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- A clinical diagnosis 1. Get px history (Gen data)
- Onset of labor characterized as: regular, painful o Chief complaint
uterine contractions -> progressive cervical Vaginal bleeding
effacement and dilatation Watery vaginal discharge
- Cervical dilatation in the absence of uterine Hypogastric pain
contractions = incompetent cervix Ask how many hours,
- Uterine contractions W/O cervical changes = NOT intervals, if accompanied
true labor by watery/bloody
discharge (VERY IMPT
Admission criteria: TO KNOW THE HOURS
Uterine contractions plus any of the ff: she has been experiencing
1. Ruptured membranes them because the longer
2. Bloody show the bag of water has
3. Complete cervical effacement and dilatation ruptured, the higher the
risk for infection =
chorioamnionitis ->
increased maternal and
STAGES OF LABOR infant mortality and
FIRST STAGE o Menstrual hx (important for determining
Stage of cervical effacement and dilatation AOG)
o Obstetrical hx
- Involves widely spaced uterine contractions (intervals
diminishes from 10 mins at onset of stage 1 to 1 min Ask for the ff: manner of delivery in
or less in stage 2) past pregnancies, complications,
duration of labor, hx of difficult
- Period of relaxation in between is important for fetal
labor, weight of babies (may
indicate a problem in descent or an
o Unremitting contractions may result to fetal
arrest in cervical dilatation)
2. Do PE
- 3 parameters to assess in uterine contractions:
o Interval o Get vital signs (monitor hourly)
o Duration Temperature: important in
o Intensity
BP is taken more frequently during
- Has 2 phases: latent phase & active phase
active phase (usually timed after
o Latent phase: period between the onset of
contraction) a rise in BP is usually
labor and when rate of cervical dilatation
seen during contraction
changes most rapidly (0-4cm dilatation)
- Abdominal exam
Contractions are still not too close
to each other (8-10 mins interval) o Fundic height: important for estimating fetal
weight and lightening (if FH is 35-36: this
Normal duration:
may be a big baby)
8 hrs in nulliparas
o Leopolds maneuver: LM3 allows
5 hrs in multiparas
determination of presentation
o Uterine contractions (normal must be
>20 hrs in nulliparas
alternating contract and relax)
> 12 hrs in multiparas
o Uterine tenderness
o Active phase: period of increased rapidity of
cervical dilatation o Tenderness over scar may indicate
Contractions w/ 2-3mins interval dehiscence or possible uterine rupture
(abruption placenta)
(ideal), lasting 40-60 secs
o Check for fetal heart tones
Ends with full cervical dilatation at
10cm (also marks the end of the
- Pelvic exam
first stage of labor)
o Cervical dilatation, effacement, station,
Also coincides with descent of PP
presentation, position, consistency of cervix
into pelvis
Normal duration and rate of o Clinical pelvimetry for primigravidas
o Check for intact bag of water and
5-7 hrs in nulliparas (1-
2cm/hr) o pH and nutracine test
o Litmus paper test and Comb (?) test used
2-4 hrs in multiparas
to confirm whether bag of water has ruptured
Pelvic exams done every o Speculum exam: important in cases where
bag of water has ruptured -> cause pooling
2-3 hrs to evaluate labor
of amniotic fluid in posterior fornix
progress (lack of progress
There are 2 indications for a
in dilatation/descent may
indicate dystocia) speculum exam:
Watery vaginal discharge
How often should you monitor ? 30 mins for 2h; high risk labor - 15 minutes
Left lateral decubitus position - most comfortable position;
Cord Prolapse may occur when the patient is ambulatory after the BOW has ruptured
3. Do a Labor Admission Test o Fleet enema
o 20 min EFM strip done on admission Do early because if you do it at 7
o Get heartbeat and acceleration and cm dilatation, the baby might come
deceleration in relation to uterine out before she empties the GI tract
contractions o Woman in lithotomy position w/ cleansing of
Purpose: to find out whether the vulva and perineal scrubbing downward and
fetus in utero can undergo the away from introitus
stress of labor o C/I: ruptured membranes, sedated
If you have decelerations while
baby is in utero, you expect that it
will be worse during labor 8. Position and Movement During Labor
Allows you to detect high o Encouraged to assume position she is most
risk/compromised fetuses and comfortable in
allows for early intervention o Supine position affects blood flow in uterus
o Studies show greater benefit in using LAT for Pregnant uterus can compress
high risk patients only aortocaval system -> reduce blood
flow to fetus -> fetal compromise
4. Check urinary bladder function May also reduce intensity of
o Head descent may cause pressure on contractions -> interferes with
urinary bladder -> voiding becomes difficult progress of labor
o Palpate suprapubic area to check if bladder o Upright position: speed contractions in early
is full labor
Mother is asked to void and empty o Exceptions to allowing pregnant woman to
bladder take desired/comfortable positions:
If bladder is distended but voiding a) Membranes have ruptured in
does not occur spontaneously do the presence of a NON-
straight catheterization engaged fetal head
b) Sedated patients
5. NPO for 8 hours usually o In these cases, ask patient to assume left
o Due to progesterone effect of delayed gastric lateral decubitus as it increases blood flow to
emptying fetus
o Regurgitated food can cause aspiration
especially after giving anesthesia 9. Fetal Monitoring
o IV fluids are given when px has nothing per o Main parameters: FHR and FHR variability
orem for 6-8 hrs to prevent dehydration Usually based on recordings while
(provide glucose and water) px is hooked to electronic fetal
Always keep an IV line open for monitor
emergencies which require Normal baseline HR: 110-160bpm
immediate infusion of medication (varies by 6-25 beats ruing
o However caution must also be exercised movement or contractions)
because full NPO may cause Accelerates appropriately
hypoglycaemia, shock, seizures for gest age
Does not decelerate
6. Pain management/Analgesia during contractions
o Give only during active phase o Fetoscope/stethoscope for auscultation OR
a. Non-medicated measures If manual ausculatation, follow one
Natural childbirth px to one attendant ratio
Support person/doula provide Normal pregnancies: get FHR
coaching during delivery after each contraction every 30
Soaking tubs (temp kept at 98- mins during 1st stage of labor and
o nd
100 F to prevent fever in mother every 15 mins during 2 stage
and baby) High risk pregnancies: get FHR
every 15 mins during 1 stage and
b. Analgesics you can give: 3-5 mins during 2 stage
Benzodiazepine Always listen for heart tones
Nalbuphine Hcl AFTER contractions because
Meperedine Hcl contractions may cause a slowing
(give in smallest possible dose to prevent of HR
adverse effects in fetus) o EFM: standard of care for high risk
pregnancies and is now used for ALL
c. Anesthesia: pudendal, epidural, spinal, Abnormal EFM findings are
general (epidural is still the best!) confirmed via fetal pulse oximetry
(help det if C/S is needed)
7. Enema and Vulvar & Perineal Preparation
o Prevent contamination of newborn with feces 10. Monitoring Progress of Labor
o Cleanse GI tract o Check for cervical dilatation - most accurate
o Minimizes infection in episiotomy wound measure of labor progress

1-1.2 cm / Hr - Primigravida Aminotomy - the bag of water usually spontaneously ruptures during the first stage of labor, when you
want to shorten the first stage of labor by doing Amniotomy; because by rupturing it, the head will proceed
1.5 cm / HR - multigravid downwards. Augmenting labor may also be achieved by giving OXYTOCIN.
Partograph (sigmoid curve) used If patient comes to you with
to assess progress of labor and ruptured membranes already, limit
identify when intervention is needed IEs to prevent infection
Graphical record of
cervical dilatation in cm SECOND STAGE
against duration of labor in Stage of Fetal Expulsion
hrs - Starts with full cervical dilatation of 10cm and ends
Highly effective in reducing with delivery of the fetus
complications from Duration:
prolonged labor Nulliparas
(postpartum hemorrhage, o Normal: 50 mins
sepsis, uterine rupture) o Abnormal: > 2 hrs w/o anesthesia; >3 hrs w/
Plotting begins in the anesthesia
active phase when cervix
is 4cm dilated Multiparas
o 3 components of partograph: o Normal: 20 mins
Fetal condition o Abnormal: >2 hrs w/ anesthesia; >1 hr w/o
Progress of labor anesthesia
Maternal condition
o Content of the partograph: (not sure if this is impt. Risk factors for prolonged 2nd stage:
We dint discuss it read nalang )
- Maternal weight/weight gain
Px info
Fetal HR (every half hour) - Nulliparity
Amniotic fluid record color every - Use of conduction/regional anesthesia
vaginal exam - Fetal occiput in posterior position
I: membranes intact - Increased birthweight
C: membranes ruptured; clear fluid
M: meconium-stained WHAT DO YOU DO IN THE 2ND STAGE?
B: blood-stained 1. Monitoring of Fetus and Mother
o Low risk pregnancies:
1: sutures apposed
2: sutures overlap but reducible FHR every 15 mins after each
3: sutures overlap but not reducible contraction
Cervical dilatation (begin plot at 4cm) Fetal heart tones best heard after
Alert line: line starts at 4cm to the point contraction or 1-2 mins before peak
of expected full dilatation at a rate of of contraction
1cm/hr) o High risk pregnancies:
You go beyond this IF FHR checked every 5 minutes
dilatation is less than 1cm/hr o Slowing of FHR during this stage may be
Action line: parallel and 4 hrs to the right
of alert line
due to compression of head during descent
You go beyond this if there is (but not all)
delay in progress (>4hrs) Other reasons: cord compression or
Descent assessed by abdominal tightening of nuchal cord,
palpation premature separation of placenta
Refers to part of head o Monitor FHR after contraction
palpable above symphysis Determines the response of FHR to
pubis temporary loss of oxygenation
At zero, sinciput is at the level You may perform the Valsalva maneuver at this point
of symphysis pubis
2. When do we ask mothers to push?
Hours time since onset of labor
Time actual time a. 2nd stage of labor
Contractions chart every half hour b. During contraction
Palpate number of c. At full dilatation (10cm)
contractions in 10 minutes
and their duration o Pushing is usually spontaneous and reflex
Oxytocin record amt of oxytocin given In nulliparas, they may need
per volume IV fluids coaching
Drugs given
Pulse (every 30 mins)
Temperature (every 2 hrs)
3. Preparations for Delivery
Protein, acetone and volume (record a. Assume a dorsal lithotomy position - legs
each time urine is passed) flexed
Asked to breathe normally until start
o Check for uterine contractions every 30 of contraction when they are asked
minutes to strain down
If patient is high risk, do every 15 Push sustained as long as possible
mins Ideal position because it increases
o IE or vaginal exam is done as needed the diameter of pelvic outlet
Done every 4 hours in latent phase
and after rupture of membranes b. Strict asepsis and antisepsis (sterile gown,
cap, mask)
If the woman is a Primigravida,
There is no strict guideline when to transfer the woman to the dorsal lithotomy
position. Since the 2nd stage of labor may be fatiguing due to this position.
Perineal area scrubbed w/ o Very large babies to prevent dystocia
antiseptic solution - Mother w/ certain medical conditions that make her
Apply antiseptic first before sterile vaginal tissues susceptible to damage
drapes are applied - Maternal exhaustion

4. Delivery of the Head and Episiotomy Delivery of Fetal Head

o Perineal opening becomes ovoid to circular - Modified Ritgen maneuver
with the descent of the fetal presenting part o When vulvar ring is at 5cm, heel of clinicians
o Perineum is stretched to almost paper thin hand that is draped with a sterile towel is
o Crowning event wherein fetal head is placed over posterior perineum overlying
encircled by the vulvar ring fetal chin
Sign that episiotomy can be done o Pressure applied upwards to extend fetus
Episiotomy o Allows control of delivery of head with
- Do only if indicated! extension so that smallest diameter passes
- Surgical incision of the mothers perineum performed through introitus
as the babys head emerges from vaginal canal - After delivery of head:
during birth o Wipe face of fetus
- Purpose: prevent tears of perineal muscles o Suction nares and throat to prevent
aspiration of amniotic fluid
Maternal benefits Fetal benefits o Check fetus neck for wrapped umbilical cord
Reduced risk of:
Shortened 2 stage of labor If loose, slip over babys head
More rapid spontaneous If cannot be reduced but not too
Perineal trauma delivery tight slip over shoulder as it is
Pelvic floor dysfunction Reduced perinatal asphyxia born
and prolapse and fetal distress If very tight double clamp cord
Urinary incontinence Higher APGAR scores and cut BEFORE delivery
Fecal incontinence Less fetal acidosis - Await external rotation or assist by bringing shoulders
Sexual dysfunction Fewer complications from into anterior-posterior position
shoulder dystocia - Deliver anterior shoulder by gentle downward traction
-> upward traction to delivery upward shoulder
o Slide one hand at back of baby and prepare
to grasp both feet
Midline Episiotomy Mediolateral episiotomy - Clamp 1 in cord halfway between mother and fetus
Easier to repair Indicated if perineum is o Clamp 2 at 5cm from babys umbilicus
Heals better very short or if more o Cut between clamps
Less postop pain room is needed because
Excellent anatomical results of an anticipated large
Less blood loss because you baby THIRD STAGE
cut throught a muscle Stage of Placental Separation and Expulsion
insertion More blood loss because - Begins after delivery of fetus until delivery of the
Less dyspareunia you cut through a muscle placenta
Transect rectum w/c is highly vascular - Usually begins 5-10 mins after delivery of the fetus
- May require less than 10 mins but may last as long as
Harder to repair 30 mins
(coaptation has to o If beyond this, consider active intervention.
simulate that of normal o Interference in the absence of hemorrhage
skin repair) may cause: hemorrhage, uterine inversion
Does not return to normal and placental entrapment
= more dyspareunia
Away from the rectum
rd th
(no 3 degree or 4 Signs of Placental Separation
degree lacerations) 1. Calkins sign (earliest sign)
Know adv; upon seeing a 3cm crowning; you may now perform epi o Change in the shape of the uterus from
discoid to globular as it contracts
** If a big baby was not anticipated, the head will pass through 2. Gush of blood from vagina
but the problem will be the shoulder. Do Mc Roberts position 3. Lengthening of the cord
(foot on stirrups, bearing down with an assistant pushing the 4. Uterus rises in abdomen as placenta descends to
babys head downwards) lower uterine segment or vagina -> displaces uterus
- If this does not work, cut through the babys clavicle upwards
because if you dont do this, the baby will die
Active Management of 3rd stage
Indications for Episiotomy - Before, they used to just wait for the placenta to go
- Fetus in definite distress and needs to be delivered out. Now, there is active management
immediately - Get anesthesia to relax the uterus -> do gloving and
sterile gowning -> insert finger inside (similar to
EINC / STEPS Size of baby
1. Extension o Very small preterm to prevent cranial truma turning a page of a book)
2. ER - Do gentle and downward traction on the cord
3. Expulsion; New concept in the management of labor:
Dry the baby, skin to skin contact; late clamping of the umbilical cord
developed due to the incidences that may lead to hemorrhage


- One hand is placed on abdomen and uterus is o You may do gentle uterine massages to
pushed cephalad until placenta reaches introitus stimulate contraction
o When majority of placenta is out, gently o Breast and nipple stimulation
grasp with both hands and pull while twisting o Uterotonic agents: oxytocin, ergot
the placenta allowing separation of the fetal derivatives, prostaglandin analogues
- Massage fundus until contraction is felt Oxytocin
o Palpate abdomen to confirm reduction in - Analog of the hormone
size of uterus and firmness - Giving this may also stimulate ADH and will cause
o Ongoing blood loss and soft boggy uterus urinary retention
suggests uterine atony o This is significant because if you do not
o If uterus is firm but with ongoing blood loss = monitor bladder distention, the lower
consider cervical or vaginal lacerations segment of the uterus may not contract
- Start oxytocin drip or give ergot derivatives (do not because bladder distention impedes
give if px is hypertensive) effective uterine contractions -> may result to
REMEMBER THIS! 4 Degrees of Laceration (Dra. o Catheterize if px is on anesthesia
Rivera asked us to know this)
First degree lacerations Involve fourchette, Methylergonovine malate
perineal skin, vaginal - Powerful agent to contract uterus
mucosa (sparing - Effect may last for hours
underlying fascia and - Effective for prevention and control of postpartum
muscle) hemorrhage but may be deleterious to mother and
Second degree Fascia and muscles of baby prior to delivery
perineal body but not - C/I: hypertensive px
anal sphincter
Third degree Vaginal mucosa, perineal Misoprostol
skin and fascia up to anal - Oxytocin and ergot derivatives more effective
sphincter but not rectal If the vital signs should be checked
Fourth degree Extension up to rectal ATONY and CERVICAL and VAGINAL LACERATIONS
mucosa The uterus should be contracted by this time (says it does not
have ATONY). Otherwise if it is bleeding check if there are
What to do: unrepaired lacerations that extend up to the vaginal canal. Suture
and repair the bleeder and ligatures
1. Incision is closed by layers using absorbable
suture. Know the types of Lacerations that can cause the bleeding.
2. Order of repair:
a. Vaginal mucosa (interlocking suture) First thing to be affected is the CARDIAC RATE.
Start repair 1cm from the apex of If you have tachycardia, uterus is contracted and bleeding is
the mucosal defect so that any apparent.
retracted blood vessels will be
ligated If uterus is relaxed and there isn't any bleeding. Give Oxytocin.
b. Subcutaneous and fascial layers
(interrupted suture)
Do not leave any dead space
potential hematoma formation
c. Ligate bleeding vessels
d. Cut sphincter muscles (interrupted
Prevent fecal incontinence
e. Skin (interrupted or subcuticular
Remember that if you are dealing with 4 degree lacerations,
repair the rectal mucosa FIRST before the vaginal mucosa.

Hour immediately following delivery
- Time to observe for postpartum hemorrhage
especially when labor was prolonged
- Maternal and vital signs monitored immediately after
delivery and every 15 mins for the first hour
- After delivery of fetus and placenta, hemostasis is
achieved by vasoconstriction at placental site
produced by a well contracted endometrium