controlled chest (costal) breathing during
contraction of the transitional phase.

Avoidance of Bearing
The patient is discouraged from bearing down until cervical dilatation is complete to
prevent cervical edema.

Emotional Support
The patient should be helped to relax between contractions.
Comfort Measures. Effleurage (slight stroking on the abdominal skin surfaces), back rubs,
and sacral pressure (the heel of the hand is placed against the sacrum) during contractions
provide relief.

The Second Stage of Labor

DEFINITION
The second stage begins with complete dilatation of the cervix and ends with delivery of the infant.
MECHANISMS OF LABOR/FETAL POSITION CHANGES

As the fetus passes through the birth canal for delivery, it goes through different position
changes so that the smallest diameter of the fetal head (in cephalic presentation) will fit through
the pelvic inlet and outlet.

Descent
The fetus goes down the birth canal. Descent either follows or includes engagement.

Flexion
As the fetus descends down the birth canal, pressure from the pelvic floor causes he fetal
heard to be flexed, so that the chin touches the chest. This brings the smallest diameter of
the fetal head into a good position, which is termed attitude. Attitude, therefore, is the degree
of flexion that the fetus assumes prior to delivery.

Internal Rotation
The wider anteroposterior (AP) diameter of the fetal head enters the wider transverse
diameter of the pelvic inlet and will rotate so that fetal head is positioned at the wide AP
diameter of the pelvic outlet.

Extension
As the head comes out, the back of the neck stops beneath the public arch.
The head then extends and the head, face, and chin are born.
External Rotation
After the head has been delivered, it rotates 45 to the left so that the anterior shoulder is just
below the public arch

NURSING MANAGEMENT
The care of the woman during the second stage of labor, which is focused on the delivery
of the baby, consists of the following:

Positioning on the Delivery Table

When positioning the woman on lithotomy on the delivery table, the legs should be put up
slowly at the same time on the strirrups in order to prevent trauma to the uterine ligaments
and back aches or leg cramps.

Bearing Down Techniques

This is the best time to encourage strong pushing with contractions. At the beginning of a
contraction, the woman is asked to take two short breaths, then to hold her breath and bear
down at the peak of the contraction.
 Care of the Episiotomy Wound
Episiotomy, a perincal incision done to facilitate the birth of the baby is made by the doctor
primarily to prevent lacerations. Other reasons for doing episiotomy are to:

Prevent prolonged and serve stretching of the muscles supporting the bladder or rectum,
which can later lead to stress incontinence of urine or even vaginal prolapse.
Reduce duration of the second stage of labor in cases of maternal hypertension of fetal distress.
Enlarge the vaginal outlet in breech presentation or forceps delivery.
Spare the infant’s head from having brain damage prolonged pressure which may result in
brain damage, especially in the premature baby.

The two types of episiotomy are:

Median – begun in the midline of the perineum and directed toward rectum
Mediolateral- begun in the midline of the preneum but directed laterally away from the rectum.

Breathing Technique
As soon as the head crowns, woman is instructed not to push any longer because it cause
rapid expulsion of the fetus.

Ritgen’s Maneuver
The basic steps is applying this method of delivery are as follows.
Time of delivery
Take note of the time the baby is delivered.

Handling of the Newborn

Immediately after delivery, the newborn should be held below the level of the mother’s vulva
so that blood from the placenta can enter the infant’s body on the basis of gravity flow.

Cutting of the cord

Cutting of the cord is postponed until pulsations have stopped because it is believed that
50-100 ml of blood is flowing from the placenta to the newborn at this time. It is then clamped
twice, an inch apart, and cut in between.

Initial Contact
Maternal-infant bonding is initiated as soon as the mother has eye-to-eye contact with her baby.
The mother is informed of her baby’s sex and helped to hold and inspect her baby if she wished.
THE THRID STAGE OF LABOR
DEFINITION
The third stage, also know as the Placenta Stage, begins with the delivery of the infant and
ends with the delivery of the placenta.

PHASE
Placental Separation Phase

Separation of the placenta results from the disproportion between the size of the placenta
and the reduced size of the site of placental attachment after the delivery of the baby.
The signs of placental separation are the following:

The uterus becomes more firm and round in shape again and rising high to the level
of the umbilicus.

Placental Expulsion Phase

This phase is effected by the mother’s bearing down or by gentle pressure on the fundus.
There are two mechanisms by which the placenta is separated and expelled from uterus.

Schultz – clear type of placenta, “aw” – separation in “center” shiny, reddish in color.

Duncan – dark, dirty “dweg” – edges (separation)

NURSING MANAGEMENT

Method of placental delivery

Do not hurry the delivery of the placental by forcefully pulling out the cord or by vigorous
fundal push as this can lead to uterine inversion.

Time of placental delivery

10 minutes immediately notified as it could be a sign of uterine atony. Uretent “atony”
never contact to massage Õ uterus

Care after placental delivery

The following aspects are important:
a. Inspection of placenta for completeness of cotyledons.
b. The initial nursing action for a non-contracted or boggy uterus is gentle massage of
the fundus. An ice cap may also help.
c. Oxytocic agents may be administered as ordered to ensure uterine contractions, thus
preventing hemorrhage.
 Methergin (0.2mg) and
 Syntocinon (10 U) are two of the more commonly given oxytocics.
 Common side effect of oxytocins in hypertension. Monitor the blood pressure.
d. Lacerations are rugged edged which heal more slowly and therefore predispose
infection, if healing process is prology.
1. First-degree – vaginal mucous skin.
2. Second-degree – vagina, perineal skin, fascia, levator ani muscle and perineal body.
3. Third-degree – entire perineum.
4. Fourth-degree – entire perineum rectal sphincter and some of the mucous membrane for the
rectum.
NURSING MANAGEMENT

Care during and after Perineal Repair.

A local anesthetic, usually Xylocaine, is given in order to minimize pain during
episiorrhaphy. In vaginal episiorrhaphy, packing is done to maintain pressure on the
suture line and, therefore, prevent bleeding. The nurse should be aware that this packing
is usually removed after 24 or 48 hours.

Estimation of blood loss.

250-300cc – N 500cc hemorrhage.
THE FOURTH STAGE OF LABOR

DEFINITION
Fourth stage first one or two hours vital signs of the mother are quite unstable.

NURSING MANAGEMENT
Nursing interventions during the fourth stage of labor are focused mainly:.

1. Assessment.
a. Fundus – should be palpated every 15 minutes during the first hour postpartum
and then every 30 minutes for the next 4 hours.
b. Bladder – checked every 2 hours during the first 8 hours postpartum and then
every 8 hours for 3 days. Suspect a full urinary bladder if the fundus is not well
contracted and is shifted to the right. A full urinary bladder prevents good
contraction of the uterus and therefore may cause hemorrhage.
c. Vaginal discharge – the amount of blood flow should be checked every 15
minutes and should be moderate. It is said that if a newly-delivered woman
saturates a sanitary napkin more often than every 30 minutes, the flow is
excessive necessitating immediate referral to the doctor.
d. Blood pressure and pulse rate – should be checked every 15 minutes during the
first hour postpartum and then every 30 minutes until stable. BP and pulse rate
are slightly increased from excitement and the effort of delivery but normally
stabilizes within one hour.
e. Perineum – should be inspected every 8 hours for 3 days. Take note of the
condition of the episiorrhaphy:
BLADDER ASSESSMENT

DEFINITION
• Voiding pattern, complete emptying, pain burning on urination
• Record first three voids with the amount and times voided
• A full bladder displaces the uterus upwards and laterally and
prevents contraction of the uterus = UTERINE ATONY = > risk of
postpartum hemorrhage.

2. Comfort Measures. Helping the mother feel comfortable after delivery can be
effective by the following measures:

a. perineal care gently

b. position her flat on bed without pillows to prevent dizziness due to sudden
release of intraabdominal pressure.
c. Mother a soothing sponge bath change her soiled gown/dress and dirty linens.
d. Additional blankets if the mother suddenly complains of chilling.
e. Mother initial nourishment of coffee, tea or milk.
f. Mother to sleep in order to regain lost energy.
PHYSICAL EXAMINATION OF THE LABORING WOMAN

Steps you should take to prepare for the examination:

• Ask woman to empty bladder (collect urine for testing).
• Prepare to follow a logical order.
• Prepare to chart logically immediately after exam (make notes).
• Remember to use all your senses during assessment.
• Remember to explain everything you are doing.
• Exam should be carried out immediately and as quickly as possible.

Urine tests used during intrapartum

Ph - Measures acidity/alkalinity of the urine, Levels below normal indicate high fluid intake,
levels above the norm indicate inadequate fluids & dehydration.
Protein - Normal = Negative, Small amounts may be in urine from vaginal secretions &
dehydration, Amounts of 2+ to 4+ may indicate be one indicator of possible UTI, Kidney
Infection or PIH.
Glucose - Normal = Negative or + I. High levels of glucose may be one indicator of high blood
sugar, gestational diabetes or diabetes mellitus. Always ask what woman has recently
eaten if her BS is high.
Ketones - Normal = Negative. Ketones are products of the breakdown of fatty acids caused by
fasting. The body breaks down fats because there are not enough carbohydrates and
proteins available. Ketones may be deleterious to fetus.
Techniques to be used in performing a physical examination:
• Inspection
• Palpation
• Auscultation

General appearance:
Edema, skin color, hygiene, pain, distress, mood

Measure vital signs:

Blood pressure, pulse, respiration, temperature

Blood pressure
Take blood pressure with woman in sitting or side lying position
Compare blood pressure with prenatal blood pressure

Pulse
Rate: 60 - 90
Increased pulse can be dehydration, anxiety.
Always question possibility of cardiac problems.
What is the most common cardiac problem in a young female?

Respiration
Don’t count during a contraction

Temperature
Think about infection and dehydration
Abdominal examination
An abdominal examination should include a measurement of fundal height as well as an
assessment of fetal size (estimated fetal weight), presentation and position using Leopold's
maneuvers.
Inspect: Scars, linea, striae, symmetry
Palpate: fundal height, fetal position
Osculate: fetal heart tones
Determine and palpate contractions

Inspect and palpate lower extremities

Press firmly with thumbs about 5 seconds over shin
If any signs of elevated blood pressure, elicit DTR
If reflexes are hyperactive, check for clonus

Measuring fundal height

Place the zero line of the tape measure on the anterior

border of the symphysis pubis and stretch tape over
midline of abdomen to top of fundus.
The tape should be brought over the curve of the fundus.
The height of the fundus in centimeters equals the number of
weeks gestation plus or minus 2.
After 32 weeks the relationship is less accurate.
Perform Leopold maneuver.
Leopold's Maneuver

Abdominal Examination for Position and Presentation and Size

1. Palpation of the uterine fundus to determine

which fetal pole "head or breech" is present in
the fundus. Using two hands and compressing
the maternal abdomen, a sense of fetal direction
is obtained (vertical or transverse).
2. The lateral sides of the fundus are palpated to
determine the position of the fetal back and small
parts.. The fetal spine will palpate as firm, flat
and linear. The fetal extremities are palpable by
their varying contour and movements. The
purpose of this maneuver is to determine
whether the fetal back is left or right.
3. The purpose of this maneuver is to determine the
pelvic position of the presenting part. The
presenting part (head or breech) is palpated
above the symphysis and degree of engagement
determined. The examiner uses the thumb the
fingers of one hand in the suprapubic region
(similar to palming a basketball) and attempts to
move the presenting part from side to side. If
little movement occurs or only the fetal neck is
palpable the presenting part is engaged.
4. The fetal occipital prominence and flexion of the
vertex is determined. If the fetal vertex is flexed,
the cephalic prominence may be palpable on a
same side as the fetal small parts. If a distinct
cephalic prominence is noted on the same side
as the spine and head the vertex is not very well
flexed.
Monitoring the Mother and Fetus During Labor

• A 20 minute fetal monitor strip is done for all patients on admission. As long as the
patient is healthy, the presentation normal, the presenting part well engaged, and the
fetus in good condition, the woman may walk about or be in bed as she wishes.
• The patient's condition and progress is checked periodically. FHT's are checked q 30
min in latent phase, q 15min. in active phase, and q 5min. in second stage. The
maternal temp is taken q 4 hrs., q 2 hours if ROM. Variations to this timing depend on
the maternal-fetal situation.
• The progress of labor is followed by abdominal or vaginal examination to note the
position of the baby, the station of the presenting part, and the dilatation of the cervix.
These examinations should be done only often enough to ensure the safe conduct of
labor, i.e., to determine that the rate of dilatation is within the normal range or to
evaluate the patient if she is requesting medication.
• Over distension of the bladder is obviated by urging the patient to void every few
hours. If she is not able to do so, catheterization may be necessary, since a full bladder
impedes progress.
• Adequate amounts of fluids and nourishment are essential. If the patient is unable to
take enough orally, a intravenous of Lactated Ringers solution may be given.
• During the first stage, the patient should be impressed with the important of relaxing
with the contractions. Help the couple as much as possible to work with the
contractions and compliment them for a good job.
• The passage of meconium stained fluid in a cephalic presentation is a possible sign of
fetal distress and if present, the patient should be continually monitored during active
labor.
Abdominal Examination for Contractions
An initial abdominal examination is carried out on admission by laying a hand on the
uterus and palpating, noting the degree of hardness during a contraction and timing its
length. This should be repeated at intervals throughout labor in order to assess the
length, strength and frequency of contractions and the descent of the presenting part.
The uterus should always feel softer between contractions.

The monitor should never be relied on;

the mother’s abdomen should be
regularly palpated by hand.

Uterine Contractions
There is no place for routine vaginal examinations in any
labor. Vaginal examination should only be done when there
is doubt about the clinical situation or symptoms, and the
information gathered is necessary or likely to be of use in
making a clinical decision.
(1) Significant vaginal bleeding of unknown etiology (delay
examination until placenta previa has been ruled out by
ultrasonography),
(2) Presence of placenta previa,
(3) Ruptured membranes in patients who are not in labor and
for whom immediate induction of labor is not anticipated,
(4) Presence of active HSV lesions in a patient with ruptured
membranes.
How to palpate presenting part:

Palpate the hard skull; palpate for sagital suture; follow to anterior or
posterior fontanel
If what you feel is soft it may be breech or face.
Assessing Cervical effacement

Cervical effacement: Palpate degree of thickness; normal cervix about 1

inch thick

Speculum examination

A speculum examination will be necessary in cases of suspected "leaking" or ruptured

membranes. The presence of "leaking" or ruptured membranes can be confirmed by
performing a nitrazine test, inspecting the posterior fornix for pooling of fluid and by obtaining
a sample of the fluid with a sterile applicator and applying the fluid to a glass slide. The glass
slide is allowed to air dry and is subsequently inspected for an arborization pattern ("ferning").
The Six Steps of Labor Progression

Labor can be defined as regular, painful uterine contractions that result in progressive
cervical change. The diagnosis of labor progression may be dependent upon the patient's
history of uterine contractions as well as information gathered from abdominal palpation
and vaginal examination. Evidence of progressive cervical effacement and/or dilation is
necessary in order to distinguish true labor from false labor.

Labor progresses in six ways and all are equally important. Frequency, duration and
intensity of contractions cannot be relied upon as measures of progression in labor.

Cervical dilatation and fetal descent are the only indicators that labor is progressing.

Cervical Ripening
The cervix ripens or softens. As a woman’s body gets ready to labor it produces prostaglandin. This causes the
cervix to soften from the consistency of rubber to something that feels like a marshmallow.

Cervical Position
The cervix moves from a posterior to an anterior position. During most of the pregnancy, the cervix points toward
the back (posterior), but during the last few weeks of pregnancy or in early labor, it moves forward (anterior). The
uterus may contract for several days intermittently before true labor begins to accomplish these first two things,
softening the cervix and bringing the cervix from the back of the vagina to the front of the vagina.
Cervical Effacement
The cervix effaces About two inches in length is average size, but in early labor, the cervix begins to get shorter
and thinner (effacement). By the active part of labor the cervix will be completely effaced and be paper-thin.

It is vital to understand that when the cervix has not undergone the first three steps (ripening, effacement, and
anterior movement of the cervix), significant dilation (beyond 3-4 cm in the nullipara, more in the multipara) rarely
occurs), but that pre‑labor contractions are accomplishing the important job of pre‑paring the cervix to dilate.

Cervical Dilatation
The cervix dilates and active labor begins. Not much dilatation can occur until the cervix has completed the above
three processes. Remember the cervix needs to get very soft, move to an anterior position and get paper-thin
before it will dilate much past 3-4 centimeters.

Fetal Head Rotation, Flexion and Molding

The fetal head rotates, flexes, and molds. The head begins to change shape to fit through the pelvis. Remember,
this is called molding. Rotation, flexion, molding, and descent of the fetal head take place in active labor and
second stage

Fetal Descent and Birth

The fetus descends and is born. Descent occurs as the baby lowers itself into your pelvis. Remember, descent is
measured in terms of "stations."
Stages of Labor Chart
The first stage of labor begins when uterine contractions of sufficient frequency, intensity and
duration result in effacement and dilation of the cervix. The first stage is completed when the
cervix reaches 10 cm. The second stage involves descent of the fetus and its eventual
expulsion from the vagina. It begins with complete cervical dilation (10 cm) and ends with
delivery of the infant. The third stage of labor involves delivery of the placenta. It begins with
the completion of the infants' delivery and ends with delivery of the placenta and membranes.

FIRST STAGE
LATENT- ACTIVE TRANSITION SECOND STAGE THIRD STAGE
LABOR
EARLY LABOR LABOR LABOR LABOR Delivery of the
LATENT
(0-3 cm.) (4-8 cm.) (8-10 cm) (10 cm. -Birth) Placenta
Pre-labor

© Ripening Contractions: Contractions: Contractions: Contractions: Contractions:

and effacement © 5-20 minutes © 2-5 minutes © 1 -2 © 3-5 minutes apart © Irregular
of the cervix apart apart minutes apart
© 60-120 seconds © A feeling of
© 30-45 © 45-60 © 45-90 long fullness and
seconds long seconds long seconds long cramping as
placenta separates
© Less aware of
© Mild, feel © Stronger © The contractions,
like cramps, and more intense strongest they more aware of © A time for
back pain, will get urge to push and mom to hold and
pressure fullness in vagina as enjoy baby.
baby moves down
Crowning and birth of the baby and placenta
 Father or SO Cuts the Cord

Hand baby to mom: if baby is stable