Course Manual

Midwifery I
1st Semester, ,A.Y.2012

Christian University of Thailand College of Nursing

Christian University of Thailand, College of Nursing Midwifery 1, Academic Year 2011

Table of Contents

Title Page Table of contents ………………………………………………………………………………2 I. Midwifery Related Concepts 1. Critical Factors in Labor …………………………………………………………………….4 2. Exercise During Pregnancy ………………………………………………………………….5 3. Components of the Birth Process……………………………………………………………10 4. Stages of Labor and Nursing Care…………………………………………………………..19 5. Steps in Bathing the Newborn……………………………………………………………….35 6. Laboratory Exercise………………………………………………………………………….37 II. Laboratory Procedures for Graded Return Demonstration 1. Mechanism of Labor…………………………………………………………………………41 2. Leopold’s Maneuver…………………………………………………………………………43 3. Assisting in Birth and Delivery………………………………………………………………45 III. Evaluation Checklists IV. Resources

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Midwifery Related Concepts

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CRITICAL FACTORS IN LABOR

1. Birth Passage a. Size of the maternal pelvis ( diameters of the pelvic inlet, midpelvis and outlet). b. Type of maternal pelvis (gynecoid, android, anthropoid, platypelloid, or a combination). c. Ability of the cervix to dilate and efface and ability of the vaginal canal and the external opening of the vagina (the inroitus) to distend. 2. Fetus a. Fetal head ( size and pressure of molding). b. Fetal attitude ( flexion or extension of the fetal body and extremities). c. Fetal Lie d.Fetal presentation ( the body part of the fetus entering the pelvis in a single or multiple pregnancy). 3. The relationship between the passage and the fetus a. Engagement of the fetal presenting part. b. Station ( location of fetal presenting part to in the maternal pelvis). c. Fetal position ( relationship of the presenting part to one of the four quadrants of the maternal pelvis). 4. Physiologic forces of labor a. Frequency, duration, and intensity of uterine contractions as the fetus moves through the passage. b. Effectiveness of the maternal pushing effort. 5. Psychosocial considerations a. Mental and physical preparations for childbirth. b. Sociocultural values and beliefs. c. Previous childbirth experience. d. Support from significant others. e. Emotional status.

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EXERCISE DURING PREGNANCY General Exercise Guidelines
     

Exercise regularly. Stop if you feel pain. Finish eating at least 1 to 11/2 hours before working out. Drink water before, during, and after your work -- out -- even if you aren't thirsty. Don't go on a calorie-restriction diet during pregnancy. This is very dangerous for your baby. Eat a nutritious, balanced diet.

Prenatal Exercise Safety It is particularly important that you not begin exercising on your own if:
     

you have any type of cardiac (heart) or respiratory condition you have diabetes that developed before or during pregnancy you have high blood pressure, whether the onset was before pregnancy or occurred as a symptom of toxemia you have a history of premature labor your placenta is implanted completely over or near your cervix (placenta previa) you have physical impairments or musculoskeletal disease that would prevent exercise even in the nonpregnant state.

Appropriate Clothing
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Wear loose-fitting, comfortable clothes. Wear a good support bra while exercising. Wear good shoes.

Aerobic Exercises During Pregnancy Three parts: A warm-up period, the aerobic workout, and a cool-down period The Warm-Up Spend a minimum of five minutes (ten minutes is much better) stretching and limbering up. Stretch just to the point of mild tension (not pain), and then hold the stretch for a slow count of ten. Release and repeat, three times in all. Whichever warm-up stretch you choose, do not bounce! It only makes your muscles tighter. Concentrate stretches mainly on the lower body (legs, ankles, hips, knees), but don't completely neglect the upper body (arms, shoulders, neck). If you are lap swimming, walking, biking, or engaging in some other independent activity, spend another five minutes moving slowly, and then gradually move faster and faster toward your target zone. In other words, don't stretch and then try to burst into your pulse range.

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Outer Thigh Lift Start with 5 repetitions. Create an easy feeling of stretch in your calf muscle. shifting your weight to your right arm. 3. Change sides and repeat. your body aligned. extend your left leg straight behind you. Lie on your left side. Change sides and repeat. Cross the right leg over the left. Midwifery 1 Course Manual Page 6 . 5. with your back flat and abdominal muscles squeezed tightly (do not let your abdominal muscles hang loose). 2. Repeat several times. 5. Bend one knee and bring it toward the wall. propping yourself on your left elbow and forearm. Lie on your left side. 2. With your foot flexed. Rest on your hands and knees. 1. Repeat with the other leg. For balance. bend your bottom leg. Slowly lower your leg to the floor-do not just drop it! 4. 1. lift your left leg up until it is level with your back. Strength-Training Exercise During Pregnancy Hamstring Lift Start with 5 repetitions and increase to 20. Face a wall for support. Keep your back leg straight and your foot flat. your heel pressed into the floor. Slowly lift your top leg straight up and slightly back. Hold an easy stretch for 10 seconds. shift your weight to your left arm. Inner Thigh Lift Start with 5 repetitions. rest your bent leg behind the bottom leg. Place your forehead on the backs of your hands. increase to 20. 3. Keeping your back flat. 1. be sure to keep your body aligned. 4. then increase the stretch feeling just slightly for another 10 seconds. placing the right foot on the floor next to your left knee. and keep your back flat.) 2. then lower slowly. With your foot flexed. your head resting on your hand. At the same time. 3. As you repeat the lifts. Hold for a slow count of 5. Do not roll back onto your buttock. Stand a little distance from the wall and rest your forearms on the wall. (Alternatively.The Stretches Hold each stretch for 10 seconds. lift your left leg slowly two to three inches (as far as is comfortable). 2. Calf Stretch: 1. increase to 20. Lower your leg.

your back straight and your knees comfortably apart. your knees bent and feet flat. Place your hands either behind your head or across your chest. 1. change sides. . 2. Lock your fingers and pull against your fingers for a slow count of 5. Slowly arch your lower back. holding the tucked position for a full count of 10. Lie flat on your back. After you've completed your repetitions. Hold for a slow count of 4. Slowly return to the starting position-do not allow your back to sag. increase to 20. Midwifery 1 Course Manual Page 7 . 1. Caution: Do not perform this exercise after the first trimester of pregnancy. 1. Squeeze your pelvic floor at the same time for an added benefit. Rest on your hands and knees.3. 3. Chest Muscle Exercise Start with 5 to 10 repetitions. Clasp your hands in front of you at chest level. Repeat the tuck. Press palms together for a slow count of 5. (This stage of the exercise strengthens muscles in the upper back. lift your abdomen. Diagonal Knee and Arm Reach Do 5 to 10 repetitions. Do not hold your breath.) Pelvic Rock on All Fours Start with 5 repetitions. increase to 20. 2. 3. and tuck your pelvis under (as if a string attached to your spine is pulling you upward).

Slowly bend your knees. your arms held in front of you parallel to the floor. 2. Lie on your back. gradually increasing to 20. your face toward the ceiling. To advance the exercise. Press your lower back to the floor. (If you find this exercise easy to perform. lift your head and shoulders. The lift comes from the shoulders and should be straight up. Flatten your lower back to the floor. shoulders. Do not pull on your neck! 3. Repeat. Slowly return to the starting position. 1. Stand with your feet about two feet apart and toes turned comfortably out. Exhale as you curl back. keeping your back flat. 4. 2. Return to the sitting position. Curl-Up Perform 5 to 20 repetitions. Caution: Do not perform this exercise after the first trimester of pregnancy. then raise your head (straight up toward the ceiling. 1. (Do not attempt this with a straight back!) 3. raising your left arm and right knee. Rise slowly. 2. stay down for 15 to 30 seconds. 3. 1. inhale as you do so. then rise slowly. Midwifery 1 Course Manual Page 8 . with your knees bent and your feet close to your buttocks. right arm. and left knee all together slowly. and do not throw your head forward! Relax the jaw and neck muscles. do the exercise with your arms crossed over your chest. concentrating on the leg muscles as you push upward. Keep your heels flat during the entire movement. Never lower your buttocks past your knees. ) Do not try to curl back to the floor and up again. Slowly return to the starting position. Tuck your chin to your chest and curl back slowly until you are halfway down. 3. not with your chin down on your chest). increase to 20. Do not lift your lower back off of the floor! Perform this exercise slowly (no jerky movements). As you slowly exhale. Inhale slowly and deeply. keeping the sides of your feet on the floor and your back rounded. Sit with the soles of your feet together and comfortably away from your body.2. Plies Start with 5 repetitions. Sit-Back Start with 5 repetitions. Keep your knees over your toes-don't let them roll in.

2. with your palms on the wall slightly farther apart than shoulder width. Place your feet about two to three feet from the wall. Push-Away Start with 5 repetitions. Keep the movement smooth and don't rush. increase to 20. Keeping your shoulders down and your knees together. Concentrate on the sensations of tension and lifting. and lowering within the pelvis. 1.Pelvic Floor Squeeze (Kegel Exercise) Do 3 or 4 sets at one time. or keep them flat on the floor. Do not arch your back. touching your left leg on the floor. Lie on your back. Note: Because these muscles fatigue easily. 2. place your legs farther apart. Straighten your arms. Trunk Roll Do 5 to 10 repetitions. Tighten the pelvic floor as if to lift the internal organs or to stop urination in midstream. roll your legs to the left. Hold your arms and body straight. Touch one cheek to the wall. 1. Midwifery 1 Course Manual Page 9 . Caution: Do not perform this exercise after the first month of pregnancy. anywhere. pushing your body (still aligned) away from the wall. relaxing. To make this exercise more challenging. then to the right. 3. Make sure your knees are not bent too close to the chest. your knees bent and arms on the floor straight out at your side. repeat in sets of 3 or 4 squeezes throughout the day anytime. 1. Hold as tightly as possible for a slow count of 5 (be sure to breathe). 3. 3. 2. allowing your arms to bend. Stand facing a wall. Relax completely. 5 times per day. Keep your palms on the wall at all times. Roll your legs back to the starting point. Lean toward the wall. Lift your feet off the floor. Sit or stand comfortably (you can perform this exercise in most positions).

Inlet view. B. well-rounded forepelvis (anterior segment) D. A. the woman adds her voluntary pushing efforts to the force of uterine contractions to propel the fetus through the pelvis. A wide. vagina. Maternal Pushing Efforts. Uterine Contractions. introitus and maternal pelvis. Inlet view.consists of the soft tissues of the pelvic floor. 2. The bony pelvis is divided by the Linea Terminalis (pelvic brim) into the false pelvis above and the true pelvis below. Subpubic arch view. C. Bones ranging from medium to delicate in structure Engagement in this type of pelvis occurs most frequently with the fetus in a transverse position. PASSAGEWAY. Subdivisions of the Pelvis  Inlet or upper pelvic opening  Midpelvic or pelvic cavity  Outlet or lower pelvic opening Four Basic Pelvic Shapes  Gynecoid.has an ape-like shape  Platypelloid. Midwifery 1 Course Manual . A forward sacral inclination Page 10 II. Lateral view.  Anthropoid. A narrow sacrosciatic notch E. A. A An inlet with a slightly ovoid or round shape C. An average sacral inclination and curvature F. A. A wedge-shaped inlet B. uterine contractions are the primary force moving the fetus through the maternal pelvis.this is the most common shape in males and is not favorable for child birth. POWERS. A flat. A wide subpubic arch G. 1. followed in frequency by the anterior and posterior positions. The four major types of maternal pelves and their characteristics are outlined as follows: I. A sacrosciatic notch of medium size E.is broad and flat shaped. Lateral view. Gynecoid Gynecoid pelvis.  Android.During the first stage of labor (onset through full cervical dilation). Wide interspinous and intertuberous diameters H. Softening of the cartilage linking the pelvic bones occurs at term because of the hormone Relaxin. B. A narrow retropubic angle (anterior segment) C.During the second stage of labor (full cervical dilation through the birth of the baby). Subpubic arch view. C.COMPONENTS OF THE BIRTH PROCESS The four major factors during childbirth. cervix.this is the most common shape in females and is the most favorable for childbirth. A spacious and well-rounded posterior segment B. Android Android pelvis. wide posterior segment D.is the uterine contraction which is the primary force moving the fetus through the pelvis and the maternal pushing efforts during the second stage which add to the forces of the uterine contraction to propel the fetus. A.

narrow. A transverse. oval-shaped inlet B. Fetal Head. C. oval-shaped inlet B. the two parietal bones at the crown of the head and. Sutures and Fontanels The bones of the fetal head involved in the birth process are the two frontal bones on the forehead. H. Straight side walls with below-average interspinous and intertuberous diameters H. A narrow sacrosciatic notch E. III. C. round retropubic angle C. A. which connect the two frontal. A long. followed in frequency by the posterior and anterior positions. A very wide. Lateral view. The fetal shoulders are important because of their width. G. Platypelloid Platypelloid pelvis. Average sacral inclination F. Medium to delicate bones Engagement in this type of pelvis occurs with the fetus in either an anterior or transverse position. A very wide subpubic arch G. A. A long. Bones. Inlet view. Subpubic arch view. The clinician should be alerted by this type of pelvis that the possibility of posterior positions exists. and the two parietal bones. Anthropoid Anthropoid pelvis. A long. A very wide. which connect the two parietal bones and the occipital bone. Subpubic arch view. B. The anterior fontanel-is diamond shaped and formed by the intersection of four sutures: the two coronal. PASSENGER. A. A very wide. well-rounded anterior segment C. A slightly narrow subpubic arch G. A. A narrow wedge-shaped ―Gothic‖ subpubic arch Converging side walls. narrow interspinous and intertuberous diameters Bones ranging from medium to heavy in structure Engagement in this type of pelvis occurs most frequently with the fetus in a transverse position. B. and the sagittal.the fetus plus the membranes and placenta. Bones ranging from medium to delicate in structure IV. one sagittal and two lambdoid. narrow sacrum with average inclination and curvature F.The fetus enters in the birth canal in the cephalic presentation 96% of the time. but they are usually movable and adapt to the pelvis. Midwifery 1 Course Manual Page 11 . the frontal. Lateral view.F. but the anterior position appears to be more characteristic. flat posterior segment D. Inlet view. narrow posterior segment D. and the occipital bone at the back of the head. Straight side walls with very wide interspinous and intertuberous diameters H. shallow sacrosciatic notch E. 3. A long. narrow. A. The posterior fontanel has a triangular shape formed by the intersection of three sutures.

It is difficult to deliver because the widest diameter of the head enters the pelvis first. In more than 99% of pregnancies. 1. FETAL ATTITUDE The relationship of fetal body parts to each other is the attitude of the fetus. This is normal attitude in cephalic presentation. In cephalic presentation.B. The back is curved in a convex C shape." This allows the smallest cephalic diameter to enter the pelvis. This type of cephalic presentation may require a C/Section if the attitude cannot be changed. it occurs in less than 1% of pregnancies. In the longitudinal lie. or parallel to the long axis of the woman. which gives the fewest mechanical problems with descent and delivery. The normal fetal attitude is one of flexion. (b) Moderate flexion or military attitude. Types of attitudes. with the head flexed toward the chest and the arms and legs flexed over the thorax. A larger diameter of the head would be coming through the passageway. The transverse lie exists when the long axis of the fetus is at right angles to the woman’s long axis. This would be called a brow presentation. An oblique lie is one at some angle between the longitudinal lie and transverse lie. Midwifery 1 Course Manual Page 12 . A-Complete flexion B-Moderate flexion C-Poor flexion D-Hyperextension (a) Complete flexion. either the head or buttocks of the fetus enter the pelvis first. (c) Poor flexion or marked extension. there is complete flexion at the head when the fetus "chin is on his chest. II. the fetus head is only partially flexed or not flexed. FETAL LIE The orientation of the long axis of the fetus to the long axis of the woman is the fetal lie. In reference to the fetus head. It gives the appearance of a military person at attention. the lie is longitudinal lie. Variations in the passenger I. it is extended or bent backwards. With cephalic.

is the most favorable among the three. If there is adequate room in the pelvis.  Military. (c) Incomplete breech.  Brow-fetal head is partly extended  Face-the head is fully extended. In reference to the cephalic position. Incomplete. This allows a face or chin to present first in the pelvis. C-- (a) Complete or full breech. full breech.  Suboccipito. (d) Arches of the feet-rested on the anterior surface of the legs. Cephalic Presentation. the fetus head is extended all the way back. B--Frank. This involves flexion of the fetus legs. and hard. This is the most common and easiest breech presentation to deliver. or side could present. This is when all of the above areas are flexed appropriately as described. (2) Areas to look at for flexion. caesarian section may be performed Midwifery 1 Course Manual Page 13 . (c) Knees-flexed at the knee joints. 3. FETAL PRESENTATION Fetal presentation refers to the part of the fetus which enters the pelvis first.the fetus is in a transverse lie. His legs are against his trunk and feet are in his face (foot-in-mouth posture). Breech Presentation.(d) Hyperextended. abdomen. depending on whether 1 or 2 feet appear first. It looks like the fetus is sitting in a tailor fashion. Types of breech presentations Breech positions. (3) Attitude of general flexion. round. A--Complete. It can gradually change shape to adapt to the size and shape of the maternal pelvis. and the fetal occiput is near the fetal spine.the disadvantages of Breech Presentation are that the buttocks are not smooth and firm like the head and is less effective at dilating. Three Categories of Fetal Presentation 1. the fetus may be delivered vaginally. Variations of the breech presentation are frank breech. The fetus feet or knees will appear first. The arm. (e) Arms-crossed over the thorax. The buttocks and feet appear at the vaginal opening almost simultaneously. 2. is the neutral position. part of the fetus lying over the pelvic inlet. The fetal head is smooth. The fetal head is the largest angle of the fetal part. There are three variations of cephalic presentation. His feet are labeled single or double footing.the brow is partly extended.most favorable. and footling. These are:  Vertex. The fetus thighs are flexed on his abdomen. back. Shoulder Presentation. III.the face is fully extended. (a) Head (b) Thighs-flexed on the abdomen. If the fetus does not rotate spontaneously or if the fetus cannot be manually turned. (b) Frank and single breech.

While some fetuses deliver in this position." or "soft spot. Direct OA Midwifery 1 Course Manual Page 14 . Shown here is the "direct OA" position. the fetus is still considered to be an an "anterior" position. these landmarks may become obscured. Anterior Fontanel The bones of the fetal scalp are soft and meet at "suture lines. Either way. Posterior Fontanel The occiput of the baby has a similar obstetric landmark. it is better to not attach it to the area of the fontanel. but at birth." This junction of suture lines in a Y shape that is very different from the anterior fontanel. but in most cases. called the "anterior fontanel. Feeling this fontanel on pelvic exam tells you that the forehead is just beneath your fingers. they can identify the fetal head position as it is engaged in the birth canal. After the patient is nearly completely dilated. the "posterior fontanel." Over the forehead. Early in labor. The anterior fontanel is an obstetrical landmark because of its' distinctive diamond shape. it is usually difficult (if not impossible) to feel the anterior fontanel.IV. it becomes easier to feel the fontanel. Posterior Fontanel Occiput Anterior (OA) Occiput anterior is usually the easiest position for the fetal head to traverse the maternal pelvis." This will close as the baby grows during the 1st year of life. When attaching a fetal scalp electrode. it is open. where the bones meet. In cases of fetal scalp swelling or significant molding. FETAL POSITION Fetal position reflects the orientation of the fetal head or butt within the birth canal. is a gap. others deliver slightly rotated clockwise (LOA) or counterclockwise (ROA).

Left Occiput Anterior (LOA) The fetal position is often described using three letters. converting this LOT to an LOA or OA as the head delivers. and  Mothers with flat pelvises that favor a transverse delivery Women with this condition who fail to deliver spontaneously are treated with cesarean section. this is called a "deep transverse arrest. the occiput usually rotates anteriorly. forceps. If the head fails to rotate despite steady descent. Transverse) position and its' mirror image. anterior side. meaning:  Left  Occiput  Anterior In other words. depending on the clinical circumstances. ROT. and experience of the operator. LOA Right Occiput Anterior (ROA) This is an example of ROA." and is common among:  Babies who are too big to come through. This is an example of LOA. As labor progresses and the fetal head descends. the fetal occiput is directed towards the mother's left. Occiput. available resources. LOT ROT Midwifery 1 Course Manual Page 15 . meaning:  Right  Occiput  Anterior These anterior presentations (ROA and LOA) are normal and usually are the easiest way for the fetus to traverse the birth canal. ROA Transverse Position This LOT (Left. or vacuum extraction. are common in early labor.

 Sacrum Anterior (SA) means the fetal sacrum is closest to the mother's symphysis. but there is controversy whether the fetus should be delivered in the posterior position.  Left Sacrum Anterior (LSA) means the fetal sacrum is closest to the mother's symphysis and rotated slightly to the mother's left (clockwise from direct SA). LOP ROP Breech Positions The terms used for breech positions are the same as for cephalic positions. In posterior positions. including direct OP.  Babies can deliver in the posterior position. Much depends on the clinical circumstances and the experience of the operator. instead of the occiput. LOP (Left Occiput Posterior) and ROP (Right Occiput Posterior) are positions favored by certain internal pelvic shapes.  Normally.  Forceps are often used to deliver babies in this position. the biparietal diameter is still a couple centimeters above the pelvic inlet.OP Occiput Posterior Occiput posterior positions. except the sacrum of the fetus is used as the identifying landmark. at 0 Station. This position has some obstetrical significance.  Right Sacrum Anterior (RSA) means the fetal sacrum is closest to the mother's symphysis and rotated slightly to the mother's right Page 16 RSP Midwifery 1 Course Manual . the biparietal diameter is at the pelvic inlet and the head is fully engaged. meaning that the head is not fully engaged. or rotated with the forceps to the anterior position. if the head is at 0 Station. but the pelvis needs to be large enough and it usually takes longer.

c) Knowing positions will help you to identify where to look for FHT's.This refers to the entrance of the presenting part of the fetus into the true pelvis or the largest diameter of the presenting part into the true pelvis. the fetus is said to be engaged when it reaches the midpelvis or at a zero (0) station. Once the fetus is engaged. (e) An occiput in the anterior quadrant means that you will feel a more smooth back. 4. PSYCHE. (5) Below the ischial spines is referred to +1 to +5. Measurement of station.     (counterclockwise from direct SA). In relation to the head. (b) LOP and ROP positions usually indicate labor may be longer and harder. This refers to the depth that the presenting part has descended into the pelvis in relation to the ischial spines of the mother's pelvis. 2Vertex. the fetus is said to be "floating" or ballottable. it (fetus) does not go back up. The mother may experience anxiety and fear. indicating the lower the presenting part advances. below the umbilicus. If delivered in that position. Station. (3) Above the ischial spines is referred to as -1 to -5. If delivered in that position. (d) An occiput in the posterior quadrant means that you will feel lumpy fetal parts. (4) The ischial spines is zero (0) station. the infant will come out looking down at the floor. This will be lower R or L quad.is the most crucial part of childbirth. and the mother will experience severe backache. Measurement of the station is as follows: (1) The degree of advancement of the presenting part through the pelvis is measured in centimeters. the infant will come out looking up. the numbers going higher as the presenting part gets higher in the pelvis (see figure10-3). Midwifery 1 Course Manual Page 17 . Examples of fetal vertex presentations in relation to quadrant of maternal pelvis. Prior to engagement occurring. This will be upper R or L quad. Engagement. (2) The ischial spines is the dividing line between plus and minus stations. arms and legs. above the umbilicus. Right Sacrum Transverse (RST) Left Sacrum Transverse (LST) Right Sacrum Posterior (RSP) Left Sacrum Posterior (LSP) Sacrum Posterior (SP) Observations about positions (a) LOA and ROA positions are the most common and permit relatively easy delivery. 1Breech.

a. Midwifery 1 Course Manual Page 18 . Powers (Contractions). (2) Resistance of the soft tissues as the fetus passes through the birth canal. b. Passage (Birth Canal). d. (a) Patient extremely anxious. (1) Site of implantation. (3) Size of the fetus. (b) Emotional factors related to the patient. c. (1) Force of the uterine contractions. (2) Position of the fetus (ROP. powers. e. They are easily remembered as the five Ps (passenger.SUMMARY There are five essential factors that affect the process of labor and delivery. Passenger (Fetus). placenta. LOP). if she has ever delivered before. (2) Frequency of the uterine contractions. transverse). (2) Whether it covers part of the cervical os. Placenta. (3) Fetopelvic diameters. (1) Parity of the woman. Psychology (Psychological State of the Woman). (1) Presentation of the fetus (breech. and psychology). passage. (c) Amount of sedation required for the patient.

TRUE LABOR VS FALSE LABOR Many women often experience "false labor" before "true labor" actually begins. Is present. duration. Occur regularly and increase in frequency. and Usually uneffaced and closed. show. OVERVIEW Labor is defined as the onset of rhythmic contractions and the relaxation of the uterine smooth muscles which results in effacement or progressive thinning of the cervix and dilation or widening of the cervix. even May intensify for a short period or it though fetus continues to may remain the same.STAGES OF LABOR AND NURSING CARE I. Are irregular and do not increase in frequency. Not present. move. duration. and intensity. May have brownish discharge that may be from vaginal exam if within the last 48 hours. No significant change. FALSE LABOR Do not produce progressive dilatation and effacement. False contractions may begin as early as three or four weeks before the termination pregnancy. Contractions. FACTOR Contractions TRUE LABOR Produce progressive dilation and effacement of the cervix. the cervix. Midwifery 1 Course Manual Page 19 . This process culminates with the expulsion of the fetus and expulsion of the other products of conception (placenta and membranes) from the uterus. Show Cervix Fetal Movement Becomes effaced dilates progressively. and intensity. and fetal movement all are vital in distinguishing between true and false labor. Stages of effacement and dilatation.

b. Second Stage of Labor. Third Stage of Labor. This is the period from birth of the baby until delivery of the placenta. The forces involved are uterine contractions Midwifery 1 Course Manual Page 20 . This is the period from complete dilatation of the cervix to birth of the baby. The third stage of labor is referred to as the "placental" stage. (3) Transient or transitional. (2) Active or accelerated. The first stage of labor is referred to as the "dilating" stage. d. The forces involved are uterine contractions plus intra-abdominal pressure. It is the period from the first true labor contractions to complete dilatation of the cervix (10cm) The forces involved are uterine contractions. Fourth Stage of Labor. This period begins with the delivery of the placenta and ends when the uterus no longer tends to relax.OVERVIEW OF THE LABOR PROCESS-FOUR STAGES a. The first stage of labor is divided into three phases: (1) Latent (early) or prodromal. First Stage of Labor. The forces involved are uterine contractions and intra-abdominal pressure. The second stage of labor is referred to as the "delivery or expulsive" stage. c. The fourth stage of labor is referred to as the "recovery or stabilization" stage.

(2) Explain all procedures or routines. 2 Estimated date of confinement (EDC) or due date. type and screen. serologic testing. location of fetal heart tones. (b) Draw lab work--CBC.e. 2 Frequency. (f) Where patient's personal belongings will be maintained. (7) Evaluate the patient's preparation for labor through classes. At this point. (c) Use of fetal monitors. 5 Vital signs. (6) Evaluate the patient's current emotional status. Midwifery 1 Course Manual Page 21 . an admission order is written. your duties as a practical nurse are as follows: (1) Establish a rapport with the patient and significant others. (5) Review the information obtained originally in the exam room. (4) Initiate the patient's labor chart. (e) Visitation policies. 3 Membranes-ruptured or intact. (8) Evaluate for possible danger signs. (c) Presence of meconium (fetal feces) in the amniotic fluid of a mother with a vertex position. Hospital Admission. (9) Perform the admission physician's orders to include but not limited to the following: (a) Administer and maintain intravenous fluids--per physician's order and SOP. 4 Problems with previous pregnancies/deliveries. 2 Allergies. call bell). 1 Rh status.NURSING CARE DURING THE FIRST STAGE OF LABOR a. (c) Current pregnancy. or per SOP. (c) Send uterine activity (UA) which was obtained prior to admission to the lab. duration. verify and transfer the OB health record to the labor chart per ward policies. (b) Excessive vaginal bleeding. room. (e) Obvious change in the character of uterine contractions. (a) Increased pulse or temperature. (d) Alteration in fetal heart tones (FHT's) above 160 or below 120. (d) Progress reports. bathroom privileges). These include: (a) NPO except ice chips while in labor. (b) Activities allowed and disallowed according to ward policies (i. This is usually done on all patients. 4 Amount and character of show or vaginal bleeding. 5 minutes or less). 7 Plans to bottle or breast feed. 1 Gravida/para. 1 Onset of labor (contractions regular. 8 Any problems with this pregnancy. You will review the following information: (a) Obstetric history. 3 Duration of previous labors. and intensity of contractions. (b) General condition. which will be carried out prior to performing them. After a physician or nurse has evaluated the patient. 3 History of medical problems. 6 Rate. (3) Orient the patient to the surroundings (that is.

Evaluation of Uterine Contractions Continued. soap-suds enema. d. c. (2) The patient must be evaluated to determine if she has had a recent bowel movement. (3) If a cleansing enema is given. place your hand over the fundal area of the patient's uterus. There must be a physician's order to perform this task. Midwifery 1 Course Manual Page 22 . (4) Some physicians consider giving fleets to: (a) Prevent fecal contamination of the perineum during delivery. (2) This evaluation will help you in identifying the frequency (how often in minutes contractions occur). (5) Some physicians consider not giving fleets because the following factors may be present or begin: (a) Vaginal bleeding. (b) Premature labor. (b) Cleanse the bowel. (3) When palpating for contractions. help in determining the progress of labor. Perineal Preparation. (h) Results of enema may produce unmanageable amounts of loose stool at delivery. (c) Presenting part not engaged. Giving an enema is no longer considered routine. or strong [severe]). (d) Abnormal presentation--breech or transverse. (f) Advanced labor.b. (g) Membranes are ruptured or danger of prolapsed cord. (1) A cleansing enema may range from "mini-" or "Fleets" to a full. and help to evaluate any signs of fetal distress. (e) Already rapid moving labor. (c) Stimulate uterine contractions. Cleansing Enema. it is usually a small fleet. Shaving of pubic hair to prevent infection of perineal episiotomy/lacerations is rarely done anymore. moderate. and duration (how long the contractions lasts in seconds). help to detect abnormalities of uterine contractions (such as lack of uterine relaxation). (1) The purpose of this evaluation is to assess the ability of the uterus to dilate the cervix. Contractions can be felt by your fingers before the patient actually becomes aware of them. There must be a physician's order to perform this task. This provides more room for fetal passage. intensity (strength of contractions when palpitations are identified as mild.

According to the National Institute of Health (NIH). NOTE: The prolapsed cord is referred to as the umbilical cord that protrudes beside or ahead of the presenting part of the fetus. Midwifery 1 Course Manual Page 23 . between contractions that are consistently abnormal. the show becomes more blood-tinged. f. Any variations should be reported immediately. a patient receiving oxytocin infusions. (1) Fetal monitoring is done to detect presence of fetal life at time of admission and to detect development of fetal distress during labor. and immediately after rupture of membranes. A fetoscope or fetal monitor may be used to obtain FHTs. This helps to identify the location of the prolapsed cord. any high risk patient. Pressure of the presenting part on the umbilical cord can endanger fetal circulation. a patient with obstetric complications. if either the mother or fetus is considered at risk. (6) Most medical facilities are using continuous fetal monitoring during labor. Monitoring and Recording Color and Amount of Show. (5) Candidates for continuous fetal monitoring includes a patient with a multiple pregnancy. (4) Fetal monitoring continued. electronic fetal monitoring of the fetus is not necessary during normal labor. every 5 minutes during the second stage of labor. The rate may increase or decrease by 30 BPM during a contraction. A sharp increase in the amount of bloody show coupled with frequent severe contractions may indicate labor is progressing too rapidly. It should return to the baseline immediately after the contraction.Uterus between and during contractions. (b) Fetal bradycardia--FHTs sustained at less than 120 BPM. a patient with meconium stained amniotic fluid. Alternative birth centers often use intermittent monitoring. e. As labor progresses. Fetal Monitoring. every 15 minutes during the first stage of labor. (2) Fetal distress may be indicated by FHT's. However. A continued fetal heart rate of greater than or less than 30 BPM from the normal baseline after contractions may be indicative of fetal distress as defined by: (a) Fetal tachycardia--FHTs sustained at greater than 160 BPM. (3) The FHTs should be checked and recorded on admission. a more precise measurement of fetal response is indicated. Report this immediately to the Charge Nurse or physician and be prepared for possible delivery. or any patient whose pregnancy is not progressing normally. Normal fetal heart rate ranges from 120 to 160 beats per minute (BPM).

You should offer the patient an opportunity to void every 2 hours during labor. Patient is NPO During Labor. pulse (P). h. The administration of analgesics also prolongs gastric emptying. Monitor the patient's vital signs. The discomfort of contractions often causes the patient to be unaware that her bladder is full. Patient Given an Opportunity to Void. (5) More frequently if complications arise. but NOT placed on the sutures. Gastric emptying time is prolonged once labor is established. A transducer is placed on the abdomen over the uterus for external monitoring. fontanels. transition. (1) On admission. (2) Every hour during early labor. to include the temperature every hour. Vital Signs. and the second stage of labor. Internal fetal monitoring. i.(7) Methods of fetal monitoring. (4) Blood pressure. Vaseline may be applied to her lips to prevent chapping. An electrode is attached to the presenting part of the fetus. External fetal monitoring. A full bladder may impede the progress of labor. The patient may Midwifery 1 Course Manual Page 24 . and R every 15 minutes while on Pitocin®. g. The patient may have ice chips to prevent drying and chapping of the lips. to include the temperature every hour. face. (3) Blood pressure (BP). P. and respiratory rate (R) every 30 minutes during active. or scrotum for internal monitoring.

which may yield a prolapsed cord. Apply an internal fetal monitor lead or a uterine catheter. Assist the patient in turning from side to side. (3) Fluids should be carefully examined for meconium if the fetus is in the vertex presentation. This syndrome results in pressure of the enlarged uterus on the vena cava. Midwifery 1 Course Manual Page 25 . Prevention of Infection. Fresh. You should check for: (a) Slight green color--called light meconium. cervical dilatation. effacement. A patient with infections should be separated from other patients. Once membranes rupture. Being unaware of when possible complications could arise could necessitate an emergency C-section with general anesthesia. (that is. Unauthorized persons should not be allowed in the area. and reduces blood circulation to the uterus and across the placenta to the fetus. The cord may be displaced by the sudden "gush" of waters. and presenting part. clean scrub suits should be worn in the delivery area. The patient may complain of being nauseated and feeling cool and clammy. Vaginal exam. The best position for the patient is on her left side since this increases fetal circulation. Elevate the head of the bed 30 degrees. See figure below for vaginal palpation of cervical dilatation. Artificial Rupture of Membranes. Handwashing is essential before and after performing any procedure. Try to keep the patient off her back to prevent supine hypotensive syndrome. the exam should be limited even further to prevent the risk of infection. head first).vomit and aspirate since her stomach contents may not be absorbed. Care must be taken to perform good perineal cleansing before and after the procedure (vaginal exam). Only the physician or a trained nurse performs this exam. Determining fetal distress is secondary to ckompression of the cord. status of membranes. Positioning During Labor. decreases blood pressure. k. l. Vaginal Exams. m. this makes it easier for the patient to breathe. j. (1) Rupture of the membranes is done by the physician to induce or hasten labor. It is done to evaluate cervical effacement. and station of presenting part. (2) The FHTs should be checked immediately following rupture. reduces blood supply to the heart. amniotic membranes.

She may be nauseated or flushed and may vomit. Remind the patient that she still can't push even though she may have a strong urge to do so. Remind the patient that this is the shortest stage and that the baby will be born soon. and also. Preparation is usually done by the paraprofessional on duty if the scrub technicians are not employed. Continue to give support. (c) Bulging of the perineum. The local SOP will determine how soon before anticipated delivery the room can be set up. (d) Fetal heart rate immediately after the procedure and five minutes after the procedure. Emotional Support. effleurage (stroking movement used in massage. It is usually 2 to 12 hours if the tables are covered and rooms are closed. and give explanations. o. SECOND STAGE OF LABOR (DELIVERY STAGE) SECOND STAGE OF LABOR The second stage of labor begins when the cervix is completely effaced and dilated and ends when the infant is born. (b) Desire to bear down or have bowel movement (result of the descent of the presenting part). moderate. Preparation of the Delivery Room. stay and support her . (1) Imminent signs. Include significant other in these procedures. Offer support and explanations. Encouragement is especially important now since the patient is most likely losing control at this point. pant-blow). (1) First phase--latent. The room is prepared while the patient is in the first stage of labor. These signs of the second stage of labor are considered imminent or impending signs. controlled release of fluid. Remind the patient to not push down during the first stage since it could causes cervical edema.(b) Green to dark color--called moderate meconium. Reinforce breathing and relaxation techniques. Strict aseptic technique is maintained. (e) Instrument used. It could also cause cervical lacerations and fetal hypoxia. Assist the patient to turn on her side or to sit up to prevent aspiration. to provide a slow. moderate. if other than an amnihook. Use more intensive breathing techniques (high chest. (2) Second phase--active. Midwifery 1 Course Manual Page 26 . Accelerated shallow panting may be used. (4) Record the following information: (a) Time of the procedure (rupture of membranes). or heavy). Other instruments may be a fetal scalp electrode or spinal needle. (c) Dark green with chucks of meconium--called heavy meconium. (b) Amount of fluid expelled (small. Be aware that the patient may want to be left alone. n. a. or large). (c) Color--clear or meconium stained (extent of staining--light. simple phrases. Encourage her to concentrate on relaxation and breathing techniques. usually of the abdomen). Wipe her face and mouth with a cool cloth. offer encouragement. Make sure to give instructions in short. (3) Third phase--transition. (a) Increased bloody show. NOTE: The amnihook is used to tear a small opening in the amniotic sac. Instruct or reinforce breathing techniques (breathe slowly and deeply and use deep chest or abdominal breathing). but don't leave.

down each thigh. and down the rectal area. Rinse area with the remaining solution. Clean the perineum by washing the pubic area. Midwifery 1 Course Manual Page 27 . down each side of the labia. The patient usually pushes (i. (d) Pleas for relief. Discard used sponges after each step. size of the infant. b. Multipara patients are transferred when the cervix is completely effaced and dilated. familiarity of the staff with equipment. Verbal encouragement and physical contact help reassure and encourage the patient. In addition. These patients are normally not encouraged to push when in the labor room since delivery occurs more rapidly in the multipara patient. Facilities using birthing beds have the patient in an upright position. A Betadine® scrub and water are used with 4x4's. Never leave the patient alone once she has been transferred to the delivery room. Position the patient's legs in the stirrups for the lithotomy position. TRANSFER OF THE LABOR PATIENT TO THE DELIVERY ROOM Transfer the mother to the delivery room and prepare her for delivery when delivery seems imminent. Each case may be different. This is the most common position for delivery. Primigravida patients are transferred when the cervix is completely effaced and dilated and the head or presenting part is crowning.. (b) Irritability and uncooperativeness. a. effectiveness of the patient's pushes. d. Monitor the patient's blood pressure and the fetal heart tones every 5 minutes and after each contraction. NURSING CARE GIVEN WHILE IN THE DELIVERY ROOM a. and need for additional preparation time. down the perineum. Encourage the patient to rest between contractions and to push with contractions. Once dilatation and effacement are complete. e. (2) Impending signs. b. Begin cleaning at number 1 and proceed through number 7. never turn your back on the perineum because the baby could push through the vaginal opening while your back is turned. Prep the patient's perineum. arrival of the physician. Only one person should coach. the patient is instructed to push with each contraction to bring the presenting part down into the pelvis. She may be transferred prior to complete dilatation (8 to 9 cm) if she is progressing rapidly and the presenting part is descending.(d) Dilatation of the anal orifice. Timing is dependent on the parity of the patient. b. Positioning also depends upon the type of anesthesia to be used and C-section delivery. Parity refers to the condition of the woman with respect to her having borne children. (c) Complaints of severe discomfort. (a) Nausea and retching. bears down) in the delivery room.e. c.

e. Delivery of the trunk and lower body. d.Cleaning the patient's perineum. Delivery of the anterior shoulder and the posterior shoulder. Delivery of the head. Clamping and cutting of the umbilical cord. the activity of the normal birthing process is given below: a. In general. This includes suctioning of the infants nose and mouth with a bulb syringe. the appearance of the infant's head on the perineum. Crowning. b. Midwifery 1 Course Manual Page 28 . NORMAL BIRTHING PROCESS Even though most of the time the delivery remains in the hands of the obstetrician. c. A DeLee suction trap is used if meconium is present. there may be times when a practical nurse will have to assist the patient to give birth.

g. h. Type of episiotomy. A baby in excellent condition would score 9 to 10 and a dead baby would score 0. muscle tone. a. The condition of the infant will be taken at one (1) minute.e. j. The values are added giving a total APGAR score. Number of vessels in the cord. Any other pertinent facts about the delivery. respiratory effort. Use of oxygen and suction on the infant.. Completely pink extremities blue . e. Irregular Good. d. at five (5) minutes. Most babies score 7 or better. Condition of the infant (APGAR) after birth. f. b. Mother's name. Spontaneous or forceps delivery. and at thirty (30) minutes. INFORMATION TO BE RECORDED ABOUT THE DELIVERY Record the following information. i. APGAR is the most widely used method of evaluating the condition of a newborn baby. heart rate. Position of the infant at delivery. pale 1 Point 2 Points <100 >100 Slow. lacerations. and color).Birthing process (continued). Sex of the infant. A value of 0 to 2 is given for each observation (i. c. APGAR SCORE Category Heart Rate Respiratory Effort Muscle Tone Reflex Irritability Color 0 Points Absent Absent Flaccid No Response Blue. Exact date and time of delivery. Midwifery 1 Course Manual Page 29 . reflex irritability. crying Some flexion of Active motion extremities Grimace Vigorous cry Body pink.

c. continue in your observation of the fundus.THIRD STAGE OF LABOR (PLACENTAL STAGE) 2-11. THIRD STAGE OF LABOR As previously mentioned. Signs of the placental separation are as follows: a. If the placenta is delivered complete and intact or in fragments. Midwifery 1 Course Manual Page 30 . Oxytocin is never administered prior to delivery of the placenta because the strong uterine contractions could harm the fetus. INFORMATION TO RECORD Record the following information. b. The umbilical cord descends three (3) inches or more further out of the vagina. a. b. d. Allow the mother to bond with the infant. amount. Time the placenta is delivered. Following delivery of the placenta. The uterus becomes globular in shape and firmer. Placental separation and delivery. Retention of the tissues in the uterus can lead to uterine atony and cause hemorrhage. the third stage of labor is the period from birth of the baby through delivery of the placenta. Type. Sudden gush of blood. d. b. NURSING CARE DURING THE THIRD STAGE a. Continue observation. Show the infant to the mother and allow her to hold the infant. time and route of administration of oxytocin. How delivered (spontaneously or manually removed by the physician). The uterus rises in the abdomen. c. Ensure that the fundus remains contracted. This is considered a dangerous time because of the possibility of hemorrhaging. Massaging the fundus gently will ensure that it remains contracted.

e. the uterus makes its initial readjustment to the nonpregnant state. Remove both legs from the stirrups at the same time and then lower both legs down at the same time to prevent cramping. This will be done after you place a clean gown on the patient. d. NURSING CARE DURING THE FOURTH STAGE OF LABOR a. An ice pack may be applied to the perineum to reduce swelling from episiotomy especially if a fourth degree tear has occurred and to reduce swelling from manual manipulation of the perineum during labor from all the exams. NOTE: Atony is the lack of normal muscle tone. (2) Massage the fundus until it is firm if the uterus should relax.FOURTH STAGE OF LABOR (RECOVERY STAGE) FOURTH STAGE OF LABOR The fourth stage of labor. as previously mentioned. c. every 30 minutes during the next hour. b. (2) Pitocin® is available in the event of hemorrhage. In this stabilization phase. obtained a complete set of vital signs. (3) IV remains patent for possible use if complications develop. Transfer the patient from the delivery table. The primary goal is to prevent hemorrhage from the uterine atony and the cervical or vaginal lacerations. every hour until the patient is ready for transfer. evaluated the fundal height and firmness. Uterine atony is failure of the uterus to contract. and evaluated the lochia. Ensure emergency equipment is available in the recovery room for possible complications. and then. Assist the patient to move from the table to the bed. (1) Suction and oxygen in case patient becomes eclamptic. Check the fundus. Apply a clean perineal pad between the legs. (1) Ensure the fundus remains firm. Provide care of the perineum. is the period from the delivery of the placenta until the uterus remains firm on its own. Massaging the fundus. Midwifery 1 Course Manual Page 31 . Remove the drapes and soiled linen. Transfer the patient to the recovery room. (3) Massage the fundus every 15 minutes during the first hour.

foul-smelling lochia. lights. (3) Document thick. then every 30 minutes for an hour.(4) Chart fundal height. (4) Observe for constant trickle of bright red lochia. However. Monitor the patient's vital signs and general condition. call bell. Midwifery 1 Course Manual Page 32 . and then every hour as long as the patient is stable. and tissue from the uterus. (6) Encourage the patient to drink fluids. (3) Observe for any untoward effects from anesthesia. and so forth. (b) Every thirty (30) minutes times one hour. etc. f. Lochia is the maternal discharge of blood. (5) Identify lochia amounts as small. P. mucus. Take the patient's temperature every hour. (2) Identify presence of bright red bleeding or blood clots. NOTE: A boggy uterus many indicate uterine atony or retained placental fragments. (5) Allow the patient time to rest. This may last for several weeks after birth. one finger above the umbilicus (1/U). (6) Document lochia flow when the fundus is massaged. identify this and evaluate for distended bladder. This is descriptive of the postdelivery of the uterus. Monitor lochia flow. and R every 15 minutes for an hour. Assessing lochia flow. The cause of the mother being chilled following birth is unknown.). (c) Every hour until ready for transfer. This may indicate lacerations. moderate. The best means of relief is to cover the mother with a warm blanket. (a) Every fifteen (15) minutes times one hour. Boggy refers to being inadequately contracted and having a spongy rather than firm feeling. Evaluate from the umbilicus using fingerbreadths. Record the number of pads soaked with lochia during recovery. If it deviates from the middle. Observe the mother for chills. The fundus should remain in the midline. h. (4) Orient the patient to the surroundings (bathroom. This is recorded as two fingers below the umbilicus (U/2). it refers primarily to the result of circulatory changes after delivery. (5) Inform the Charge Nurse or physician if the fundus remains boggy after being massaged. (1) Keep a pad count. g. (1) Take BP. (2) Observe for uterine atony or hemorrhage. or heavy (large).

(1) Predisposing conditions includes prolonged second stage. (2) Full bladders may actually cause postpartum hemorrhage because it prevents the uterus from contracting appropriately. Observe patient's urinary bladder for distention. (3) Assessment for perineal hematoma. forceps delivery. (a) Look for discoloration of the perineum. (5) Urine output less than 300cc on initial void after delivery may suggest urinary retention.i. Evaluate the perineal area for signs of developing edema and/or hematoma. and fourth degree lacerations. Be able to recognize the difference between a full bladder and a fundus. ambulate the patient to the bathroom. (b) Spongy feeling mass between the fundus and the pubis. (b) Reevaluate and document the fundal height and bladder status after the patient urinates to accurately document an empty bladder. (b) Stress the importance of peri-care and use of "sitz-baths" on the postpartum ward. (d) Increased lochia flow. j. (1) Characteristics of a full bladder. (c) Displaced uterus from the midline. (c) Assess for urinary distention which is due to edema of the urethra. rapid delivery. (a) Apply an ice pack to the perineum as soon as possible to decrease the amount of developing edema. (a) Bulging of the lower abdomen Bulging of the lower abdomen. (4) If at all possible. (c) Observe for edema of the area. (3) Nerve blocks may alter the sensation of a full bladder to the patient and prevent her from urinating. (b) Listen for the patient's complaints or expression of severe perineal pain. (a) Document the fundal height and bladder status before the patient urinates. (d) Observe/listen for patient's feeling the need to defecate if forming hematoma is creating rectal pressure. Midwifery 1 Course Manual Page 33 . delivery of a large infant. usually to the right. (2) Nursing considerations for perineal edema.

Discontinue IV on a normal patient once she is stable and the physician has ordered removal. monitor the patient as you would any patient in a recovery room immediately during post delivery. Complete notes and transfer the stable patient to the ward (on normal vaginal delivery--others require physician clearance). pudendal block) should be assessed for possible loss of sensation in the lower extremities. (2) Vaginal or cervical lacerations. n. (3) Retained placental fragments. If not. Include monitoring of the fundus and lochia flow. p. (5) Severe hematoma in vagina or surrounding perineum. l. wipe from front to back to avoid contamination. m. (3) Ammonia ampuls should be readily available. Observe C-section patients. (1) The patient is at risk of fainting on initial ambulation after delivery due to hypovolemia from blood loss at delivery and hypoglycemia from prolonged nothing by mouth (NPO) status. Times are consistent with the normal vaginal delivery patient. The patient should use the peribottle after each void and bowel movement. (2) The patient should be accompanied on the first ambulation and observed for stability. Instruct the patient in the proper perineal care. Observe for signs of hemorrhage. Midwifery 1 Course Manual Page 34 . (1) Uterine atony. Most C-section patients are still initially recovered in the recovery room. Assess for ambulatory stability.(e) Observe for patient's sensitivity of the area by touch (by sterile glove). (4) Bladder distention. k. (4) The patient should be closely monitored while in the bathroom to prevent injury if fainting does occur. (5) The patient who received regional anesthesia at deliver (that is. o. and apply the perineal pad from front to back.

(You usually don’t need soap when cleaning most parts of your newborn — they just don’t get that dirty). his body draped along your arm) with his head over the basin. Shampoo his hair — if he has any. hold your critter football -style (the back of his head cradled in one hand. reposition the blanket so it covers the top half of his tiny body. unscented soap or body wash and shampoo (or a product that does double duty) Cotton balls Rubbing alcohol A plastic basin filled with warm water A plastic cup Baby lotion Diaper cream (if your baby is rash-prone) A clean diaper A fresh set of clothes A blanket or two (one to cover parts of him during the sponge bath and another for after the sponge bath if your baby likes to be swaddled) 2. clean the other eye. and gently wipe one eye from the inner corner outward. 5. gently wipe the folds of her vagina. especially around his mouth and under his chin where milk and drool can pool. You’ll be washing the top half of his body first. (Never use a cotton swab to clean inside your cutie’s ears. Midwifery 1 Course Manual Page 35 . Focus on his face first. Otherwise. that is. Wash his body.) Using water and a tiny bit of shampoo. 6. Next clean under his arms and between his fingers. If you have a girl. and inside and behind his ears. Set up your baby’s sponge-bath site. then clean his legs and toes. Do the same if he’s been circumcised. so drape the blanket over his lower limbs to keep him toasty. Layer one towel on top of the other. simply wipe his penis clean. Gather your supplies.) 7. dip the washcloth in warm water and wash your little one’s neck and torso. Clean the diaper area. Arrange everything else within easy reach. Prep your baby. use a washcloth on his bald noggin. it’s okay to gently wipe away any crustiness around it. Have everything you’ll need at your fingertips before you start. Maneuver carefully around the umbilical cord. If your baby boy is uncircumcised. and then follow whatever directions your doctor has given you.) It’s okay to use a little soap on your baby’s face for stubborn crud. To rinse. (If he doesn’t. Next up: that tiny tush. With the blanket still in place over his lower body. Lay him down on the top towel and strip him down to his birthday suit. Fill the cup with water and gently pour it over your baby’s head. lather your baby’s scalp. Wet the washcloth entirely and wash your munchkin’s mug. Here are the essentials: One or two cotton washcloths A couple of plush towels (the bottom one can be hooded) A mild. no need to pull back his foreskin. you’ll have to gather up your naked newborn mid–sponge bath to fetch whatever you’ve forgotten. 3. Dip a corner of a washcloth or cotton ball in the warm water.STEPS IN BATHING THE NEWBORN 1. (Be sure to use a little soap for this part of the baby sponge bath. 4. Be sure to get into those little creases and skin folds. Using a different corner of the cloth or a clean cotton ball.

swaddle him in a blanket. Midwifery 1 Course Manual Page 36 . If your baby has dry or eczema-prone skin. Dry him off. massage a hypoallergenic lotion into his skin (warm it first between your palms).8. If he needs a little soothing after his sponge bath. sweet-smelling sweetie. 10. Finished bathing your newborn? Slip on a fresh diaper and dress your little one in some clean clothes. 9. Peel off the top towel (it’s probably damp anyway) and use the bottom one to pat your baby dry. Lotion him up. Then settle in for some serious snuggling with your clean. Diaper and dress.

Indicate whether the following statements/phrases are true or false by circling the "T" for true and "F" for false. T F 17. T F 19.__________________________________________________ Third stage . T F 11._____________________________________________________ Second stage . Each stage is referred to with different events. The primigravida patient is transferred to the delivery room when her cervix is completely effaced and dilated and the head or presenting part is crowning. A boggy uterus may indicate uterine atony or retained placental fragments. The multipara patient is transferred to the delivery room when her cervix is completely effaced and dilated. T F 8. T F 12. What are the main factors involved in distinguishing between true and false labor? ______________________________ ________________________ ______________________________ ________________________ 2. Oxytocin can be administered prior to delivery of the placenta. These forces are called: _______________________________________________________________ 4. The fetus heart may increase or decrease by 40 BPM during a contraction. T F 7. Fill in the blanks identifying each event. Show is present in false labor. Complete the chart below to indicate what happens during each factor to identify true and false labor. First stage . A high risk patient is a candidate for continuous fetal monitoring. T F 13. There are four stages involved in the labor process. A cleansing enema is always given to the patient when she is in labor. A patient who has been transferred to the delivery room can be left alone for 2 minutes. T F 16. T F 14. APGAR is a method used for evaluating the condition of a newborn baby.Laboratory Exercise INSTRUCTIONS: Answer the following exercises by marking the lettered response that best answers the exercise. Rupture of the membranes is performed by the physician to induce or hasten labor. T F 9. T F 18. The first stage of labor is categorized with three phases. The contractions of true labor produce progressive dilation and effacement of the cervix. Midwifery 1 Course Manual Page 37 . 3. They are: _______________________________ _______________________________ _______________________________ Special Instructions for exercises 6 through 18. T F 15.____________________________________________________ Fourth stage . T F 10.___________________________________________________ 5. Complete dilatation of the cervix is considered _________ cm. or by writing the answer in the space(s) provided. Normal fetal heart rate ranges from 120 to 160 beats per minute. 1. 6. by completing the incomplete statement. There are forces involved when the cervix is dilating.

What are the characteristics of a full bladder after delivery? ________________________________________________________________ Midwifery 1 Course Manual Page 38 . The activity of the normal birthing process includes: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 28. place your hands when you are palpating the patient's contractions? ________________________________________________________________ 24. Where should you. the practical nurse. complains of severe discomfort. Why is fetal monitoring performed? ________________________________________________________________ ________________________________________________________________ 25. In which phase of the first stage of labor does the contractions become stronger and last longer.FACTOR Contractions Show Cervix Fetal Movement TRUE LABOR . Information to be recorded about the delivery includes: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 29. usually 45 to 60 seconds? ________________________________________________________________ 21. What nursing care is performed in the delivery room? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 27. and pleas for relief are all impending signs of labor during which stage of labor? ________________________________________________________________ 26. The patient being nauseated and retching. irritable and uncooperative. are more intensified. What are the reasons some physicians consider giving fleets? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 23. In which phase of the first stage of labor does contractions become sharp. and last from 60 to 90 seconds? ________________________________________________________________ 22. FALSE LABOR 20.

The onset of rhythmic contractions. ________ is the maternal discharge of blood. If the patient's uterus should relax after delivery. List the five factors that may extend or influence the duration of labor. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 32. What nursing care is performed to the patient after delivery? List 8 of the 16 tasks. the relaxation of the uterine smooth muscles which results in effacement or progressive thinning of the cervix. and dilation or widening of the cervix is known as: ________________________________________________________________ Midwifery 1 Course Manual Page 39 . what nursing care should be given? ________________________________________________________________ 33.________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 30. 34. and tissue from the uterus. What are the signs of placental separation? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 35. mucus. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 31.

LABORATORY PROCEDURES FOR GRADED RETURN DEMONSTRATION Midwifery 1 Course Manual Page 40 .

Laboratory Procedures for Graded Return Demonstration I. They are:  Descent  Flexion  Internal Rotation  Extension  External Rotation Midwifery 1 Course Manual Page 41 . The Cardinal Movements of Labour is composed of: The movement in upper zone of passages Engagement Flexion Descent The movement in lower zone of passages Internal rotation Extension The Movement which is out of the passages: Restitution External Rotation Expulsion Mechanism of Normal Labor There are five classical steps in the normal mechanism of labor. Mechanism of Labor Is the process of adaptation or accommodation of suitable portion of the head to the various segments of the pelvis as required in vaginal delivery.

with a normally positioned head. labor progresses in this fashion. The fetal position remains occiput transverse. When flexion occurs. may continue to flex or increase its flexion while it is also internally rotating and descending. for example. if the fetus is of average size. the head may rotate completely to the occiput anterior position. Midwifery 1 Course Manual Page 42 . the occiput rotates anteriorly and the fetal head assumes an oblique orientation. it assumes an occiput transverse position because that is the widest pelvic diameter available for the widest part of the fetal head. The fetal head. Flexion: While descending through the pelvis. Internal Rotation: With further descent. In some cases. There is overlap of these mechanisms. This functionally creates a smaller structure to pass through the maternal pelvis. Descent: As the fetal head engages and descends. in a normal labor pattern in a woman whose pelvis is of average size and gynecoid in shape.Usually. the fetal head flexes so that the fetal chin is touching the fetal chest. the occipital (posterior) fontanel slides into the center of the birth canal and the anterior fontanel becomes more remote and difficult to feel.

supine with knees flexed to relax abdominal muscles Drape properly to maintain privacy. fetal presentation. and engagement. Use the palm for palpation not the fingers. Proper assessment and findings can indicate whether the delivery would be normal. The nurse should then warm the hands and apply it to the abdomen of the mother by using firm and gentle pressure. Ask the mother to empty the bladder. Place in dorsal recumbent position.    It is a method that determines the fetal position. LEOPOLD’S MANEUVER Leopold’s Maneuver is preferably performed after 24 weeks gestation when fetal outline can be already palpated. It has 4 different actions that help determine the position and presentation of the fetus. complicated or if the mother would need to undergo Caesarian section. Preparation:       Explain procedure to the patient.II. Midwifery 1 Course Manual Page 43 .

hard.Leopold’s Maneuver Maneuvers Purpose Procedure Findings First To determine fetal Using both hands. abdomen above symphisis pubis. Fourth To determine the Facing foot part of the woman. moves independently of the body. Pawlik’s Grip presenting part. Second To identify location One hand is used to steady the Fetal back: smooth. downward about 2 inches elbows and knees. meet an obstruction on the same side as To determine fetal back (hyperextended head) attitude. If brow is very easily palpated. above the inguinal ligament. grasp The presenting part is engaged if it is not Maneuver: engagement of the lower portion of the movable. hard and round that Maneuver: part lying in the fetal part lying in the fundus. make gentle movements from side to side. Third To determine Using thumb and finger. Good attitude: if brow corresponds to the Maneuver: degree of flexion of palpate fetal head pressing side (2nd maneuver) that contained the Pelvic Grip fetal head. uterus on one side of the surface Umbilical To determine abdomen while the other hand Knees and elbows: with a number of Grip position. feel for the Head: more firm. and resistant Maneuver: of fetal back. Fundal Grip fundus. Poor attitude: if examining fingers will Use both hands. Also palpates infant’s anteroposterior position. Breech: less well defined that moves only in conjunction with the body. fetus is at posterior position (occiput pointing towards woman’s back) Midwifery 1 Course Manual Page 44 . Use gentle but deep pressure. To determine presentation. moves slightly on a angular nodulation upon palpation circular motion from top to the lower segment of the uterus to feel for the fetal back and small fetal parts. press in slightly and It is not yet engaged if it is still movable.

III. gloves. Put on gloves. 5. After the woman is in position. drapes. transfer her to the delivery room or position the birthing bed. Put the infant to the mother’s breast. cleanse the Midwifery 1 Course Manual Removes secretions and feces from the perineal Page 45 . and encourage suckling to promote uterine contraction. last-moment preparations are anxiety producing for the woman. No invasive procedure is to be done. and head with a wedge ( on a delivery table) or by raising the head of the birthing bed. solutions. Padding reduces pressure. 2. Administration of medications. 3. The nurse will be ―catching‖ the infant in this situation. Prepping and Draping 7. When placing the woman’s legs in stirrups. The exact time varies with several factors (such as overall speed of labor and rate of fetal descent). shoulders. When the woman is almost ready to give birth. Action I.Stirrups or foot rests to support the woman’s legs and feet may be used on a birthing bed. Remaining in the birth position for a long time can be tiring. usually oxytocin. Birth may occur unexpectedly. and place skin-to-skin with the mother or cover with warmed blankets to maintain warmth. Sterile gloves reduce the transmission of environmental organisms to the mother and infant. Elevate the woman’s back. Detects changes in fetal condition that may require interventions by the attendant to speed birth. During the birth    Remain with the woman to assist her in giving birth. Rationale Rushed. and instruments. After the birth     Observe the infant’s color and respirations for distress. Transfer and Positioning for Birth 1. preventing venous stasis and possible thrombus formation. Pad the surface. ASSISTING IN BIRTH AND DELIVERY Responsibilities During Birth     Preparation of a sterile delivery table with gowns. Do not separate her legs widely. Stay calm to reduce the couple’s anxiety. to prevent contamination with blood and other secretions. Continue observing the perineum while making final preparations for birth. 4. Perineal cleansing Initial care and assessment of the newborn. Suction excess secretions with a bulb syringe. Allows more effective maternal pushing and uses gravity to aid fetal descent. Dry the infant. preferably sterile. her partner. 6. Continue observing the fetal heart rate (FHR) with continuous monitoring or intermittent auscultation. and the nurse should be prepared to ―catch‖ the infant if the attendant (physician or nurse-midwife) is not in the room. elevate them and remove them simultaneously. to contract the uterus and control blood loss. and the nurse. Reduces strain on muscles and ligaments. Use the call bell or ask her partner to call for help. facilitating expulsion of the placenta and controlling bleeding.

the attendant will perform it when the head is well crowned. Minimizes blood loss from the episiotomy. it is slipped over the head. but some attendants may prefer to use them.After external rotation. Clearing the infant’s airway and cutting the Midwifery 1 Course Manual Page 46 . apply sterile gloves for the procedure. 11. 8.If it loose. area. and do not return to a clean area with a used sponge. over the perineum. perineum.As the vaginal orifice encircles the fetal head. The attendant may ask the mother to blow so that she avoids pushing or to push gently. 15. pelvic outlet. If an episiotomy is needed. The attendant may apply sterile drapes if desires. e. After handwashing. Sterile drapes are unnecessary. Use a single stroke in the middle from the clitoris over the vulva and perineum. preventing the infant from aspirating them with the first breaths. 12. Use a zig-zag motion on the inner thigh from the labia majora to about halfway between the hip and knee. this minimizes trauma to the maternal tissues. c.Take fresh sponge to begin each new area. Prevents cross-contamination or recontamination of an area that is already clean. The attendant wipes secretions from the infant’s face and suctions the nose and mouth with a bulb syringe.perineal area with a sterile iodophor and water preparation unless she is allergic. 9. The attendant then lifts the head toward the Permits the posterior fetal shoulder to be eased mother’s symphysis pubis. Birth of the Shoulders Removes blood and secretions. Six sponges are needed. The proper order and motions are as follows: a. d. the attendant applies gentle pressure to the woman’s perineum with one hand while applying counterpressure to the fetal head with the other hand (Ritgen’s maneuver). A vaginal birth is a clean procedure rather than a sterile one because the vagina is not sterile. Controls the exit of the fetal head so that it is born gradually rather than popping out. Traction on the head in the direction of her perineum allows the anterior fetal shoulder to slip under the symphysis pubis. The attendant feels for a cord around the fetal neck (nuchal cord). External rotation allows the shoulders to rotate 14. Apply a single stroke on one side on one side from clitoris over labia. b. Use warm water to dilute iodophor scrub. the attendant applies internally and aligns their transverse diameter gentle traction on the fetal head in the direction of with the anteroposterior diameter of the mother’s the mother’s perineum. Allows the rest of the birth to occur and prevents stretching or tearing the cord. and anus. Repeat for the other inner thigh. Repeat for the other side. Use a zig-zag motion from clitoris to lower abdomen just above the public hairline. f. If tight it is clamped and cut between two clamps before the rest of the baby is born. 13. Birth of the Head 10. minimizing trauma to the maternal tissues.

the attendant inspects the birth canal for injuries. Either the father or the attendant cuts the cord above the clamp. D. After the infant and placenta are born. B. The attendant clamps the cord. Birth of the anterior shoulders The attendant gently pushes the fetal head toward the woman’s perineum to allow the anterior shoulder to slip under the symphysis. Birth of Posterior Shoulder Midwifery 1 Course Manual Page 47 . Restitution and External Rotation After the head emerges. Excess traction on the cord may cause it to break. F. Prevents flow of blood between placenta and infant. The attendant maintains the infant in a slightly head-dependent position while suctioning excess secretions with a bulb syringe. Care of the Infant A. Allows parents to interact more freely with their infant. 19. it can usually be delivered of the mother bears down. aligning their transverse diameter with the anteroposterior diameter of the pelvic outlet.cord 16. The attendant (physicianor nurse-midwife) is not holding the fetal head back but rather controlling its exit by using gentle pressure on the fetal occiput. 20. Crowning The fetal head distends the labial and perineal tissues. Any feces expelled are wiped posteriorly to avoid contamination of the vulva. it becomes pink as the infant begins air breathing. This action aids the mechanism of extension as the fetal head comes under the symphysis. The anus is stretched wide. Ritgen Manuever Pressure is applied to the fetal chin through the perineum at the same time pressure is applied to the occiput of the fetal head. making the placenta harder to deliver. The infant is often placed on the mother’s abdomen. After the placenta separates. any injuries and the episiotomy (if one was done) are required. External rotation occurs as the fetal shoulders internally rotate. which might result in anemia ( if infant is higher than placenta) or polycythemia ( if infant is below the placenta). it realigns with the shoulders (restitution). Delivery of Placenta 18. 17. The attendant may pull gently on the cord. If needed. Gravity aids spontaneous drainage of secretions and prevents aspiration of oral mucus and secretions. Birth of the Head As the head emerges. The rest of the infant’s body is born quickly after the shoulders are born. C. E. the attendant prepares to suction the nose and mouth to avoid aspiration of secretions when the infant takes the first breath. Ensures that no fragments remain inside the uterus that might cause hemorrhage and infection. and it is not unusual to see the woman’s anterior rectal wall at this time. The bluish skin color of the fetus is normal at this point. The attendant inspects both sides of the placenta.

as evidenced by facial grimacing and flexion of the arms and hands. H. Midwifery 1 Course Manual Page 48 . Completion of the Birth The attendant supports the fetus during expulsion. Birth of the placenta The attendant applies gentle traction on the cord to aid expulsion of the placenta. Note that the infant has excellent muscle tone. The cord is then cut between the two clamps. the attendant clamps the umbilical cord. Samples of cord blood are collected after it is cut.The attendant now pushes the fetal head upward toward the woman’s symphysis to allow the posterior shoulder to slip over her perineum. The chorionic vessels that branch from the umbilical cord are readily visible on the fetal surface of the placenta. with the shiny fetal surface and membranes emerging. G. Note the fetal membranes that surrounded the fetus and amniotic fluid during pregnancy. This placenta is expelled in the more common Schultze mechanism. Cord clamping While the infant is in skin-to-skin contact on the mother’s abdomen. I.

Evaluation Checklists Midwifery 1 Course Manual Page 49 .

Good 0.Christian University of Thailand College of Nursing Evaluation Checklist for Mechanism of Labor Student number:_____________________ Name-Surname:__________________________________________________ Date performed:_____________________ Rating Scale: 3-Very good 2. Descent The downward passage of the presenting part through the pelvis. 5. The chin is brought into contact with the fetal thorax.Unperformed 1-Needs practice Description 1. Internal rotation brings the AP diameter of the head in line with the AP diameter of the pelvic outlet. is rotated about 45° to anteroposterior (AP) position under the symphysis. the presenting part is at 0 station. Internal rotation As the head descends. This is followed by the delivery of the fetus' head. or at the level of the maternal ischial spines. Flexion As the fetal vertex descents. 4. The rate is greatest during the second stage of labor. and the presenting diameter changes from occipitofrontal (11. Upward resistance from the pelvic floor and the downward forces from the uterine contractions cause the occiput to extend and rotate around the symphysis. the presenting part. returning to its original anatomic position in relation to the body. where the largest transverse diameter of the fetal occiput is the biparietal diameter) enters the maternal pelvis to a level below the plane of the pelvic inlet. 6. On the pelvic examination. 2. it untwists about 45° left or right. Extension With further descent and full flexion of the head. it encounters resistance from the bony pelvis or the soft tissues of the pelvic floor. the base of the occiput comes in contact with the inferior margin of the pubic symphysis. usually in the transverse position. Restitution and external rotation When the fetus' head is free of resistance. This occurs intermittently with contractions.5 cm) for optimal passage through the pelvis. 3. Engagement The widest diameter of the presenting part (with a wellflexed head. Midwifery 1 Course Manual 3 2 1 0 Remarks Page 50 . resulting in passive flexion of the fetal occiput.0 cm) to suboccipitobregmatic (9.

Expulsion After the fetus' head is delivered. further descent brings the anterior shoulder to the level of the pubic symphysis. The anterior shoulder is then rotated under the symphysis.7. followed by the posterior shoulder and the rest of the fetus. Total Score: /21 Student’s Signature:____________________________ _____/_____/_____ Evaluated by: ________________________________ _____/______/_______ Midwifery 1 Course Manual Page 51 .

Repeat for the other side. b. When placing the woman’s legs in stirrups. and anus.Good 0. shoulders. The proper order and motions are as follows: a. Stirrups or foot rests to support the woman’s legs and feet may be used on a birthing bed. transfer her to the delivery room or position the birthing bed. Continue observing the fetal heart rate (FHR) with continuous monitoring or intermittent auscultation. After handwashing. 3. Use a single stroke in the middle from the clitoris over Midwifery 1 Course Manual Page 52 2. After the woman is in position. and head with a wedge (on a delivery table) or by raising the head of the birthing bed. c. Pad the surface.Unperformed 3 1-Needs practice 2 1 0 Remarks . 2. elevate them and remove them simultaneously. 4. 6. Do not separate her legs widely. and do not return to a clean area with a used sponge. 5. apply sterile gloves for the procedure.Christian University of Thailand College of Nursing Evaluation Checklist for Assisting in Birth and Delivery Student number:_____________________ Name-Surname:__________________________________________________ Date performed:_____________________ Rating Scale: 3-Very good Action Identify the patient Explain the procedure to the patient Prepare the equipments needed for the procedure Transfer and Positioning for Birth 1. Use warm water to dilute iodophor scrub. d. When the woman is almost ready to give birth. perineum. Repeat for the other inner thigh. Use a zig-zag motion from clitoris to lower abdomen just above the public hairline. Elevate the woman’s back. Apply a single stroke on one side on one side from clitoris over labia. Continue observing the perineum while making final preparations for birth. Prepping and Draping 7.Take fresh sponge to begin each new area.Use a zig-zag motion on the inner thigh from the labia majora to about halfway between the hip and knee. 8. Six sponges are needed. cleanse the perineal area with a sterile iodophor and water preparation unless she is allergic.

Birth of the Shoulders 14.Make notations about the birth to include: (1) Fetal position and presentation.the vulva and perineum.After external rotation. Assess the amount of blood loss from the delivery. Then lift the head toward the mother’s symphysis pubis. and amount of amniotic fluid. (4) Time of delivery. blood loss is less than 500 cc. If an episiotomy is needed. Clamps the cord. it is slipped over the head. 21. Wipes secretions from the infant’s face and suctions the nose and mouth with a bulb syringe. Clearing the infant’s airway and cutting the cord 16. Delivery of Placenta 18. The rest of the infant’s body is born quickly after the shoulders are born. (6) APGAR scores. Apply sterile drapes if desired. 19. (3) Color. apply gentle traction on the fetal head in the direction of the mother’s perineum. (2) Presence of nuchal cord and method of reduction. character. perform it when the head is well crowned. (7) Approximate time of placental expulsion. Birth of the Head 10. If tight it is clamped and cut between two clamps before the rest of the baby is born. Maintains the infant in a slightly head-dependent position while suctioning excess secretions with a bulb syringe. 20. Save all evidence of blood loss. 17. Normally. Gently massage the uterus if the fundus is soft or boggy. 22. 9. After the placenta separates. The infant is often placed on the mother’s abdomen. 13. appearance. (5) Sex of infant. apply gentle pressure to the woman’s perineum with one hand while applying counterpressure to the fetal head with the other hand (Ritgen’s maneuver). Feels for a cord around the fetal neck (nuchal cord). 15.If it loose. Assess for intactness of the placenta 23. 12. May pull gently on the cord. As the vaginal orifice encircles the fetal head. 11. Midwifery 1 Course Manual Page 53 . Inspects both sides of the placenta. need for stimulation or resuscitation. May ask the mother to blow so that she avoids pushing or to push gently. Either the father or the attendant cuts the cord above the clamp. it can usually be delivered of the mother bears down.

Monitor BP and administer methergin drug Total: /99 Evaluated by: ________________________________ _____/______/_______ Student’s Signature:____________________________ _____/_____/_____ Midwifery 1 Course Manual Page 54 . 24. (9) Any unusual occurrences during the delivery. (8) Maternal condition (affect.and completeness. and status of uterine contraction). amount of bleeding.

Use both hands. 4.Christian University of Thailand College of Nursing Evaluation Checklist for Abdominal Examination and Leopold’s Maneuver Student number:_____________________ Name-Surname:__________________________________________________ Date performed:_____________________ Rating Scale: Unperformed 3-Very good 2. 7. Drape properly to maintain privacy. 3. Ask the mother to empty the bladder. 9. 6. First maneuver: Fundal Grip Using both hands.Good 3 1-Needs practice 2 1 0 0Remarks Description 1. grasp the lower portion of the abdomen above symphisis pubis. 8. Fourth maneuver: Pelvic Grip Facing foot part of the woman. 2. Second maneuver: Umbilical Grip One hand is used to steady the uterus on one side of the abdomen while the other hand moves slightly on a circular motion from top to the lower segment of the uterus to feel for the fetal back and small fetal parts. Explain the procedure to the patient. Warm the hands and apply it to the abdomen of the mother by using form and gentle pressure. press in slightly and make gentle movements from side to side.Document Findings Total: /42 Evaluated by: ________________________________ _____/______/_______ Student’s Signature:____________________________ _____/_____/_____ Midwifery 1 Course Manual Page 55 . 13. Place the patient in dorsal recumbent position. Identify the patient. Use the palm for palpation and not the fingers. Explain the results of the examination 14.Listen to the fetal heart sound correctly. 12. 11. 10. feel for the fetal part lying in the fundus. palpate fetal head pressing downward about 2 inches above the inguinal ligament. supine with knees flexed to relax abdominal muscles. 5. Use gentle but deep pressure.Third maneuver: Pawlik’s Grip Using thumb and finger.

St. Louis : Mosby-Year. St. 7th ed.childbirth.shtml http://www. et. S. Inc.L.nurse. T.html http://www. Olds.S.htm http://health.net/sweethaven/MedTech/ObsNewborn/default. Maternal – Newborn Nursing Women’s Health Care. D. S. E.E. D.B. (1998) Foundation of Maternal Newborn Nursing.org/Products/Obstetric_and_Newborn_Care_II/lesson_2_Section_1.ac. (1998) Obstetrics & Gynecology. Philadelphia : W. 8th ed.brooksidepress. al (2008).H. S. Book.com/health/TEXTS/PHYSIOLOGY_LABOR.asp?iNum=11001 http://www. Missuri. Book.htm http://www.M.com/laborandbirth. Maternal – Newborn Nursing Women’s Health Care.cmu.L.html http://gowingo.org/articles/efm.B. 8th ed.th/ceneweb/e-learning/Program554312eng/index.brooksidepress.html Midwifery 1 Course Manual Page 56 .Resources: Olds.htm http://cene. Lowdermilk. J. http://medical-dictionary. Philadelphia:W. Saunders Company.howstuffworks. and Perry.org/Products/Obstetric_and_Newborn_Care_II/lesson_1_Section_1A. 2nd ed. al (2004).com/pregnancy-and-parenting/pregnancy/issues/how-to-exercise-whilepregnant4. Murray. (2000). (2004) Maternity and Women’ Health Care. Mattos.waybuilder. Maternal – Child Nursing. and Perry.8th ed. Mosby. (2004) Maternity and women’s Health Care.B. Louis : Mosby-Year. New Jersey : Pearson. McKinney.Saunders.baby2see.thefreedictionary. Makinney. 1st ed. Lawdermilk.S. New Jersey : Pearson. Goorrle. Inc. E.com/High-risk+pregnancy http://www. S. al.E. S.S.B.

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