1

Handout #10 – Decreased fundal height

– Floating – is when the head is still
LABOR AND DELIVERY movable above the pelvic inlet in
palpation.
– Engagement – is the descent of the
Theories of Labor
biparietal plane of the fetal head to a
level low that of the pelvic inlet. In
Uterine Stretch Theory
cephalic presentation, the
• Uterus becomes stretched and pressure
suboccipitobregmatic diameter in fixed
increases, causing physiologic changes that
into the inlet & in breech presentation,
initiate labor.
the intertrochanteric diameter is fixed
• According to this theory, “any hollow muscular
into the inlet.
organ when stretched to capacity will contract
– Fixation – is the descent of the fetal
& empty…”
head to the inlet to a level that it can no
longer be moved.
Fetal Adrenal Response Theory
2. Increased Level of Activity
• Hippocrates, the Father of Medicine, was 1 st
• Initiated by low progesterone level, the adrenal
person to propose this theory w/c states that
gland secretes large amounts of epinephrine or
certain hormones produced by the fetal adrenal
adrenalin starting about 2 weeks prior to labor
& pituitary gland initiates labor contractions.
to provide the woman w/ energy for the
Oxytocin Stimulation Theory
strenuous work of delivering a baby.
• Studies have shown that as pregnancy nears
 
term, oxytocin production by the posterior
3. Slight Weight Loss
pituitary gland increases while the production
• About 2 weeks before labor, the woman
of oxytocinase by the placenta decreases.
experiences sudden weight loss amounting to 1
Progesterone deprivation Theory
to 3 pounds.
• Progesterone helps maintains pregnancy by its
• This is due to the decline in progesterone level.
relaxant effect on the muscular muscles of the
uterus, thereby preventing uterine contractions.
4. Increased Braxton-Hicks Contractions
Prostaglandin Theory
• The irregular painless contractions of pregnancy
• It has been known that when the fetus has
become stronger, longer, & more frequent
reached maturity, the fetal membranes produce
when labor is near at hand.
large amounts of arachidonic acid w/c is
5. Ripening of the Cervix
converted by maternal deciduas into
• Throughout pregnancy, the cervix feels softer
prostaglandin, a hormone that initiates uterine
than normal to palpation similar to consistency
contractions.
of an earlobe (Goodell’s Sign)
Theory of the Aging Placenta
• At term, the cervix becomes softer described as
• As the placenta “ages”, it becomes less efficient,
“buttersoft”.
producing deceasing amount of progesterone.
• This is an internal announcement that labor is
• This progesterone decline allows the
very close at hand.
concentration of prostaglandin & estrogen to
6. Uterine Contractions
rise steadily.
• Surest sign that labor has begun.
• Signs of Labor
7. Show
1. Lightening “The Baby Dropped”
• As the fetus descends in the birth canal, the
• Lightening is the settling of the presenting part
continuous pressure exerted by the presenting
to the pelvic brim or inlet.
part against the soft tissues result in the rupture
• Lightening results in:
of several blood vessels in the cervix.
– Relief of dypsnea
– Increased frequency of urination
– Leg pains 8. Rupture of Membranes
– Increased vaginal discharge
 2

• Rupture of membranes or bag of water is • Its inlet is oval shaped with AP diameter wider
signified by a gush or steady trickle of clear fluid than transverse diameter.
from the vagina. •
• True & False Labor 4. Platypelloid
• Duration of Labor • The flat pelvis which is the rarest type of pelvis
1. Passages found only in about 5% of women.
• Hard passages: Bony prominence • Its transverse diameter is wider than its AP
• Soft passages: Lower uterine segment, cervix, diameter.
vagina, pelvic floor & perineum • THE PASSAGES OF LABOR
2. Power Types of Pelvis
• Primary force: Involuntary uterine contractions •
• Secondary force: Voluntary use of thoracic, THE PASSAGES OF LABOR
diaphragm & abdominal muscles when the Parts of the Pelvis
mother “bears down” 1. Inanimate Bones
3. Passenger _ these bones form the anterior and lateral
• Fetal positions, presentation & attitude aspects of the pelvis. It consists of the following parts:
4. Person • Illium
• Maternal attitude during labor • Ischium
5. Position • Pubes
• Maternal position during labor & delivery 2. Sacrum
6. Psyche • the sacrum is a triangular shaped bone forming
• Refers to feelings that the woman brings to the posterior protion of the pelvis.
labor • It is composed of five sacral vertebra.
• For some, feelings may include apprehension & • The first sacral vertebrae, called sacral
fear; for others excitement are common promontory, is an important obstetrical
• landmark used in measuring important pelvic
THE PASSAGES OF LABOR diameters.
Functions of the Pelvis 3. Coccyx
• It provides protection to the organs found w/in • it is the posterior portion of the pelvis
the pelvic cavity composed of five fused vertebra.
• It provides attachment to muscles, fascia & • Its sacrococcygal joint joins the sacrum to
ligaments coccyx and allows the coccyx some degree of
• It supports the uterus during pregnancy movement.
• It serves as birth canal
• THE PASSAGES OF LABOR •
Types of Pelvis THE PASSAGES OF LABOR
1. Gynecoid Parts of the Pelvis
• The female type pelvis that is most ideal for •
childbirth.
• The inlet of this type of pelvis is round shaped THE PASSAGES OF LABOR
with transverse diameter larger than DIVISION OF THE PELVIS
anteroposterior (AP) diameter. • The pelvis is divided into two parts,
2. Android 1. the false pelvis and
• The male-type pelvis that presents the most 2. the true pelvis.
difficulty during childbirth as the fetal head has •
difficulty getting out of this pelvis.
• Its AP diameter is wider than its transverse •
diameter. •
3. Anthropoid THE PASSAGES OF LABOR
• The ape-like pelvis which is the deepest type of DIVISION OF THE PELVIS
pelvis. 1. False pelvis
 3

2. True pelvis • Lightening has not yet taken place after 37

a. inlet or pelvic brim is the entrance to true weeks in primis.
pelvis • There is history of stillbirth, difficult labor and
b. Pelvic channel is situated b/n inlet & outlet forceps delivery in multis.
• •

THE PASSAGES OF LABOR THE PASSAGES OF LABOR

DIVISION OF THE PELVIS TRUE PELVIS
• Pelvic articulations
• Pelvic articulations or joints serve as points of
THE PASSAGES OF LABOR attachment between pelvic bones; they also
DIVISION OF THE PELVIS allow the bones some degree of movement.
• • Symphisis pubis joins the two pubis bones
• Sacroiliac joints joins sacrum and iliac
THE PASSAGES OF LABOR • Sacrococcygeal joint joins sacrum and coccyx
TRUE PELVIS •
a. inlet or pelvic brim is the entrance to true pelvis
• AP Diameters: THE PASSAGES OF LABOR
– Diagonal conjugate: 12.5 cm. it is the TRUE PELVIS
distance between the midpoint of Effect of hormones
sacral promontory and the lower • Hormones of pregnancy especially
margin of symphisis pubis. Measured by progesterone, causes relaxation and softening
internal examination. of pelvic joints that result in increased mobility
– Obstetric Conjugate: 11cm. it is the of the pelvic bones. Increased joint and bone
distance between the midpoint of mobility:
sacral promontory and the midline of •
symphisis pubis which is ascertained by
subtracting 1 to 1.5 cm from the The Passengers of Labor
diagonal conjugate.
– True conjugate: 11.5 cm. distance The head of the fetus is the most important part of its
between the midpoint of sacral body because of the following reasons:
promontory and the upper margin of 1. largest part of the fetal body
symphisis pubis. 2. Usually the presenting part
• Transverse diameter: 13.5 cm 3. Least compressible
• Right and left oblique diameter: 12.75 cm •
b. Pelvic canal is situated between inlet and outlet
• The pelvic canal curves at its lower half, below The Passengers of Labor
the level of the ischial spines. Structure of the Fetal Skull
• AP diameter at level of Ischial spines: 11.5cm CRANIAL BONES
• Posterior sagittal diameter: 7.5cm • The fetal skull is composed of the
• following cranial bones:
– 1 frontal
THE PASSAGES OF LABOR – 2 parietal bones
TRUE PELVIS – 2 temporal bones
Contracted pelvis – 1 occipital bone
• A contracted pelvis refers to a pelvis with a – 1 sphenoid bone
measurement of less than 1.5 to 2cm in any of – 1 ethmoid bone
its important diameters, and therefore, makes • The frontal, parietal & occipital bones are the
vaginal delivery of the fetus not possible. A most important fetal skull bones because they
contracted pelvis is suspected if: form the presenting part when the fetus is in
cephalic presentation.

• •
The Passengers of Labor
8 Cranial Bones
• The Passengers of Labor
8 Cranial Bones
• diameter.
The Passengers of Labor
SUTURE LINES
• The suture lines are important because they
allow the skull bones to overlap, called
Molding, during delivery in order to reduce the
size of the fetal head.
• Sutures also provide allowance for further brain
development.
– Sagittal suture – is located between the
2 parietal bones
– Frontal suture – is located between the
2 frontal bones
– Coronal suture – is located between
frontal & parietal bones
– Lamdoidal suture – is located between
parietal & occipital bones
•   - Average size is 12.5.
• The Passengers of Labor
Suture Lines
• The Passengers of Labor
Suture Lines
• The Passengers of Labor
Suture Lines
• The Passengers of Labor
Suture Lines
• 2.
The Passengers of Labor
FONTANELS
Fontanels are membrane covered spaces between the
intersections of suture lines.
1. Anterior Fontanel or Bregma
• is formed by the intersection of the sagittal,
frontal & coronal sutures.
• It is diamond shaped & closes between 12-18
months of age
2. Posterior fontanel or Lambda
• Is formed by the intersection of sagittal &
lambdoidal sutures.
• It is triangular in shape & closes by 2-3 months
of age
• fetal body, head & extremities, or the
The Passengers of Labor
FONTANELS
4
The Passengers of Labor
DIAMETERS OF THE FETAL HEAD
The fetal head is wider in its anteroposterior (front to
back) diameter than in its transverse (side to side)
1. Transverse Diameters
• Biparietal: Average measurement is 9.5cm.
• Bitemporal: average measurement is 8 cm.
• Bimastoid: average measurement is 7 cm.
2. Anteroposterior Diameters
• Suboccipitobregmantic
- this is the smallest AP diameter of the fetal
head
- When the head is fully flexed, it is this
diameter of the head that is presented
- It is measured from the inferior aspect of
occiput to the anterior fontanel.
- Average size is 9.5 cm
2. Anteroposterior Diameters
• Occipitofrontal
- Measures from the bridge of the nose to the
occipital prominence
• Occipitomental
- Measured from the chin to the posterior
fontanel
- Average size is 13.5
•
The Passengers of Labor
DIAMETERS OF THE FETAL HEAD
•
The Passengers of Labor
DIAMETERS OF THE FETAL HEAD
2.
•
The Passengers of Labor
FETAL PRESENTATION & POSITION
ATTITUDE OR HABITUS
• Attitude refers to the degree of flexion of the
relationship of fetal parts to each other.

• The fetus usually assumes an attitude of
complete flexion.
- The spinal column is bent; head is flexed
forward w/ the chin touching the chest, legs bent at the
knees & the calves pressing against the thighs
- This is the ideal attitude of the fetus
• The Passengers of Labor
The Passengers of Labor
FETAL PRESENTATION & POSITION
ATTITUDE OR HABITUS
Areas to look at for flexion:
• Head-discussed in previous paragraph
• Thighs-flexed on the abdomen
• Knees-flexed at the knee joints
• Arches of the feet-rested on the anterior
surface of the legs
• Arms-crossed over the chest
• Attitude of general flexion occurs when all of
the above are flexed appropriately as described.
STATION
• Station is the relationship of the
presenting part of the fetus to an imaginary line
drawn at the level of ischial spines of the
mother.
• It is used to determine the degree of
advancement or descent of the presenting part
through the pelvis & is measured in
centimeters.
• c.) Brow Presentation
The Passengers of Labor
FETAL PRESENTATION & POSITION
• Zero station (0) is when the presenting part is
ASSYNCLITISM
• Assynclitism occurs when the sagittal
suture does not lie exactly midway between the
sacral promontory & the symphisis pubis but is
deflected posteriorly or anteriorly.
• When it is deflected posteriorly toward the
sacral promontory, it is called Anterior
Assynclitism or Naegele’s Obliquity.
• When is deflected anteriorly toward the
symphisis pubis it is called Posterior
Assynclitism or Litzman’s Obliquity.
FETAL LIE
• Lie refers to the relationship of the long
axis of the fetus to the long axis of the mother.
• It describes the position of the spinal column of
the fetus in relation to the spinal column of the
mother.
5
FETAL LIE
1. Longitudinal Lie
2. Transverse Lie
3. Oblique Lie
•
FETAL PRESENTATION & POSITION
FETAL LIE
PRESENTATION AND PRESENTING PART
• The presenting part is that part of fetal body
that enters the true pelvis 1st & w/c is also the
1st part to come out during delivery.
• The presentation of the fetus is determined by
fetal lie & attitude.
•
The Passengers of Labor
Types of Fetal Presentation
1. Cephalic Presentation: when it is the head that
comes out 1st.
a.) Vertex Presentation
• Occurs when the head is completely flexed so
that the chin touches the chest.
b.) Sinciput Presentation
• Occurs when the head is partially flexed & the
anterior fontanel is the presenting part.
• The occipitofrontal diameter (12.5 cm) is
presented for delivery.
• When the head is extended or bent backward
causing the occipitomental diameter (13.5 cm)
to be presented for delivery.
d.) Face Presentation
• Occur when the head is sharply extended
causing the occiput to come in contact w/ the
back of the fetus.
• During the course of labor, resistance in the
pelvic floor can cause the head to extend
further causing neck fracture & damage to the
cervical cord.
e.) Chin/Mentum Presentation
• Occur when the head is hyperextended w/ the
chin as the presenting part.
•
The Passengers of Labor
Types of Fetal Presentation
d.) Face Presentation
2. Breech: when the feet or buttocks come out 1 st
during delivery.
 6

a.) Complete Breech • Position refers to the relationship of the

• Occurs when the feet & legs are flexed on the presenting part to one of the quadrants of the
thighs & the thighs are flexed on the abdomen. mother’s pelvis.
b.) Frank Breech Pelvic Landmarks: the pelvis is divided into several
• Occurs when the hips are flexed & the legs are areas in order to locate accurately the position of the
extended, the anterior thighs are in contact w/ presenting part.
the abdomen & the buttocks are the presenting - These areas are known as the four quadrants
part. of the maternal pelvis.
• This is the most common type of breech Pelvic Landmarks:
presentation. • Left anterior quadrant
c.) Footling Breech • Left posterior quadrant
• Occurs when one or both feet (single or double • Right anterior quadrant
footling) are the presenting parts. • Right posterior
• • Left transverse
• Right transverse
The Passengers of Labor Fetal points of direction: this is an arbitrary point on
Types of Fetal Presentation the presenting part used to orient it to the maternal
2. pelvis (usually occiput, mentum or sacrum.) fetal points
• of direction depend on presentation.
•
The Passengers of Labor
Types of Fetal Presentation The Passengers of Labor
2. Types of Fetal Position
3. Shoulder Presentation •
• In this presentation, the fetus is lying
perpendicular to the long axis of the mother & The Passengers of Labor
the shoulder is the presenting part. Types of Fetal Position
• Vaginal delivery is not possible in shoulder Cephalic or head presentation:
presentation. • Occiput (O). This refers to the Y sutures on the
• Causes of shoulder presentation: top of the head.
a.) relaxed abdominal wall due to grand • Brow or fronto (F). This refers to the diamond
multiparity sutures or anterior fontanel of the head.
b.) pelvic contraction • Face or chin presentation (M). This refers to the
c.) Placenta previa mentum or chin.
Breech or butt presentation:
• • Sacrum or coccyx (S). This is point of reference.
Shoulder presentation:
The Passengers of Labor • Scapula (SC) or its upper tip, the acromion (A)
Types of Fetal Presentation would be used for the point of reference.
3. Coding of positions: coding uses the first letter of the
pelvic landmarks and fetal points of direction to simplify
• explaining the various positions.
• The first letter of the code tells which side of
The Passengers of Labor the pelvis the fetus reference point is on (R for
Types of Fetal Presentation right, L for left).
• The second letter tells the specific presenting
• part of the fetus (occiput-O, fronto-F,
mentum-M, breech-s, shoulder-SC or A).
The Passengers of Labor • The last letter tells which half of the pelvis the
Types of Fetal Position reference point is in (anterior-A, posterior-P,
POSITION transverse or in the middle-T).

• • Full descent occurs when the head extrudes
The Passengers of Labor
Types of Fetal Position
Possible positions: with the exception of shoulder
presentation, each presenting part has the possibility of
six positions.
Possible positions:
Shoulders
• LADA: left acromiodorsoanterior
• LADP: left acromiodorsoposterior
• RADA: right acromiodorsoanterior
• RADP: right acromiodorsoposterior
•
The Passengers of Labor
Types of Fetal Position
• The most favorable and common fetal position
is LOA (left occipitoposterior) which means
that the fetus is in vertex presentation
(occipito), facing the anterior left side of the
mother’s pelvis (left anterior).
• The head usually accommodates itself on the
left side of the mother because of the bladder
placement to the right side.
• it meets resistance from the cervix, pelvic floor
The Passengers of Labor
Types of Fetal Position
• LOP and ROP positions makes labor longer and
harder for the mother, involving more back
pain, as the head must make a 180 degree turn
pressing against the bony sacrum in process.
• Knowing positions will help the nurse-midwife
to identify where to look for FHT.
• This is the reason why abdominal palpation is
performed before taking FHT.
• In breech, the FHT will be upper R or L
quadrant, above the umbilicus.
• In vertex, FHT will be lower R or L quad, below
the umbilicus.
• • If the fetus starts to descend in LOA or LOT,
Mechanism (Cardinal Movements) of Fetus
(DFIEREE)
Descent
• Descent involves the entrance of the greatest
biparietal diameter of the fetal head to the
pelvic inlet.
7
from the cervix & touches the vaginal floor
causing the mother to feel pushing sensations.
Descent
• When the mother begins to feel the urge to
push, measure FHT because cord compression
can occur after full fetal descent.
• In primiparas, descent usually occurs w/
lightening at about 2 weeks before labor onset.
• In multiparas, descent usually takes place w/
engagement at the start of labor.
•
Mechanism (Cardinal Movements) of Fetus
(DFIEREE)
•
Mechanism (Cardinal Movements) of Fetus
(DFIEREE)
Flexion
• As the fetal head moves deeper into the pelvis,
or walls of the pelvis.
• This resistance causes the head to flex so that
the chin is brought in close contact w/ the
chest.
• Flexion of the fetal head makes the smallest
diameter of the head, soboccipitobregmatic
diameter, to be presented to the pelvis for
delivery.
Internal rotation
• When the head reaches the level of the ischial
spines, it rotates from transverse diameter to
AP diameter so that its largest diameter is
presented to the largest diameter of the outlet.
• This movement allows the head to pass thru the
outlet.
rotation is only a short distance – 45 to 90
degrees
• If the head is in a posterior position, it may
mean a turn of 180 degrees
• Some fetuses do not rotate at all to anterior
position & is born occiput posterior
•

Mechanism (Cardinal Movements) of Fetus
(DFIEREE)
Extension
• The combined forces of uterine contractions,
pushing effort of the mother & the resistance of
the pelvic floor cause the head to extend
towards the vaginal opening.
• As the head extends, the chin is lifted up & then
it is born.
• In this movement, the fetal spine is no longer
flexed, but extends to accommodate the fetal
body to the contour of the birth canal.
• the cervix to dilate and efface.
Mechanism (Cardinal Movements) of Fetus
(DFIEREE)
Restitution
• After the head is out, it will turn to its original
position before it assumed internal rotation.
• As a result, the head is once again in line w/ the
shoulder & the back w/c is still inside the birth
canal.
• The return of the head to its original position is
called restitution.
• This movement makes it easier for the shoulder
inside to make an internal rotation.
• • Stretching of the cervix during dilation
Mechanism (Cardinal Movements) of Fetus
(DFIEREE)
External rotation
• When the head comes out, the shoulder w/c
enters the pelvis in transverse position turns to
anteroposterior position for it to become in line
w/ the anteroposterior diameter of the outlet &
be able to pass through the pelvis.
• As the shoulder moves inside, it brings along
corresponding rotation of the head outside in
the same direction; w/c is called external
rotation.
• phase.
Mechanism (Cardinal Movements) of Fetus
(DFIEREE)
8
Expulsion
• When the head is born, the shoulder & the rest
of the body follow without difficulty.
•
Components of Labor
Powers (strength of uterine contractions)
The Powers of Labor (primary & secondary)
1. Primary power: uterine contractions
• The most important forces during the first stage
of labor are the uterine contractions that cause
Characteristic of uterine contractions:
a. Involuntary
• Uterine contractions are involuntary and
independent of extrauterine control. Uterine
contractions occur spontaneously in the same
way as the heart muscles beat.
Characteristic of uterine contractions:
b. Intermittent
– Characterized by alternating periods of
contraction and relaxation. Periods of
rest are necessary on order to allow
blood flow and oxygenation of tissues.
c. Involves discomfort: this is called labor pains and
caused by:
• Compression of nerve ganglia in the cervix
• Stretching of the peritoneum overlying the
uterus
• Hypoxia of the contracted myometrium
• Stretching of ligaments
• Uterotropin are agents that prepare the uterus
and cervix for labor. They cause the uterus to
become irritable, sensitive to uterotonins and
the cervix to soften.
• Uterotonin are agents that stimulate uterine
contraction such as oxytocin, prostaglandin and
endothelin-1.
Phases of Uterine Contractions:
1. Increment or Crescendo
• The time when contraction is starting and
intensity is building up. This is the longest
2. Acme or Apex
• The peak of contraction.
3. Decrement or Decrescendo
• The time when muscles start to relax.

• •
Components of Labor
Powers (strength of uterine contractions)
Intensity refers to the strength of uterine contractions.
Intensity is classified as:
1. Mild contractions
2. Moderate contractions
3. Strong contractions
Frequency
• Refers to the rate at which contractions are
occurring.
• It is measured from the beginning of a
contraction to the beginning of the next
contraction.
Duration
• Refers to the length of contraction.
• It is measured from the beginning of
contraction to the end of the same contraction.
Interval
• Refers to the time that lapse between two
uterine contractions.
• It is measured from the end of a contraction to
the beginning of the next contraction.
• •
Components of Labor
Powers (strength of uterine contractions)
Upper and Lower Uterine Segments
• Retraction refers to the permanent shortening
of the muscle fibers that occurs w/ each
contraction.
• Retraction causes the uterus to differentiate
into 2 parts:
I. Upper Segment
– This is the active part of the uterus
found at fundal area w/ great force.
II. Lower Segment
– The lower passive portion of the uterus
contains less muscle fiber & is therefore
not as contractible as the upper
portion.
III. Physiologic Retraction Ring
– This is the boundary between the upper
active segment & lower passive
segment.
2. Secondary Forces
9
The force is combined efforts of the diaphragm,
abdominal & thoracic muscles.
• These groups of muscles are effective only in
pushing the fetus out when the cervix is fully
dilated.
•
Components of Labor
Psyche (emotional condition of the mother)
Psyche /Psychological Outlook
• Refers to the feelings that the woman brings to
labor
• For some, feelings may include apprehension &
fear; for others, excitement & wonderment are
common
• A major component is the woman’s
psychological readiness for labor
Factors affecting psychological readiness:
a.) Presence of a support person
b.) The degree of preparation for childbirth
c.) Past experiences & coping measures
d.) Accomplishment of the tasks of pregnancy
e.) Ideally, the outcome is to provide the woman with as
much control over the situation as possible.
Components of Labor
Person in Labor
Person in Labor
• The attitude of the mother during labor greatly
affects labor process & outcome. Maternal
attitudes & behaviors during labor depend on
several important factors. They are:
• Perception & meaning of childbirth
• Readiness & preparation for childbirth
• Past experiences
• Coping skills
• Cultural & social background
• Presence of significant others & support system
Labor pain is caused by:
• Compression of nerve ganglia in the cervix
• Stretching of cervix during dilatation
• Stretching of peritoneum overlying the uterus
• Hypoxia of contracted myometrium
• Stretching of ligaments
 10

• First Stage of Labor: Cervical dilatation and

effacement
• The period from the onset of true labor
contractions until full cervical dilatation &
Components of Labor effacement is achieved.
Person in Labor • Two important events take place during the 1 st
stage:
a.) Cervical Effacement or Obliteration or Taking Up
1st Stage: is associated w/ dilatation of the cervix, b.) Cervical Dilatation
hypoxia of uterine muscle cells & stretching of lower a.) Cervical Effacement or Obliteration or Taking Up
abdominal wall & over the lower lumbar & sacral areas. • It refers to the shortening of the cervical canal
2nd Stage: is associated w/ hypoxia of muscle cells, from a length of about 1 to 2 cm until it is paper
distention of vagina & perineum & pressure on adjacent thin.
structures. The pain is felt in the lower portion of the •
uterus, around the upper margin of the legs & in the
perineal area.
3rd Stage: is associated w/ uterine contractions &
cervical dilatation during the birth of placenta. Stages of Labor
Position - Maternal position during labor
1. Standing or Walking
2. Squatting •
3. Side lying
4. Kneeling over a chair
•
Stages of Labor

Components of Labor b.) Cervical Dilatation

Position • Refers to the enlargement of widening of the
cervical canal.
• Uterine contraction causes dilatation by pulling
Position the cervix over the presenting part, called
5. Birthing Balls FERGUSON REFLEX.
Position • The BOW & the FETAL HEAD also act as a wedge
6. Hands and knees (on all fours) in dilating the cervix.
• •

Components of Labor Stages of Labor

Position

•
•

Stages of Labor
Stages of Labor

Second Stage: Expulsive Stage/Delivery of the baby


• This occurs from full cervical dilatation until the
birth of the baby.
• The main event of this period is the birth of the
baby.
Third Stage: Placental Stage/Expulsion of the placenta
• This is the period from delivery of the baby to
the expulsion of the placenta.
• The main event in this period is the delivery of
the placenta.
Fourth Phase: Immediate Postpartum
Period/Transition phase
• The period from delivery of placenta until the
condition of the woman has stabilized.
• Fluid Balance
Stages of Labor
• replacement necessary if labor is prolonged
Maternal & Fetal Responses of Labor
Physiologic Effects of Labor on a Woman
Cardiovascular System
• Decrease blood flow to the uterus because the
contracting uterine wall puts pressure on the
uterine arteries.
• The increase of blood remains in the woman’s
circulation.
• Do not take BP during contraction, it will lead to
wrong reading.
• Pushing during labor may increase cardiac
output by 40%-50% above prelabor level.
Blood Pressure
• Rises an average of 15mmhg due to increased
cardiac output. Higher increases could be a sign
of pathology.
Hemapoietic System
• There is sharp increase in the WBC
(leukocytosis)
• Possibly a result of stress & heavy exertion
• Average woman has a WBC of 25,000-30,000
cells/mm3
• Normal WBC count is 5,000-10,000 cells/mm3
Respiratory System
11
• Increase RR to supply additional oxygen in
response to increase cardiovascular parameters
• Total oxygen consumption increases by about
100% during 2nd stage of labor
• May result to hyperventilation (same w/
strenuous exercise)
• Use appropriate breathing patterns during labor
to avoid hyperventilation
Temperature Regulation
• Increased muscular activity associated w/ labor
can result in a slight elevation (1F) temperature
• Diaphoresis occurs w/ accompanying
evaporation to cool & limit excessive warming
• Increase insensible water loss due to
diaphoresis & increase in rate & depth of
respiration (w/c cause moisture to be lost w/
each breath)
• Combination of decreased oral intake (NPO) &
increased fluid losses may make IVF
Urinary System
• Kidneys begin to concentrate urine to preserve
both fluid & electrolytes brought by decreased
fluid intake during labor & increased insensible
water loss.
• Pressure of the fetal head as it descends in the
birth canal reduces bladder tone (ability of the
bladder to sense filling)
• Asked woman to void every 2 hours
Musculoskeletal System
• Throughout pregnancy, relaxin, an ovarian-
released hormone, has acted to soften the
cartilage between bones
Gastrointestinal System
• Becomes fairly inactive during labor, probably
due to the shunting of blood to more sustaining
organs & also due to pressure on stomach &
intestines from contracting uterus
Neurological & Sensory Responses
• Neurologic responses are related to pain
(increased PR & RR)
• Pain during labor is registered at uterine &
cervical nerve plexuses (11th & 12th thoracic
nerves)
• At moment of birth, pain is centered on the
perineum as it stretches to allow fetus to move
past, registered at S2 to S4 nerves
Fatigue
• Tired due to burden of carrying much extra
weight

• Sleep hunger during the last month due to
backache in side-lying position & fetal kicks that
awakens the woman
Fear
• Review process of labor as a reminder that
labor is not strange; labor is predictable but
variable; contractions last a certain length but
always have pain-free rest periods in between
• Woman worry that her infant may die or born
w/ abnormality
Cultural Differences
• Address these differences, & make arrangement
to accommodate her beliefs or customs
– Providing warm food/fluids
– Saving placenta
– Arrange for interpreter if w/
communication barrier
• hemmorrhage
Maternal & Fetal Responses of Labor
Physiologic Effects of Labor to Fetus
Neurologic System
• decrease FHR as much as 5bpm during
contraction due to exerted pressure on the fetal
head during contraction
• Do not take FHT during contraction to avoid
false reading
Cardiovascular System
• Reduced oxygen & nutrients during
contractions because uterine arteries are
constricted causing slight fetal hypoxia
• Increased ICP caused by uterine pressure on the
fetal head serves to keep circulation from falling
below normal during the duration of a
contraction
Integumentary System
• Minimal petechiae or ecchymotic areas on the
fetal presenting part
• There may also be edema of the presenting part
(caput succeedeneum)
Musculoskeletal System
• The force of uterine contractions tends to push
fetus into position of FULL FLEXION, the most
advantageous position for birth
Respiratory System
• The process of labor aid in the maturation of
surfactant production by alveoli of fetal lung.
12
• The pressure applied to the chest from UC &
passage thru birth canal helps to clear lung
fluid.
•
Danger Signs of Labor
Maternal Danger Signs
Maternal tachycardia, hypertension and hypotension
• A systolic pressure greater than 140mmhg &
diastolic pressure greater than 90mmhg
• Increase in SP of more than 30mmh & DP of
more than 15mmhg
• Falling BP may be the 1st sign of intrauterine
Abnormal pulse
• Most pregnant woman have a PR of 70-80bpm
• PR normally increases slightly during 2nd stage of
labor
• PR greater than 100bpm in normal labor is
unusual, may be an indication of hemorrhage
Inadequate or prolonged contractions
• If becomes less frequent, less intense, or
shorter in duration, may indicate uterine
exhaustion. If not corrected, perform CS.
• UC lasting longer than 70 sec should be
reported, it may begin to compromise fetal
well-being by interfering w/ adequate uterine
artery filling
Pathologic Retraction Ring
• An indention across a woman’s abdomen
• May be a sign of extreme uterine stress &
possible impending uterine rupture
Abnormal Lower Abdominal Contour
• full bladder:
– A round bulge may appear on lower
anterior abdomen
– pressure of fetal head may injure the
bladder
– Pressure of bladder may not allow fetal
head descend
Increasing Apprehension
• may be a sign of oxygen deprivation or internal
hemorrhage
Fever, foul smelling vaginal discharge
• May be a sign of chorioamniotis
Vaginal bleeding
• May be placenta previa or abruptio placenta

• during w/c the uterus returns to its normal size
Danger Signs of Labor
Fetal Danger Signs
High or Low FHR
• FHR more than 160bpm (tachycardia) or less
than 110bpm (bradycardia) is sign of possible
fetal distress
Meconium Staining
• Amniotic fluid is greenish in color
• May be a sign of fetal distress
Hyperactivity
• Ordinarily, fetus is quiet & barely moves during
labor.
• May be a sign of hypoxia
• Frantic motion is common reaction to oxygen
need
Oxygen Saturation
• When oxygen saturation level is under 40%,
assessed by catheter inserted to the cheek
• Ph ≤7.2 by fetal blood obtain by scalp puncture
– Suggests that fetal well-being is
compromised
– Normal saturation: 40-70%
Cord Prolapse
• If it is normal, the cause of headache is probably
Maternal & Fetal Assessment during Labor
OBTAIN PERSONAL DATA
• Name, address, telephone number, age, date of
birth, religion
ASSESS MATERNAL CONDITION
• Health History
– Time & content of the last meal
– Past & present illnesses, allergies,
immunization history, current
medications
– Ask if smoking, using alcohol & drugs –
amount & time of last ingestion
Obstetric History
• Past pregnancies: parity, gravity, outcome of
previous pregnancies, labor & puerperium (the
period of up to about 6 weeks after childbirth,
13
called involution)
• Present pregnancy: LMP & EDC, any problem
encountered w/ present pregnancy. If the
patient has a bleeding incident, do not perform
IE as it is disallowed by law & as precautionary
measure.
• Inquire about other concerns of the woman
regarding labor fears, questions,
misconceptions, etc.
Vital Signs
1. Vital signs are taken on admission.
2. Latent Phase:
• Take BP, PR & RR every 1-2 hours (depending
on hospital policy). A rapid pulse may indicate
hemorrhage & dehydration. Report to physician
any deviation from normal.
• Take temperature every 4 hours. Assess every
hour after rupture of membranes because of
the increased risk of infection. Above normal
temperature may be due to infection or
dehydration.
2. Latent Phase:
• Take BP between contractions not during
contraction as it tends to rise during a
contraction. Take every hour w/ patient in left
lateral position. After anesthesia is
administered, take every 15-20 minutes.
• Check BP when woman complains of headache.
the stress of labor. Encourage relaxation
technique.
• BP may decrease if taken w/ woman in supine
position & after anesthesia is given. BP may
increase during UC & PIH. If result is suspicious,
wait 2 minutes & read again.
3. Active & Transition Phase:
• Take every 30 minutes to one hour (depending
on hospital policy)
4. Second Stage
• Take every 15 minutes to one hour
5. Vital signs are taken more frequently in the presence
of complications & when certain procedures are done
such as induction & after administration of anesthesia.
Plans for Newborn Care
• Intent to breastfeed or bottle feed
• Rooming in preference
• Circumcision preference in male infant
• Choice of pediatrician
ASSESS IMMINENCE & PROGRESS OF LABOR
1. Uterine Contractions (UC)

• Assess the ability of the uterus to dilate the
cervix
• Determining the progress of labor
• Detect abnormalities of uterine contractions
• Evaluate any signs of fetal distress.
2. Methods of Monitoring UC:
a.) Manual
• Assessment by palpation using fingers place
over fundus. Anew nurse may have difficulty
assessing intensity of UC, a practice guide is to
compare it w/ consistency of the following parts
of the face:
• Can be indented as far as the tip of the nose:
Mild UC
• As firm as the chin: Moderate UC
• As firm as the forehead: Strong UC
b.) External Pressure Monitor
• Uses a tocodynanometer, a transducer that
converts pressure to electrical signals. A flat
disk w/ flush plunger is secured over the
abdomen w/ an elastic belt.
• As the uterus contracts, the abdominal wall
rises & presses against transducer. This
movement is converted to an electrical signal &
is recorded on a paper.
b.) External Pressure Monitor
• The external pressure monitor may not be as
accurate as palpation by a skilled nurse.
• For example, in a thin & small woman, a mild
contraction may be interpreted as a strong
contraction. And in an obese woman who has a
lot of adipose tissue, a strong UC may be
interpreted as a mild or moderate contraction.
c.) Internal Pressure Monitor
• Uses a catheter w/ sterile water. The catheter
tip is inserted inside the uterus, just above the
presenting part.
Assess & report the following abnormal findings:
a.) intensity: if uterus does not relax completely
in between UC
b.) duration: more than 70 seconds
c.) interval: less than 2 minutes
d.) frequency: exceeds 3 times every 10 min
Techniques:
a.) when timing contraction place warm hands w/palms
facing down over the fundus where the strongest UC
can be felt
b.) use finger pads to feel for the UC as they are the
most sensitive area of the palms
c.) Time 3-4 contractions to have a good picture of
frequency
14
d.) check the contractions every 15 to 30 minutes
during the 1st stage
Show
• 1. Show is slightly blood tinged mucus discharge
that becomes heavier & more blood stained as
labor progresses. In normal labor only an
increasing amount of blood stained mucus
discharge is expected not actual bleeding.
• 2. The presence of vaginal bleeding is an
abnormal sign that must be reported
immediately. Instruct patient not to discard
away perineal pad as used for inspection.
Internal Examination (IE)
The purpose of IE is to assess the following:
1. Status of amniotic fluid
2. Consistency of the cervix
3. Effacement
4. Dilatation
5. Presentation
6. Station
7. Obtain pelvic measurement
• Nurses & midwives are legally allowed to
perform IE. However, they cannot perform IE if
the patient is bleeding during labor or has a
history of bleeding during pregnancy.
GUIDELINES WHEN DOING IE:
1. IE is performed in between contractions when the
uterus is relaxed.
2. IE performed during a contraction causes a lot of pain
& may cause intact membrane to rupture.
3. Less IE is done once membranes have ruptured.
4. IE is not done in the presence of vaginal bleeding &
cord prolapsed.
5. IE is a sterile procedure, wash hands & wear sterile
gloves.
6. Place patient in dorsal recumbent position. Place
pillow under the head.
During IE:
• Check for escaping fluid & cord prolapsed
before inserting fingers.
• Insert middle & index finger toward the
posterior vaginal wall.
• Assess cervical consistence, it is buttersoft
during labor.
• Assess effacement; length of cervix is about 1-2
cm (2.5 cm. other book)
• Assess dilatation, remember that index finger is
1 cm & middle finger is 1.5 cm.
During IE:

• Assess membranes if they are intact, during a
contraction they tend to bulge.
• Locate ischial spines at 4 & 8 o’clock position to
assess station.
• Confirm presentation if it is cephalic (fontanels)
or breech (anus)
• Establish position: in cephalic presentation,
note where fontanelles are pointing.
• suspected amniotic fluid.
Maternal & Fetal Assessment during Labor
Status of Amniotic Fluid
1. Every pregnant woman is instructed to report
immediately any leakage of fluid from the vagina. This is
because once membranes are ruptured:
• There is danger of cord prolapsed if fetal head is
not engaged.
• There is danger of serious intrauterine infection
if delivery does not occur in 24 hours.
• Labor & delivery will most probably occur
within 24 hours.
• • Gray colored or cloudy: infection
Maternal & Fetal Assessment during Labor
2. If not determine if membranes are ruptured, perform
to assess status of BOW:
a. Nitrazine paper test
• Insert a sterile cotton-tipped applicator into the
vagina to moisten it w/ the suspected amniotic
fluid
• Touch nitrazine paper w/ cotton-tipped
applicator
• Negative: Nitrazine paper is yellow if BOW is
intact
• Positive: It will turn blue if BOW is ruptured
• Excessive amount of bloody show & bleeding
can give false positive result because blood, like
amniotic fluid, has almost the same pH & gives
the same reaction in Nitrazine.
c. Positive Fern Test or Cervical Mucus
• Take sample of vaginal secretion from cervix,
swab in a slide & allow it to dry for 5-7 minutes.
View specimen under the microscope.
15
• If ferning pattern is noted, it indicates ruptured
membranes.
• Ferning pattern is caused by the estrogen found
in the amniotic fluid.
d. Nile blue sulfate staining of fetal squammous cells in
suspected amniotic fluid.
e. Identification of high values of glucose, fructose,
prolactin, alpha-fetoprotein or diamine oxidase in
f. Injection of various dyes such as Evans Blue,
methylene blue & flourescan into the amniotic sac via
abdominal amniocentesis.
3. Immediately after membranes have ruptured:
a. After rupture of BOW, the 1st intervention is to assess
FHR for one full minute. If bradycardia is present,
perform IE to assess for cord prolapsed & change
position of the woman to relieve pressure on the cord.
b. Assess odor of amniotic fluid. Cloudy & foul smelling
amniotic fluid indicates infection.
c. Assess the amount & color of amniotic fluid. It should
be clear & straw colored w/ specks of vernix caseosa.
• Green tinged: Fetal distress in non breech
presentation
• Yellow colored: Hemolytic disease,
hyperbilirubinemia
• Pinkish or Red Stained: bleeding
• Brownish/Tea-colored/Coffee-colored: Fetal
death
d. Record time of rupture, characteristics of fluid & FHR.
• Fundic Height & correlate w/ AOG: Take fundic
height after asking the patient to empty her
bladder. A full bladder may cause higher fundic
height.
• Abdominal palpation (Leopold’s maneuver):
Perform abdominal palpation to determine fetal
presentation.
• four maneuver's employed to determine fetal
position:
1) determination of what is in the fundus;
2) evaluation of the fetal back and extremities;
3) palpation of the presenting part above the
symphysis;
4) determination of the direction and degree of
flexion of the head.
•
Maternal & Fetal Assessment during Labor

FETAL ASSESSMENT DURING LABOR
1. Methods of assessing FHT:
• Stethoscope
• Fetoscope (De-Lee stethoscope, Left
stethoscope)
• Doppler
• Electronic fetal monitoring equipments
2. Intermittent monitoring of FHT can be accomplished
using a stethoscope, fetoscope, hand held Doppler
device & external fetal monitor. The intermittent
auscultation of FHT is advisable for normal pregnancies.
a. Advantages:
• Woman has more freedom to move about
because no electrodes are attached to her.
• The nurse can provide more attention to the
woman & her partner.
b. Disadvantages:
• The nurse must spend time in monitoring.
• There is a possibility of missing an abnormal
FHT.
3. Electronic fetal monitors can be applied externally or
internally & may be used intermittently or continuously.
• Continuous electronic fetal monitoring of the
fetus is not necessary during normal labor.
• However, if the mother or the fetus is classified
high risk, a more precise & continuous
monitoring is desirable for early detection of
complication.
• Candidates of continuous electronic fetal
monitoring would include:
a.) women w/ multiple pregnancy & other obstetric
complications
b.) those receiving oxytocin infusions
c.) women who passed meconium stained amniotic fluid
d.) other high risk conditions
3.1. External Fetal Monitor has a transducer that is
placed on the maternal abdomen. Before applying the
transducer, Leopold’s maneuver is done to locate the
FHT & fetal back. The transducer is applied on the area
of the abdomen where the fetal back is located.
a. advantages:
• Noninvasive & does not pose risk of infection
• Provides continuous tracing of FHT
• Enable the nurse to detect signs of fetal
compromise early
b. Disadvantages:
• May not be able to detect short term variability
16
• Fetal movement & maternal movement may
interfere w/ continuous monitoring so woman
is instructed to limit changing positions.
•
Maternal & Fetal Assessment during Labor
3.2. Internal Fetal Monitor is attached to the fetal scalp.
Membranes must be ruptured & the cervix be partially
dilated (at least 2 cm), & the fetus descends to be able
to attach the electrode on the fetus.
a. advantages:
• Not affected by fetal movement
• It provides continuous & accurate recording
even if the woman moves & changes position
• It provides accurate information regarding
variability
b. disadvantages:
• The primary risk for the invasive monitoring is
infection:
• Chorioamnionitis & Osteomyelitis or fetal scalp
cellulitis
• Trained practitioner must insert the electrode.
•
Maternal & Fetal Assessment during Labor
Frequency of Monitoring FHT
1. Low Risk:
• Latent Phase – take FHT every hour
• Active Phase – take FHT every 15-30 minutes
• Second Stage – take FHT every 5-15 minutes. As
the fetus descends deeper into the birth canal,
some variable deceleration may be noted
during uterine contraction because of cord
compression. This is usually not ominous as
long as the FHR returns to normal baseline after
the end of the contraction & pressure against
the cord is relieved.
2. At Risk: FHT is taken more frequently or continuously:
• Latent Phase - take FHT every 30 minutes
• Active Phase – take FHT every 15 minutes
• Second Stage – take every 5 minutes
3. Take FHT immediately after the rupture of the BOW,
whether artificially or spontaneously.
 17

4. Before & after: • Fetal distress – initial fetal reaction to poor

• Drug administration & at the peak action time oxygenation supply is tachycardia followed by
of the drug bradycardia
• Ambulation of laboring woman • Maternal infection & fever; Dehydration
• Performing invasive procedure: IE, enema, • Hyperthyroidism
amnioinfusion catheterization • Drugs: Atropine, Vistaril, Ritodrine &
5. After any significant change in the uterine contraction Terbutaline, Epinephrine, Caffeine,
is noted. Theophylline, Cocaine
NORMAL FHT PATTERN ABNORMAL FHT PATTERN
1. Baseline Rate 1. Tachycardia
• Normal: 120-160 BPM c. Management:
• Rates of 110-120 are usually acceptable if all • Reduce maternal fever
other signs are reassuring or normal • Increase fluids
• The baseline rate should be measured between • monitor for chorioamnionitis (inflammation of
uterine contractions, initially for a full 10 the embryonic membrane that totally
minutes period surrounds the embryo)
2. Baseline Variability refers to FHT fluctuations caused 2. Bradycardia
by the balancing acts of the sympathetic (increase FHT) a. Moderate – 100-119 BPM, Marked – below 100 BPM
& the parasympathetic branches (decrease FHT) of the b. Causes:
autonomic nervous system. The presence of normal • fetal hypoxia as a result of analgesia &
variability is a reassuring sign that the fetus’s nervous anesthesia
system is intact. There are 2 types of variability: • maternal hypotension
a. Short-term variability (STV) or Beat to Beat variability • prolonged umbilical cord compression
• Is the difference between successive heart • vagal stimulation caused by compression of
beats or the moment to moment fluctuations of head during contraction
FHT. • fetal decompression from prolonged hypoxia
b. Long-term variability c. Management:
• Is wider fluctuations, over minute/s, that causes • place mother on the left side
the wavy appearance in the FHT tracing in the • assess for cord prolapsed
monitor. • administer oxygen
• Absent: no fluctuations in FHT 3. Late Deceleration: FHT decreases during uterine
• Minimal: 5 BPM or less contraction & do not return to normal after the end of
• Moderate/Normal: 5BPM to 25 the same contraction is a sign of uteroplacental
• Marked: greater than 25BPM below or above insufficiency.
the baseline a. Causes:
3. Early Deceleration • uterine tetany (spasm & twitching of muscles)
• Rate of FHT decreases at onset of uterine from oxytocin administration
contraction but return to normal before the end • maternal supine hypotension
of contraction. • hypertensive disorders
• This is a normal response of the fetus to head • DM
compression caused by UC. • Chronic disorders
4. Acceleration b. Management:
• When the fetus moves, it is expected that the • Position on left side
FHT will increase. • Discontinue oxytocin
• Accelerations by at least 15BPM for 15 seconds • Give mask oxygen at 8-10 L/m
are considered normal. • Increase IVF
ABNORMAL FHT PATTERN • Notify physician
1. Tachycardia • Prepare for birth if no improvement
a. Moderate: 161 to 180 BPM, Marked: above 180 BPM • Tocolytics may be ordered by the physician to
b. Causes: relax the uterus & allow more blood flow to the
placenta

4. Sinusoidal Pattern: Decreased or absence of
variability in FHT
a. Causes:
• Fetal hypoxia
• Fetal anemia
• Fetal sleep (normal sleep cycle is about 20
minutes)
• Prematurity
• Medications taken by the mother: magnesium
sulfate, narcotics, tocolytics
5. Variable Pattern/Deceleration
• Deceleration occurring at unpredictable times
during contractions.
• It has erratic & jagged pattern in the FHT
tracing, shaped like a V, U or W owing to
sudden drops & elevations of FHT.
a. Causes:
• Most often due to cord compression. Note here
that the deceleration is often not continuous,
occurring only as long as the cord is compressed
& FHT normalizes when the compression is
relieved after uterine contraction.
• Oligohydramnios
b. Management:
• Relieve pressure on the cord: change position to
lateral or knee chest. The compression is
relieved when the variability disappears & FHT
tracing is normal.
• Perform IE to check for cord prolapsed
• Give oxygen by face mask if persists after
changing position
• Stop oxytocin infusion
• Notify physician
• Amnioinfusuion (infuse saline into the uterus)
may be performed by the physician to relieve
compression
• • b.) expulsive stage
Maternal & Fetal Assessment during Labor
LOCATION OF FHT
• Mark the location in the abdomen where the
FHT was auscultated if it is being monitored
using a stethoscope to facilitate subsequent
FHT auscultation.
•
18
Maternal & Fetal Assessment during Labor
•
Uterine Phases of Parturition (childbirth)
Phase 0
• This extends from the time before implantation
until late in pregnancy when the uterus is
relaxed or quiescent & the cervix is firm & rigid.
• Initiation of parturition is the transition from
Phase 0 to Phase 1
Phase 1
• This is the time when the uterus & cervix
undergo several changes in preparation for
labor.
• This phase occurs late in pregnancy & is
characterized by the uterus becoming more
irritable as shown by more frequent & intense
Braxton-Hicks contractions. The lower uterine
segment is formed & the cervix softens in
preparation for dilatation.
• The onset of Labor is the transition from Phase
1 to Phase 2
Phase 2
• This is the time of active labor when the
contents of the uterus are expelled.
• It is divided into 3 stages:
• a.) cervical stage
• c.) placental stage
of the baby & ends w/ the 1st ovulation after delivery.
Phase 3
• This is the time when the newly delivered
mother recovers from the effects of pregnancy
& childbirth.
• It begins from the birth of the baby & ends w/
the 1st ovulation after delivery.
•
CARE OF PARTURIENT IN THE FIRST STAGE

Carry Out Dependent Functions:
• Perform the admission orders of the physician
& other admission procedures of the institution
w/c often include but not limited to the
following:
• Administer IVF per institution policy. IVF is
usually as SOP on laboring patients admitted in
hospitals.
• Initiate labor progress notes: FHT, uterine
contractions, vital signs
• Notify patient’s attending doctor upon patient’s
request
IV Fluids
The purposes of inserting the IVF upon admission are:
1. Prevention of dehydration/fluid & electrolyte
imbalance
2. Having a life-line for emergencies
3. Usually required before administration of anesthesia
& analgesia
4. For administration of oxytocin after delivery to
prevent uterine atony
Perineal Preparation
1. Purpose
• a. to clean & disinfect the external genitalia in
order to prevent contamination & infection of
the birth canal.
• There is no difference in infection site rate
among women whose hair were clipped & not
clipped.
• Shaving increases infection because of the
myriads of nicks that can occur
• b. To provide better visualization of the
perineum
2. Important Considerations
a. Assemble all equipments & materials to be used
b. Provide good lighting
c. Ensure privacy & comfort during the procedure,
drape properly. Use bed screen if patient is in ward
d. Explain the procedure to patient to allay anxiety &
gain cooperation
3. Procedure: Perineal Preparation
a. Wash hands & wear gloves
b. Place patient supine w/ legs flexed & dropped
sideways, heels facing each other
c. Place patient on bedpan
d. Using cotton balls (sterile sponges, disposable or
reusable wash cloths can also be used) soaked in mild
antiseptic solution, cleanse perineum from front to
19
back. Moving from clean to dirty area. Anything that has
passed over the anal area should not be returned to the
vulvar area to prevent infection. Do not let solution
enter the vaginal introitus.
e. pour warm water over the vulva to rinse it.
f. after cleaning the vulva, turn woman on her side and
flex thighs and hips to expose perineal and anal area.
Cleanse.
g. if perineal shaving is to be done, soap and lather the
hair of vulva to soften it, use dry gauze square to stretch
the skin while shaving hair. The skin is stretched to keep
it taut so that the razor will move smoothly over it
avoiding skin cuts. Start from labia majora moving
towards the direction of the anal area. Use single
strokes. Rinse razor after each stroke.
h. when shaving is finished, wash with antiseptic soap
and sterile water. Check for thoroughness.
i. turn woman on her side and shave anal area.
j. instruct woman not to touch the perineum after it has
been shaved and cleansed to keep it clean.
Turn patient on her back and drape.
Care of the Bladder
1. A woman in labor should be encouraged to void
frequently, at least every 2 hours to prevent bladder
distention because a full bladder:
Delay fetal descent
Increases discomfort of labor
Predispose to urinary tract infection
Can be traumatized during labor
2. a distended bladder can be palpated above the
symphisis pubis as it bulges or protrudes. Percussion of
a full bladder produces a reasonant sound while empty
bladder produces dull sound.
Foods & Fluids
1. Early in labor, clear fluids may be allowed. If not, the
woman may be given ice chips to prevent drying of the
mouth and for comfort.
• During active labor, foods and oral fluid should
be withheld because gastric emptying is
prolonged. Foods taken stays in the stomach
longer which the woman may vomit and
aspirate especially if she has been given
anesthetics and analgesics.
Ambulation
1. Encourage woman to ambulate during the latent
phase of labor to shorten first stage if membranes are
still intact. When the woman stands or squats, the
diameter of the inlet is increased making the passage of
the fetus through the birth canal faster and easier.

2. Ambulation has also been found to decrease the
need for analgesia, decrease incidence of FHT
abnormalities and to promote comfort
Enema
• 1. Enema is a procedure of emptying the colon
of fecal matter to:
• Stimulate uterine contractions
• Prevent infection- expulsion of feces during the
second stage predispose mother and infant
infection
• Facilitate descent of fetus
2. Enema is not a routine procedure in the preparation
of woman in labor. Commonly used enemas are tap
water enema, fleet enema and prepacked disposable
type enema. Soap suds enema is not recommended
because they have been associated with several
complications. Suppositories are also used.
3. Contraindications to enema:
• Not given during active phase and ruptured
BOW
• Vaginal bleeding
• Abnormal fetal presentation and position
• Fetus not yet engaged
• Premature labor because of the danger of cord
prolapsed
• Abnormal fetal heart rate pattern
Transfer to Delivery Room
• 1. Primiparas are transferred to the delivery
room when the cervix is fully dilated and
perineum is bulging.
• 2. Multiparas are moved to DR when cervix is
8cm dilated
• to be performed.
CARE OF PARTURIENT IN THE SECOND STAGE
• The second stage of labor begins as soon as the
cervix is fully dilated and is completed with the
birth of the baby.
• Never leave the patient alone once she is
transferred to the delivery room.
• Never turn your back on the perineum because
the baby could push through the vaginal
opening while your back is turned.
•
20
CARE OF PARTURIENT IN THE SECOND STAGE
SIGNS OF THE SECOND STAGE OF LABOR
PREPARE DELIVERY EQUIPMENTS
• Place the instrument table near the delivery
table and uncover it.
• Prepare instruments to be needed by the
newborn. Turn on radiant warmer and place
receiving blanket under it to warm.
• Ready resuscitation equipments.
• Prepare also forms and charts that must be
filled up in delivery room.
DELIVERY POSITION
• Anesthesia, if indicated, is administered first
before the woman is made to assume the
delivery position.
1. Lithotomy position - Procedure:
– Cover legs of woman with sterile cotton
leggings and raise them up to the
stirrups at the same time.
– Adjust the stirrups so that the legs are
not widely separated and so that both
legs are of the same height.
– Elevate the head portion of the table to
enable the woman to push effectively.
• Indication: This position is used when surgical
procedures, such as forceps and episiotomy are
• Advantage: This position gives east access to
the perineum providing the birth attendant with
good control of the delivery of the baby.
• Disadvantages:
– Supine hypotensive syndrome
– Positioning injuries: Clot formation due
to compression, muscle strain when
legs are improperly placed on stirrups.
•  
2.Dorsal Recumbent
• Procedure:
– The head of the bed is 35 to 45 degrees
elevated, knees are flexed and feet flat
on bed. This position facilitates the
pushing effort of the mother.
• Indication: Home delivery

• Advantage: This position gives easy access to
the perineum providing the birth attendant with
good control of the delivery of the baby.
• Disadvantages: Supine hypotensive syndrome
and may be uncomfortable.
 
3. Side-lying position
• Procedure: The woman is placed on her side
• Indication: Heart disease
• Advantage: This position increase comfort to
the mother and avoids supine hypotension
syndrome.
• Disadvantages:
– Less control of delivery and decreased
access to the perineum.
– Danger of woman losing balance during
delivery.
• in the middle area.
CARE OF PARTURIENT IN THE SECOND STAGE
STERILE PREP
• Using a gloved hand, cleanse perineum, anus,
and upper inner thighs with an antiseptic
solution. The direction should always be from
the vulva outwards, from clean to dirty area.
Each sponge is discarded after use.
• The woman is catheterized (if ordered) after the
perineal cleansing and draped properly. The
vulva, perineum and anus are left exposed.
• • Open-glottis pushing when the
CARE OF PARTURIENT IN THE SECOND STAGE
PREVENTING INFECTION
• Persons with infection or have been exposed to
infections or communicable disease are not
allowed to enter the DR.
• No one should be permitted in the DR without a
sub suit, mask covering mouth and nose and
cap that completely covers hair. Anything that
21
touches the patient’s perineum should be
sterile.
• Ideally, nurses and midwives attending delivery
must wear eye shields, gowns and gloves to
protect themselves from accidental splashing of
blood and body fluids.
• During labor, the nurse-midwife should perform
handwashing before and after patient care,
when providing care between patients and
whenever there is contact with blood and body
fluids.
• In addition, the nurse-midwife should also wear
gloves at all times that there is possibility of
touching body fluids and when performing any
procedure at or near the perineum.
• When handling perineal pads, they should be
handled from ends using gloved hands and not
ASSISTING MOTHER IN THE DELIVERY ROOM
1. Coach mother to push effectively, instruct her:
– To avoid the Valsalva maneuver, this
involves holding breath and tightening
the abdominal muscles while pushing.
Valsalva maneuver decreases blood
returning to the heart, increases venous
pressure and increases intathoracic
pressure which consequently,
diminishes blood supply to placenta and
fetus.
There are two methods of pushing:
• Urge to push method when the
woman pushes only when the
urge to push is felt and relaxes
completely after a contraction
to replenish her energy.
woman pushes during uterine
contraction with open glottis so
air is released as she pushes.
• The woman may use any
method but she should never
be left alone when doing
pushing.
•
CARE OF PARTURIENT IN THE SECOND STAGE

• – Facilitates extension of the head
CARE OF PARTURIENT IN THE SECOND STAGE
– To grasp below the knees or other hard
objects as she bears down.
– To push 3 to 5 times with each
contraction but push no longer than 5
to 6 seconds.
2. To avoid exhaustion, instruct the woman to pant
(rapid shallow breathing) during some contraction. If
woman complains of lightheadedness and tingling
sensations on fingers (this is respiratory alkalosis) let
her breathe through a paper bag or cupped hand.
3. The woman may complain of leg cramps. This is due
to the pressure exerted by the fetal head against the
pelvic nerves. Provide relief by dorsiflexing the affected
foot and straightening the leg until the cramps
disappear.
4. As the presenting part moves towards the outlet,
perform ironing on vaginal orifice to stretch and
prepare soft tissues.
5. When the head is crowning (largest diameter of the
head encircles the vulvar ring):
– Instruct mother to pant and not to push
to prevent rapid expulsion of the baby
and to avoid lacerations. Rapid
expulsion will result in sudden change
of intracranial pressure which can cause
cerebral hemorrhage in infant.
– Episiotomy if necessary is performed at
this time by the doctor to prevent
lacerations.
• blood from placenta to infant. This
CARE OF PARTURIENT IN THE SECOND STAGE
6. Perform Ritgen’s maneuver while delivering the head.
Place a sterile towel over the rectum and apply forward
22
pressure on the chin while the other hand presses
downward the occiput. Ritgen’s maneuver will:
– Slows down deliver of the head
– Lets the smallest diameter of the head
to be born
•
CARE OF PARTURIENT IN THE SECOND STAGE
7. Deliver the head slowly in between contractions.
Immediately after the delivery of the head:
– Wipe the nose and mouth of secretions,
suction with bulb syringe to establish
patent airway.
– Insert fingers into vagina and feel for
cord looped around the neck (nucchal
cord). If present, slip cord down the
shoulder or over the baby’s head. If
tight, clamp twice and cut in between.
8. Holding the sides of the head with two hands, apply a
slight downward push to deliver the anterior shoulder,
and then elevate the head to deliver the posterior
shoulder. The rest of the body follows without difficulty
after the delivery of the shoulder.
9. Take note of the exact time of baby’s birth. A child is
considered born when the whole body is delivered.
10. Immediately after birth of baby, place newborn in
dependent position to facilitate drainage of secretions.
9. Place the infant over the mother’s abdomen to help
contract the uterus.
• Clamping the cord:
– Usually, the cord is clamped after
pulsation has stopped to allow
transfusion of about 50 mL of extra
practice provides additional iron and
helps prevent iron deficiency anemia.
– Clamp the cord twice and cut in
between, about 8 to 10 inches from the
umbilicus.
•

CARE OF PARTURIENT IN THE SECOND STAGE
– After cutting the cord, count blood
vessels, there should be two arteries
and one vein. The vein is larger than the
two arteries.
– Later in the nursery, the cord is cut
again and umbilical cord clamp
(Hollister, Double Grip Umbilical Clamp)
is applied about 2 to 3 cm from the
abdomen.
– Clamp the cod after baby’s delivery
without waiting for pulsation to stop in
cases of twins, maternal
alloimmunization and prematurity.
– Wrap the infant in sterile diaper, show
to mother or let her hold the baby
(depending on institution’s policy). Be
sure to establish eye contact between
mother and baby to promote bonding
before bringing newborn to nursery.
14. Wrap Record the delivery. Information to include in
the nurses’ notes are:
– Exact date and time of delivery.
– Sex of the infant.
– Condition of the infant (APGAR) after
birth.
– Position of the infant at delivery.
– Type of episiotomy, lacerations.
– Spontaneous or forceps delivery.
– Use of oxygen and suction on the
infant.
– Number of vessels in the cord.
– Any or other pertinent facts about the
delivery.
– – Do not hurry placental delivery. No
CARE OF PARTURIENT IN THE THIRD
STAGE
METHODS OF PLACENTAL SEPARATION
• Schultz Mechanism – Separation of the
placenta starts from the center. The shiny
23
smooth fetal side is delivered first in this type of
separation. About 80% of placental separation
occurs by Shultz Mecahnism.
• Duncan Mechanism – Separation begins from
the edges of placenta. The maternal side is
delivered first. About 20% of separation occurs
by Duncan Mechanism.
•
CARE OF PARTURIENT IN THE THIRD STAGE
METHODS OF PLACENTAL SEPARATION
MATERNAL ASSESMENT
1. Monitor vital signs every 15 minutes.
– Tachycardia and failing BP may be due
to hemorrhage and shock and should
be reported immediately.
– Suspect amniotic fluid embolism if
woman complains of sudden dyspnea,
chest pain and tachypnea. Refer to
physician at once.
2. Monitor time interval between birth of the baby and
the placenta.
• Normally, the placenta is delivered within 5 to
20 minutes after baby’s birth.
• If a longer period of time elapsed before the
placenta is delivered, the mother is at risk of
losing greater than normal amount of blood in
the third stage.
3. Watchful waiting: If the uterus remains contracted
and there is no severe bleeding, watchful waiting is
employed until the placenta is delivered.
fundal push, no uterine massage and no
pulling of the cord. These actions can
result in uterine inversion.
– Rest one hand over the fundus to make
sure the uterus remains firm and does
not fill with blood.
– Wait for signs of placental separation:
• Calkin’s sign is usually the first
sign of placental separation.
The uterus becomes firm and
globular rising to the level of
umbilicus.

• Sudden gush of blood from the
vagina.
• Lengthening of the cod as the
placenta separates from the
uterus.
• Appearance of the placenta at
the vaginal opening.
• Place a hand just above the symphisis pubis
with palms facing the umbilicus, push the
uterus upwards. With the other hand, tract the
cord slowly while gently rotating it around the
clamp until the placenta come out. Rotate the
placenta as you deliver it. Inspect for
completeness of cotyledons right after placental
delivery. Retained placental fragments can
cause severe hemorrhage by preventing the
uterus to contract.
– Suspect a succenturiate lobe retained in
the uterus when upon inspection of the
placenta after delivery fetal vessels are
coursing to the placental edge and
abruptly ending at a tear in the
membranes.
5. Massage the uterus to keep it contracted.
6. Placental expression: If bearing down effort of the
mother is not enough to deliver the placenta, apply
gentle downward pressure on the fundus to expel the
placenta. Make sure the uterus is firm or contracted
and placenta has already separated when performing
placental expression to prevent uterine inversion.
7. Oxytoxic agents are drugs that stimulate the uterus to
contact. It is given to:
– Initiate labor – Given slowly and in small
doses until desired UC are achieved.
– Used to augment weak UC that has
already begun.
– Used to control postpartum atony –
May be given rapidly as a bolus to
immediately control bleeding.
• Route: IV, IM, oral and nasal
•
CARE OF PARTURIENT IN THE THIRD STAGE
• Oxytocin (Pitocin, Syntocinon) 10 units: It is
ideally given IM in a dose of 10 USP units or as a
24
much more dilute solution by continuous
intravenous infusion. Oxytocin should not be
given intravenously as a large bolus because it
causes titanic uterine contractions and
hypotension. Its major adverse effect is
antidiuresis or fluid retention.
•
CARE OF PARTURIENT IN THE THIRD STAGE
MAJOR SIDE EFFECTS
• Ergonovine maleate (Ergotrate) 0.2 mg: This is a
drug obtained from ergot, a fungus that grows
on rye and other grains.
• This drug is a powerful stimulus of uterine
contraction, with an effect that persists for
hours.
• Thus it is very effective for the control of
postpartum hemorrhage. However the adverse
effect of this drug is hypertension so it is
contraindicated in women with elevated blood
pressure.
Care when administering oxytocin:
• Never leave client unattended.
• Have oxygen and emergency equipment
available.
• Use infusion control device for IV
administration.
• Discontinue if abnormal UC occur.
• Assess BP and pulse every 15 minutes.
• Monitor FHR.
•
CARE OF PARTURIENT IN THE THIRD STAGE
Record the following information in the notes:
– Time the placenta is delivered.
– How delivered (spontaneously or
manually removed by the physician).
– Type, amount time and route of
administration of oxytocin. Oxytocin is

never administered prior to delivery of
the placenta because the strong uterine
contractions could harm the fetus.
– If the placenta is delivered complete
and intact or in fragments.
•
CARE OF PARTURIENT IN THE FOURTH STAGE
• The main danger during the fourth stage is
hemorrhage. Therefore the goal of nursing care
during this period is to prevent bleeding from
uterine atony and birth canal lacerations
sustained during labor.
REPAIR OF LACERATIONS
• 1. Right after the birth of placenta, the
perineum is inspected carefully for lacerations
and necessary repairs are made. During
episioraphy (repair of episiotomy and
lacerations) a local anesthesia is injected to the
area to be repaired.
• When the uterus feels firm but there is
continuous oozing of bright red blood, suspect
lacerations.
• To stop the bleeding, these lacerations must be
repaired.
• If lacerations are discovered after the patient is
transferred to the recovery room or her private
room, return woman immediately to the
delivery room for repair.
2.Classifications of perineal lacerations:
• First degree: Involves the fourchette, vaginal
mucous membrane, perineal skin
• Second degree: Involving fourchette vaginal
mucous membrane, perineal skin, muscles of
perineal body
• Third degree: Involves fourchette, vaginal
mucous membrane, perineal skin, muscles of
perineal body and anal sphincter
• Fourth degree: Involves fourchette, vaginal
mucous membrane, perineal skin, muscles of
perineal body, anal sphincter and mucous
membrane of rectum
• and firm. If the fundus deviates from the middle, check
25
CARE OF PARTURIENT IN THE FOURTH STAGE
3. Midwifery care:
• Perineal care: Clean the perineum with an
antiseptic solution and apply a sterile sanitary
pad on the perineum. An ice pack may be
applied to the perineum to reduce swelling
from episiotomy especially if a fourth degree
tear has occurred.
• Lowe legs from the stirrups at the same time
and remove soiled drapes and linens. Change
mother into clean gown.
• Provide extra blanket to keep patient warm.
Chilling, called postpartum tremors, is common
at this period and is due to the circulatory
changes that occurred after delivery.
VITAL SIGNS
• 1. Monitor vital sign every 15 minutes for
an hour then every 30 minutes for the next
hour. Then every hour until transferred to the
RR or private room.
• 2. If the patient in stable, take them every
2-4 hours in the succeeding hours after transfer.
If not, continue monitoring frequently.
• 3. The temperature may be slightly
increased during the immediate postpartum
period because of mild dehydration.
ASSESMENT OF THE FUNDUS
• 1. Check fundus for consistency every 15
minutes during the first hour or until it no
longer tends to relax. The first action to take
when a baggy or relaxed uterus is noted is to
massage the fundus gently to stimulate uterine
contraction. If the fundus does not respond to
massage and bleeding continues, eport to
physician right away.
• 2. Massage the fundus every 15 minutes
during the first hour, every 30 minutes during
the next hour, and then, every hour.
ASSESMENT OF THE FUNDUS
3. Locate fundal height. Immediately after
placental delivery, it is located between the umbilicus
and the symphisis. It gradually rises to the level of the
umbilicus afterwards. It should be located at midline
for fullness of the bladder which is usually the cause.
 26

4. Assess the bladder when assessing the fundus.

Bladder distention displaces the uterus and prevents
proper uterine contaction. This can cause bleeding.
ASSESSMENT OF LOCHIA FLOW
• 1. Record the number of pads soaked with
lochia during recovery.
• 2. Assess color, amount, smell, presence
of clots.
• 3. Observe for constant trickle of bright
red lochia. If fundus is firm, this may be caused
by lacerations.
• 4. Observe lohia flow when the fundus is
massaged.
PROVIDING COMFORT AND PAIN RELIEF 
• During the immediate postpartum period, the
woman may experience pain and discomfort fro
several causes which include cramping from
uterine contractions and perineal pain from
episiotomy and delivery trauma.
• Relief can be provided by providing pain
medications and applying ice compress over the
perineum.
TRANSFER TO RECOVERY OR PRIVATE ROOM
• If the patient is transferred to the delivery or
private room, ensure that emergency
equipment is available for possible
complications.
• 1. Suction and oxygen in case patient
becomes eclamptic.
• 2. Pitocin® is available in the event of
hemorrhage.
• 3. IV remains patent for possible use if
complications develop.
• 4. Oxygen.

------ End-----