Ob lecture
CHAPTER 15 – LABOR AND BIRTH
Labor
- Uterine contractions and abdominal
pressure
- Progressive dilatation
- Baby to be pushed from the birth canal
- Time of change
COMMON NURSING DIAGNOSIS PERTINENT TO
LABOR INCLUDE
- Pain related to labor contractions
- Anxiety related to process of labor and
birth
- Health-seeking behaviors related to
management of discomfort of labor
- Situational low self-esteem related to
inability to use prepared childbirth method
THEORIES OF LABOR ONSET
Labor normally begins between 37 and 42 weeks of
pregnancy, when a fetus is sufficiently mature to adapt
to extrauterine life, yet not too large to cause
mechanical difficulty with birth.
Progesterone Withdrawal
- Biochemical changes towards end of
pregnancy
- Changes in the ratio of estrogen to
progesterone occurs, increasing estrogen in
relation to progesterone, which is interpreted
as progesterone withdrawal.
- Decreased availability of progesterone to
myometrium
• Antiprogestin at term inhibits relaxant
effect and enables estrogen to stimulate
contractions
Uterine Stretch Theory
- The uterus reaches a crucial point of
distention, which may cause tension on
muscle fibers and stimulate their activity
- Which results in release of prostaglandins.
Oxytocin Theory
- Nerve impulses from the uterus to the
posterior pituitary gland (when there is
pressure in the cervix) may bring about
release of oxytocin
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Prostaglandin Synthesis
- Vaginal application of prostaglandin
“ripens” cervix for induction of labor
- Amnion and decidua possible sources of
prostaglandin
Placental Aging Theory
- The physical aging of the placenta may
cause insufficient nutrients to reach the
fetus
- The placenta reaches a set age, which
triggers contractions.
• Rising fetal cortisol levels reduce
progesterone formation and increase
prostaglandin formation.
• Semen does contain prostaglandins, which can
be helpful in softening, also known as
“ripening,” of the cervix
• if a cervix is ready to ripen, semen
prostaglandins could possibly stimulate the
beginning of contractions.
• Rhythmical contractions brought on by a
woman’s orgasm can conceivably help as well
Premonitory Signs of Labor
➢ Lightening
- Fetus descends into pelvic inlet
- Occurs about 2 weeks before onset of
labor; after the start of regular
contractions in multis
- Woman breathes more easily after
lightening, but urinary frequency returns
- There is no cervical effacement or
dilatation
➢ Braxton Hicks contractions
- Irregular, intermittent contractions that
occur during pregnancy
- Cause more discomfort closer to onset of
labor
➢ Cervical changes
- Cervix begins to soften and weaken
(ripening)
• Effacement
¬ shortening and thinning of the
cervical canal
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¬ the longitudinal traction from the
contracting uterus shortens the
cervix so much that the cervix
virtually disappear
• Dilatation
¬ refers to the enlargement or
widening of the cervical canal
from an opening a few millimeters
wide to one large enough
(approximately 10 cm) to permit
passage of a fetus
¬ increase in the amount of vaginal
secretions (show) because minute
capillaries in the cervix rupture
and the last of the mucus plug
that has sealed the cervix since
early pregnancy is released.
§ Show – vaginal secretions
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Electrolyte shift – water loss
➢ Flu-like symptoms – diarrhea, nausea,
indigestion
Onset of Labor
- Expulsion of mucus plug; pink/brown-
tinged discharge (bloody show)
- Regular contractions increasing in
frequency, duration, and intensity
- Spontaneous rupture of membranes (SROM)
may occur before or during labor
- Check FHR by auscultation for 1 minute and
with next contraction
➢ May be a gush or trickle
➢ Report strong / foul odor (infection)
➢ Meconium-stained (fetal distress /
fetal anoxia)
➢ Wine-colored (indicative of
premature

There is no cervical effacement or Questionable leakage of amniotic fluids should be

dilation. The fetal head is cushioned
by amniotic fluid.
Beginning cervical effacement.
As the cervix begins to efface, more
amniotic fluid collects below the head
tested for alkalinity to differentiate from urine:
a) Nitrazine tapen turns blue/gray/green
(alkaline); urine(acidic) does not change the
yellow color
b) A mixture if cervical mucus and amniotic
fluid dried on a slide looks like crystallized
ferns by microscopic examination

TRUE AND FALSE LABOR CONTRACTIONS

Cervix is about one half (50%) effaced
and slightly dilated. True Labor False Labor
The increasing amount of amniotic Regular; intervals Irregular;
fluid below the fetal head ejects. gradually shorten intervals remain
Lower back; sweep long
In the fundus, lower
around the abdomen abdomen, groin
Complete effacement and dilation
Increase in intensity Intensity the same or
and duration variable
Often relieved by
➢ Bloody show Intensified by walking
walking
- loss of cervical mucous plug (may
happen even before labor)
SHOW
- blood-tinged discharge
Usually present; Pink- Usually absent; if
tinged present, brownish
➢ Sudden burst of energy
- From 24 to 48 hours prior to labor onset
CERVIX
(Nesting)
Becomes effaced and No change
dilated
➢ Weight loss of 1 to 3 lbs
Changes in estrogen and progesterone levels
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SEDATION
Does not stop Tends to decrease - Uterine contractions cause dilation and
contractions contractions effacement
- Uterine contractions begin in the fundus
and spread downward
COMPONENTS OF LABOR - They are involuntary
1. THE PASSAGE - They are intermittent allowing for the
¬ a woman’s pelvis uterus (incomplete)
¬ adequate size and contour.
2. THE PASSENGER Origin
¬ the fetus - Like cardiac contractions, labor
¬ appropriate size and in an contractions begin at a “pacemaker”
advantageous position and point in the uterine myometrium near
presentation. one of the uterotubal junctions
3. THE POWERS OF LABOR - Each contraction begins at that point and
¬ uterine factors are adequate. then sweeps down over the uterus as a
4. THE PSYCHE wave. After a short rest period, another
¬ woman’s psychological state which may contraction is initiated and the downward
either encourage or inhibit labor sweep begins again.
¬ can be based on her past life - In early labor, the uterotubal pacemaker
experiences as well as her present may not operate in a synchronous manner.
psychological state. - This makes contractions sometimes strong,
sometimes weak, and somewhat irregular.
IN DEPTH EXPLANATION FOR COMPONENTS OF - This mild incoordination of early labor
LABOR OR THE 4 Ps of LABOR improves after a few hours as the
pacemaker becomes more attuned to
calcium concentrations in the myometrium
1. POWERS and begins to function effectively.
- Refers to uterine contractions
- During a uterine contraction the muscle Contour changes
shortens then returns to normal while ➢ Physiologic retraction ring Upper uterine
ultimately the shortening remains fixed segment (thick and active), Lower uterine
segment (thin walled, suppled, andpassive)
➢ Pathologic retraction ring (Bandl’s ring):
prominent abdominal indentation, signifies
impending uterine rupture if obstruction to
labor is not relieved.
Phases:
Primary power = contractions
o Increment
Secondary power = to the bearing down efforts
o Acme (peak)
o Decrement
• Frequency – uterine contraction is the time
from the beginning of one u/c to the
beginning of the next; from start to next
• As labor progresses, the relaxation intervals
contraction
decrease from 10 minutes early in
• Duration - time from the onset to end of u/c
• labor to only 2 to 3 minutes. The duration of
• Interval - time in between u/c; just the rest
contractions also changes, increasing from
period
• 20 to 30 seconds at the beginning to a range
• Intensity- mild, moderate, strong palpation
of 60 to 70 seconds by the end of the first
• Stage

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Baseline
Normal FHR ranges from 120-160 bpm
-
➢ Above 160 bpm is tachycardia
2. PASSAGEWAY
➢ Below 120 bpm is termed radychardia - a woman’s pelvis
- adequate size and contour.
Fetal Tachycardia - Bony pelvis
- Sustained rate of 161 bpm or above - Soft tissues
- If rate is 180 bpm of above, is marked - Maternal hormones Relaxin in later pregnancy
tachycardia soften the cartilage
- Causes of fetal tachycardia - True pelvis / False pelvis
➢ Early fetal hypoxia
➢ Maternal fever
➢ Maternal dehydration
➢ Amnionitis
➢ Maternal hyperthyroidism
➢ Beta-sympathomimetic drugs
➢ Fetal anemia
- Ominous sign if tachycardia is
accompanied by:
➢ Late decelerations
➢ Severe variable decelerations
➢ Decreased variability

Fetal Bradycardia
- Beat less than 110 bpm during a 10-
minute period or longer
- Causes include:
➢ Profound hypoxia in fetus
➢ Maternal hypotension
➢ Prolonged umbilical cord • inlet – transverse (larger)
compression • outlet – AP (larger)
➢ Fetal arrhythmias • diagonal conjugate (usually 12.5cm)–
➢ Uterine hyperstimulation can be measured by IE, while the other
➢ Abruptio placentae conjugate cannot
➢ Uterine rupture ¬ if less than 12.5 cm, can be CS
➢ Vaginal stimulation in second stage of 3. PASSANGER
labor
¬ the fetus
¬ appropriate size and in an
Hypotonic Uterine Hypertonic
advantageous position and
Contractions Uterine Contractions
presentation.
- Decrease in - Usually occur before
• Molding - overlapping of skull bones along
frequency and 4cm
the suture lines, which causes a change in
intensity - Increased muscle
the shape of the fetal skull to one long and
- Uterine muscle tonus
narrow, a shape that facilitates passage
weakness - Pain out of proportion
through the rigid pelvis. Molding is caused
- Tension not with cervical dilation
by the force of uterine contractions as the
synchronous - Increasing frequency
vertex of the head is pressed against the
- Over - Uterus remains
passageway
distension contracted between
uterine contraction

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• Fetal position - the relationship of the fetal
presenting part to a specific quadrant of the
woman’s pelvis
• Fetal lie - relationship between the long
(cephalocaudal) axis of the fetal body and
the long (cephalocaudal) axis of a woman’s
body—in other words, whether the fetus is
lying in a horizontal (transverse) or a vertical
(longitudinal) position.
Þ Vertex – well-flexion
Þ Sinciput or Military – chin not
touching the chest; causes the
next-widest AP diameter, the
occipital frontal diameter, to • Fetal presentation - the fetal body part that
present to the birth canal will initially contact the cervix; denotes the
Þ Brow – Frontum – some body part that will first contact the cervix or
extension of the forehead be born first and is determined by the
Þ Face – Mentum – combination of fetal lie and the degree of
hyperextension of the chin fetal flexion(attitude).
➢ 95 % are cephalic (head) also vertex
➢ Breech – 3%
TYPES OF BREECH PRESENTATIONS
Frank
- Attitude is moderate
because the hips are
flexed, but the knees are
extended to rest on the
chest.
- The buttocks alone
present to the cervix.
Complete
Brow or Face
- The fetus has the thighs
- may occur if there is less than the normal
tightly flexed on the
amount amniotic fluid present
abdomen
(oligohydramnios)
- both the buttocks and the
- may reflect a neurologic abnormality in the
tightly flexed feet present
fetus causing spasticity
to the cervix.
Know the measurements (even the pelvis) Footling
Suboccipitobregmatic - 9.5 cm - one or both legs
Occipito frontal - 12 cm extended
Occipito mental - 13 cm - Neither the thighs nor
lower legs are flexed
- If one foot presents, it is a
single-footling breech;
- if both present, it is a
doublefootling breech.

• Station – fetal presenting part in

relation to ischial spines
- (-): above
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- (+): below presentations) always presenting to the smallest
- floating: not engaged in pelvis diameter of the pelvis.
- engagement: widest diameter of fetal head
has passed into the inlet, usually “0” station
- When the presenting fetal part is at the level of
the ischial spines, it is at a 0
- station (synonymous with engagement).
§ If the presenting part is above the
1. ENGAGEMENT
spines, the distance is measured and
o settling of the presenting part of a
described as minus stations, which
fetus far enough into the pelvis that it
range from −1 to −4 cm.
rests at the level of the ischial spines,
§ If the presenting part is below the ischial
the midpoint of the pelvis.
spines, the distance is stated as plus
stations (+1 to +4 cm).
2. DESCENT
§ At a +3 or +4 station, the presenting
Forces that cause descent
part is at the perineum and can be seen
o Pressure of the amniotic fluid
if the vulva is separated (i.e., it is
o Contraction of the uterine fundus
crowning).
o Contraction of the mother’s
diaphragm and abdominal
• Position – fetal presenting part in
muscles
relation to the maternal pelvis
o Extension of the fetal body
st
» 1 letter – Right or Left of mother’s o Measured by station
spine o Accelerates in the active phase
nd (cervical dilatation of 5-7 cm)
» 2 letter – depends on attitude
and presentation Occiput/ Mentum/ o Rapid after rupture of
Sacrum/ Acromion/ Dorsal membranes
o Assessed in Leopold’s maneuver
» 3rd letter – Anterior, Posterior, or
o downward movement of the biparietal
Transverse of pelvis diameter of the fetal head within the
pelvic inlet.
LOA, and ROA, OA – most common and favorable
for delivery 3. FLEXION
o Happens when the head meets
4. PSYCHE resistance from the cervix and
pelvic floor
- woman’s psychological state which may either
o Allows the
encourage or inhibit labor
suboccipitobregmatic diameter
- can be based on her past life experiences as
to present
well as her present psychological state.
o the fetal head touches the pelvic
- Physical preparation for childbirth
floor, the head bends forward
- Cultural heritage
onto the chest, causing the
- Previous experience
smallest anteroposterior
- Support system
diameter to present to the birth
- Self-esteem
canal
- Psyche disorders

4. INTERNAL ROTATION
MECHANISMS OR CARDINAL MOVEMENTS OF
o Fetal head enters the pelvis with
LABOR
the biparietal diameter parallel to
the pelvic AP diameter
are different position changes in order to keep the
o Internal rotation
smallest diameter of the fetal head (in cephalic
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o Fetal head passes through the
pelvic outlet with the biparietal
diameter perpendicular to the
pelvic AP diameter
o Begins at the level of the ischial
spine
o Brought about by the bony
pelvis and levator ani
o As the head flexes at the end of
descent, the occiput rotates so the
head is brought into the best
relationship to the outlet of the pelvis,
or the anteroposterior diameter is now
in the anteroposterior plane of the
pelvis. This movement brings the
shoulders, coming next, into the
optimal position to enter the inlet
5. EXTENSION
o The perineum deflects the fetal
head anteriorly
➢ occiput passes under the
lower border of the
symphysis pubis
➢ head emerges by extension
(occiput – face – chin)
o As the occiput of the fetal head is
born, the back of the neck stops
beneath the pubic arch and acts as a
pivot for the rest of the head. The head
extends, and the foremost parts of the
head, the face and chin, are born.
6. RESTITUTION / EXTERNAL ROTATION
o Head rotates to its position during
engagement at the inlet (restitution)
o Fetal heal realigns with the back and
shoulders
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o anterior shoulder rotates to the
midline (external rotation)
o anterior shoulder delivered from
under the public arch
o Posterior shoulder is guided over
the perineum
o the head rotates a final time (from the
anteroposterior position it assumed to
enter the outlet) back to the diagonal
or transverse position of the early part
of labor. This brings the after coming
shoulders into an anteroposterior
position, which is best for entering the
outlet. The anterior shoulder is born
first, assisted perhaps by downward
flexion of the infant’s head.
7. EXPULSION
o head and shoulders are lifted up
towards the mother’s pubic bone
➢ trunk is born by flexing it
laterally in the direction of the
symphysis pubis
➢ delivery is completed!
o Once the shoulders are born, the rest of
the baby is born easily and smoothly
because of its smaller size. This
movement, called expulsion, is the end of
the pelvic division of labor.
STAGES OF LABOR
Labor is traditionally divided into 3 stages:
st
1 stage– begins with the initiation of true labor
contractions and ends when the cervix is fully
dilated
2nd stage – extending from the time of full
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dilatation until the infant is born - Effacement: 50-75%
rd
- Dilation: 4-7 cm
3 stage– lasting from the infant is born until after
the delivery of the placenta. - Contraction:
➢ F: every 3-5 mins
4th stage - The first 1-4 hrs after birth of placenta, to
emphasize the importance of the close maternal ➢ I: Moderate
observation ➢ D: 40-60 sec
- Station: - 1 – 0
- Primiparas: 3 hr
FIRST STAGE - Multiparas: 2 hr
CERVICAL DILATION - Division: Acceleration (4-5 cm), Max
- from onset of regular contractions to full Slope (5-9 cm)
dilation
- averages 13-18 hrs for nulliparas
- 8-9 hrs for multiparas
TRANSITION PHASE
PHASE DURATION CERVICAL INTENSITY - contractions reach their peak of intensity a
DILATION woman may experience intense discomfort
LATENT 20-40 0-3 cm Mild that is so strong, it might be accompanied by
Seconds nausea and vomiting.
ACTIVE 40-60 4-7 cm Moderate - She may also experience a feeling of loss of
Seconds control, anxiety, panic, and/or irritability
TRANSITION 60-90 8-10 cm Strong - 8- 10 cm – contractions may be every 1.5 to
Seconds 2 min and last 60-90s
- Effacement: 70-100%
LATENT PHASE - Dilation: 8-10 cm
- The latent or early phase begins at the onset - Contraction:
of regularly perceived uterine contractions ➢ F: every 2 mins
and ends when rapid cervical dilatation ➢ I: Strong
begins. ➢ D: 60-90 sec
- the cervix begins effacing and dilating and - Station: 0- +1
contractions become increasingly stronger - Nulliparas: should not be more than 3
and more frequent - Multiparas: 0.5 – 1 hr
- Effacement: 0-50%
- Dilation: 0-3 cm May be accompanied by:
- Contraction: - irritability and restlessness
➢ F: 5-10 mins - hyperventilation
➢ I: Mild - dark heavy show
➢ D: 20-40 sec - leg cramps
- Station: - 2 – 0 - nausea/vomiting, hiccups, belching
- Nulliparas: 6 hr - possible rectal pressure creating a
- Multiparas: 4.5 hr desire to push
- may cause maternal exhaustion and
ACTIVE PHASE cervical and fetal trauma
- More rapid dilation of cervix and descent of - extreme back pain
presenting part
- During the active phase of labor, cervical Nursing Care for First Stage of Labor
dilatation occurs more rapidly. PSYCHOLOGICAL PREPARATION
- Show (increased vaginal secretions) and - orientation to the process of labor and
perhaps spontaneous rupture of the general environment
membranes may occur during this time - establishment of nurse-patient
relationship
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- providing assurance
PHYSICAL PREPARATION
- nutrient and fluid intake
- management of discomfort
(pharmacologic and non-pharmacologic)
- vulvar and perineal preparation
- Enema (contraindications)
» unengaged vertex
» nonvertex life
» abnormal amount of vaginal bleeding
» placenta previa and abruptio placenta
» advanced labor
SECOND STAGE
FETAL EXPULSION
- from complete dilation of cervix to
delivery of the baby
- A woman typically feels contractions
change from the characteristic
crescendo–decrescendo pattern to an
uncontrollable urge to push or bear
down with each contraction as if to
move her bowels.
- She may experience momentary
nausea or vomiting because pressure is
no longer exerted on her stomach as
the fetus descends into the pelvis.
- She pushes with such force that she
perspires and the blood vessels in her
neck become distended.
- The fetus begins descent and, as the
fetal head touches the internal
perineum to begin internal rotation,
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her perineum begins to bulge and
appear tense.
- The anus may become everted, and
stool may be expelled.
• CROWNING - As the fetal head
pushes against the vaginal
introitus, this opens and the
fetal scalp appears at the
opening to the vagina and
enlarges from the size of a
dime, to a quarter, then a half-
dollar.
- Contractions are now severe, lasting 60-
90s at 1.5-3 min intervals
- Nulliparas: averages 2hr for
- Multiparas: 20 mins
- Bearing down/ pushing increases intra-
abdominal pressure (pushes the
presenting part against the pelvic floor)
- Causing a stretching, burning sensation,
and bulging of the perineum
- “crowning” – occurs when the presenting
part appears at the vaginal orifice,
distending the vulva
TIMING OF TRANSFER TO DELIVERY ROOM
nd stage when
1. NULLIPARAS – during 2
the presenting part begins to distend the
perineum
MULTIPARAS – at the end of the 1st stage
2.
when the cervix is dilated 8-9 cm
NORMAL SPONTANEOUS VAGINAL DELIVERY
a. The mother is encouraged not to push as
the head is delivered;The infant cries (or
is encouraged to do so to expand the
lungs); If the cord is encircling the neck
(nuchal cord), it is gently slipped over the
head
b. Episiotomy (a surgical incision of the
perineum) may be done at the end of the
second stage of labor to facilitate delivery
and to avoid laceration of the perineum
SYMPTOMS OF THE 2ND STAGE OF LABOR
- Woman’s involuntary bearing down –
Ferguson reflex due to pressure of the
presenting part on stretch receptors of the
pelvic floor
- Woman’s increasing apprehension
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- Sudden increase in show
- Woman’s feeling of wanting to defecate
- Rupture of membranes
- Bulging of the perineum
Nursing Care for Second Stage of Labor
- Asepsis and antisepsis
- Preparation of birth area and instruments
- Positioning the woman
- Coaching the woman on bearing down
efforts
- Providing psychological support
- Pain management
• Amniotomy – artificial rupturing of
amniotic sac
• Episiotomy – latter part of 2nd stage
• 4th degree laceration – till anus
» Midline incision
» Mediolateral incision
DELIVERY OF THE BABY
- Remove fecal material with sponges PRN
- As soon as crowning occurs, place a towel
over the rectum while exertingforward
pressure on the baby’s chin with one hand.
At the same time, exert downward
pressure on the occiput using the other
hand (Ritgen’s maneuver) – prevents
perineal lacerations
- Immediately after the birth of the head,
wipe the baby’s face with a towel and
suction the mouth the nose (do not wipe
hands unless it contains feces)
- Pass a finger along the occiput to the
baby’s neck to feel for umbilical loops
➢ LOOSE NUCHAL CORD – slip
over the baby’s head
➢ TIGHT NUCHAL LOOP – clamp
and cut
- The anterior shoulder is delivered first,
then the posterior shoulder, followed by
the rest of the baby’s body
- Take note of the time of delivery
- Clamp the umbilical cord with 2 clamps.
Cut between the clamps. (Surgeon
will clamp and cut UC)
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THIRD STAGE
PLACENTAL STAGE
- From the delivery of the baby to delivery
of the placenta
- Two separate phases are involved:
placental separation and placental
expulsion.
- After the birth of the infant, the uterus can be
palpated as a firm, round mass just below the
level of the umbilicus.
- After a few minutes of rest, uterine
contractions begin again, and the organ
assumes a discoid shape.
- It retains this new shape until the placenta has
separated, approximately 5 minutes after the
birth of the infant.
- If more than 30 mins, placenta is
considered retained
SIGNS OF PLACENTAL SEPARATION (CULS)
- Calkin’s sign (globular-shaped uterus)
- Uterine fundus rises in abdomen
- Lengthening of the cord
- Small gush of blood from vagina
MECHANISM OF PLACENTAL SEPARATION
If the placenta separates first at its center and lastly at
its edges, it tends to fold on itself like an umbrella and
presents at the vaginal opening with the fetal surface
evident. Approximately 80% of placentas separate and
present in this way.
1. Shultze Mechanism of Placental
Separation
- Shiny Schultz; Fetal side
- Appearing shiny and glistening from the fetal
membrane
- Retroplacental clot
- Placenta/ membranes dragged
downwards
- Membranes peel from periphery
- Placental delivered by inversion
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2. Duncan Mechanism of Placental Separation
- Dirty Duncan; Maternal side
- Separation at periphery of placenta
- Placenta descends to vagina sideways
- Maternal surface of placenta appears first
- separates first at its edges, it slides along
the uterine surface and presents at the
vagina with the maternal surface evident
- looks raw, red, and irregular, with the
ridges or cotyledons that separate blood
collection spaces evident;
Nursing Care for Third Stage of Labor
- Do controlled cord traction
- Deliver the placenta slowly
- Massage fundus until it is hard /
contracted
- Administer methergine / oxytocin as
ordered
- Check if placenta is complete
- Inspect perineum for laceration
FOURTH STAGE
- Immediate recovery period from delivery of
placenta to stabilization of maternal
systemic responses and contraction of the
uterus; from 1 to 4 hr
a. Mother begins to readjust to
nonpregnant state
b. Areas of concern include discomfort due to
contraction of uterus (afterpain) and/ or
episiotomy fatigue or exhaustion, hunger
thirst, excessive bleeding, bladder
distention
PSYCHOLOGICAL RESPONSE
1. Fatigue
• By the time the date of birth approaches, a
woman is generally tired from the normal
• discomforts of pregnancy and has not slept
well for the past month
• Sleep hunger from this type of discomfort can
make it difficult for a woman to perceive
situations clearly or to adjust rapidly to new
situations.
• It can make a small deficiency such as a
wrinkled sheet appear as a major threatening
discrepancy in her care.
• It can make the process of labor loom as an
overwhelming, unendurable experience unless
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she has competent people with her to offer
support, reassurance, and comfort.
2. Fear
• They appreciate a review of the labor process
early in labor as a reminder that childbirth is
not a strange, bewildering event but a
predictable and well-documented one.
• Being taken by surprise—labor moving faster or
slower than the woman thought it would or
contractions harder and longer than she
remembers from last time—can lead a woman
to feel out of control and increase the level of
pain she experiences.
• Explain and repeat as necessary that labor is
predictable but also variable.
• Contractions last a certain length and reach a
certain intensity but always have a rest period
in between so she can have a break from pain.
• Fear of labor this way releases adrenaline, and
adrenaline interferes with oxytocin release and
so can limit the effectiveness of uterine
contractions
3. Cultural Influences
- Cultural factors can strongly influence a
woman’s experience and satisfaction with
labor.
- women are encouraged to help plan their
care. In addition, every woman responds to
cultural cues in some way. This makes her
response to pain, her choice of nourishment,
her preferred birthing position, the proximity
and involvement of a support person, and
customs related to the immediate postpartal
period highly individualized.
- . If a woman has traditions that run counter to
hospital protocols, address these differences
and make arrangements to accommodate her
desires, beliefs, or customs, if possible, such
as advocating for special foods to eat,
ballroom dancing in order to remain upright,
or saving the placenta for the mother to take
home.
FOURTH STAGE PHYSIOLOGIC CHANGES
- Increased pulse
- Decreased BP
- Uterus remains contracted and located
between umbilicus and symphysis pubis
- Urine may be retained due to decreased
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bladder tone and possible trauma to the
bladder
MATERNAL SYSTEMIC RESPONSE TO LABOR
CARDIOVASCULAR SYSTEM CHANGES
- Cardiac output increases 40%–50% from
prelabor levels.
- Blood loss at birth is 300–500 ml on average.
- Blood pressure may rise with pain response
and, due to work of the system during
contractions, by an average systolic rise of 15
mmHg per contraction.
- Epidural anesthesia may cause hypotension.
- BP Rises with each contraction
- May rise further with pushing
st
➢ 1 stage: systolic pressure increasesby
about 35 mmHg and diastolic pressure
by 25 mmHg
RESPIRATORY SYSTEM CHANGES
- Increase in oxygen demand and
consumption (100%)
- Mild respiratory acidosis usually occurs
by the time of birth
- Hyperventilation
RENAL CHANGES
- Increase in renin, plasma renin activity,
angiotensinogen
- Edema may occur at base of bladder due to
pressure of fetal head
GI AND IMMUNE SYSTEM
- Gastric motility decreased - Blood shunts to
life sustaining organs causing the GI system to
become fairly inactive during labor.
- Gastric emptying is prolonged
- Digestive and emptying time of the stomach
becomes lengthened.
- Some women experience a loose bowel
movement as contractions grow strong.
- Gastric volume remains increased
- WBC count increases to 25,000 to
30,000/mm 3
- Blood glucose decreases
Nursing Care for Fourth Stage of Labor
- Perineal care
- Feel for the fundus
- Check q15 mins for 1 hr; q30 mins for 4 hrs
st
- Above the umbilicus 1 12 hr postpartum
WANG | TOQUILAR
- Fundal massage
- If bleeding – Trendelenburg
• BP, pulse return to normal within 1 hr, BV
reabsorbed within 5 mins
• Watch out for vaginal bleeding
• Keep bladder empty
• Provide nourishing liquids or foods
• Encourage rest and sleep
• Prevent infection by handwashing
prior caring for the mother
• Discuss importance of
breastfeeding, immunization
• Motivate use of family planning
CAUSES OF PAIN DURING LABOR
st
1 stage:
• Dilatation of cervix
• Stretching of the lower uterine
segment
• Pressure on the adjacent structures
• Hypoxia of the uterine muscle cells
during contraction
2nd stage
• Hypoxia of the contracting uterine
muscles
• Distention of the vagina and
perineum
• Pressure on the adjacent structures
rd
3 stage
• Uterine contractions and cervical
dilatation as the placenta is expelled
FACTORS AFFECTING RESPONSE TO PAIN
» Childbirth preparation classes
» Culture
» Fatigue and sleep deprivation
» Previous experience with pain and anxiety
» Attention and distraction
FETAL RESPONSES TO LABOR
Fetal Response to Labor
1. Heart Rate Changes
➢ Early fetal heart rate decelerations
➢ decreases by as much as 5 beats/min
during a contraction, as soon as
contraction strength reaches 40 mmHg
➢ although not measurable, fetal blood
pressure also rises.
2. Acid-Base Status in Labor
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➢ A slow decrease in pH status
➢ Feta l oxygen saturation drops to
10%
3. Hemodynamic Changes
➢ Altered exchange of gas and
nutrients
4. Fetal Sensation
5. Intergumentary System
➢ The pressure involved in the birth process
is often reflected in minimal petechiae or
ecchymotic areas on a fetus (particularly
the presenting part). There may also be
edema
➢ of the presenting part (caput
succedaneum) from this pressure.
6. Respiratory System
➢ The process of labor appears to aid in the
maturation of surfactant production by
alveoli
➢ in the fetal lung. Both the pressure applied
to the chest from contractions and passage
➢ through the birth canal help to clear the
respiratory tract of lung fluid. For this
reason,
➢ an infant born vaginally is usually able to
establish respirations more easily than a
fetus
➢ born by cesarean birth.
FETAL DANGER SIGNS
• FETAL HEART RATE (ABNORMALITY)
- As a rule, an FHR of more than 160 beats/min
(fetal tachycardia) or less than 110 beats/min
(fetal bradycardia) is a sign of possible fetal
distress.
• MECONIUM STAINING
- This is not always a sign of fetal distress but is
highly correlated with its occurrence.
- Meconium staining, a green color in the
amniotic fluid, reveals the fetus has had a loss
of rectal sphincter control, allowing
meconium to pass into the amniotic fluid.
- It may indicate a fetus has or is experiencing
hypoxia, which stimulates the vagal reflex and
leads to increased bowel motility
• HYPERACTIVITY
- Fetal hyperactivity may be a subtle sign that
hypoxia is occurring because frantic motion is
a common reaction to the need for oxygen.
WANG | TOQUILAR
• FETAL ACIDOSIS / LOW OXYGEN SATURATION
- Oxygen saturation in a fetus is normally 40%
to 70%. A fetus can be assessed for this by a
catheter inserted next to the cheek (under
40% oxygenation needs further assessment).
- If fetal blood is obtained by scalp puncture,
the finding of acidosis (blood pH lower than
7.2) suggests fetal well-being is becoming
compromised and that further investigation is
also necessary.
MATERNAL DANGER SIGNS
1. VITAL SIGNS ABNORMALITY
o High or Low Blood Pressure
¬ blood pressure rises slightly in the
second (pelvic) stage of labor because
of her pushing effort.
¬ systolic pressure greater than 140
mmHg and a diastolic pressure
greater than 90 mmHg, or an increase
in the systolic pressure of more than
30 mmHg or in the diastolic pressure
of more than 15 mmHg
¬ falling blood à may be the first sign
of intrauterine hemorrhage, although
a falling blood pressure from
hemorrhage is often associated with
other clinical signs of hypovolemic
shock, such as apprehension,
increased pulse rate, and pallor.
o Abnormal Pulse
¬ Most women during pregnancy have a
pulse rate of 70 to 80 beats/min.
¬ A maternal pulse rate greater than 100
beats/min during labor is unusual
2. INADEQUATE/ PROLONGED
CONTRACTION
- Uterine contractions normally become more
frequent, intense, and longer as labor
progresses. I
- f they become less frequent, less intense, or
shorter in duration, this may indicate uterine
exhaustion (inertia).
- This problem may be correctable but needs
augmentation or other interventions to
accomplish this.
- Observe also if there is a period of relaxation
between contractions so the intervillous
spaces of the uterus can fill and maintain an
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adequate supply of oxygen and nutrients for
the fetus.
- contractions lasting longer than 70 seconds
are becoming long enough to compromise
fetal well-being because this interferes with
adequate uterine artery filling.
WANG | TOQUILAR
- If there is an Rh blood incompatibility
between the baby and the mother
- If the mother or baby has a medical
problem that requires delivery of the
baby (premature rupture of the
membranes)

3. PATHOGENIC RETRACTION RING Amniotomy

- (Bandl’s ring): prominent abdominal - Artificial rupture of membranes to induce
indentation, signifies impending uterine labor and for augmentation
rupture if obstruction to labor is not relieved. - Risks:
➢ Cord prolapse
4. ABNORMAL LOWER ABDOMINAL ➢ Infection
CONTOUR ➢ FHR decelerations
- If a woman has a full bladder during labor, a
round bulge appears on her lower anterior External Version
abdomen. - Abdominal maneuver that externally
- the bladder may be injured by the pressure of rotates the fetus from a breech
the fetal head pressing against it presentation to a vertex presentation
- the pressure of the full bladder may not allow - The fetus is manipulated by a forward roll
the fetal head to descend. or back flip

5. INCREASING APPREHENSION FACTORS MAY CAUSE A FETUS TO PRESENT

- Warnings of psychological danger during BREECH
labor are as important to consider in - Placenta previa
assessing maternal well-being as are physical - Multiple gestation
signs. - Uterine anomalies
- a woman who is becoming increasingly - Fetal anomalies
apprehensive despite clear explanations of - Poor uterine tone
unfolding events may not be “hearing” - Prematurity
because she has a concern that has not been - Majority of cases have no apparent
met. cause
- Increasing apprehension also needs to be
investigated for physical reasons because it EXPULSION CRITERIA
can be a sign of oxygen deprivation or - Multiple pregnancy
internal hemorrhage. - Evidence of uteroplacental insufficiency
- Significant third-trimester bleeding
INDUCTION OF LABOR - Suspected intrauterine growth restriction
- Involves using artificial means to assist - Amniotic fluid abnormalities
the mother in delivering her baby - Uterine malformation
➢ Amniotomy - Placenta previa
➢ Pitocin - Maternal cardiac disease
➢ Prostaglandin get suppository - Pregnancy-induced hypertension
➢ Misoprostal - Uncontrolled hypertension

Indications: Protocol in External Version

- Post term pregnancy • Ultrasound examination
- Mother shows no signs of going into • Empty the bladder
labor • Non-stress test
- Mother is suffering from diseases • CBC, blood type, and screen
(preeclampsia, chronic hypertension) • IV access
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• Tocolytic agent such as terbutaline (Brethine)
• Supine or slight Trendelenburg position to
facilitate disengagement/mobility of the
breech
• Nonstress test and ultrasound examination
• Rhogam is administered after the procedure to
Rh negative in patients
WANG | TOQUILAR
disproportion (CPD)
CESAREAN SECTION
Indications: Maternal and Fetal
- Cephalopelvic disproportion
- Failed induction or progression of labor
- Abnormal uterine contraction pattern

Benefits MATERNAL DISEASES:

- Speed up the birth ¬ Eclampsia or preeclampsia with non- inducible
- Prevent tearing cervix
- Protects against incontinence ¬ Diabetes mellitus
- Protects against pelvic floor relaxation ¬ Cardiac disease
- Heals easier than tears ¬ Cervical disease
¬ Active herpes genitalis
Complications
- Infection PREVIOUS UTERINE SURGERY
- Increased pain ¬ Classic cesarean section
¬ Previous uterine rapture
- Increase in 3rd and 4th degree vaginal
¬ Full-thickness myomectomy
lacerations
- Longer healing times
OBSTRUCTION TO THE BIRTH CANAL
- Increased discomfort when intercourse is
¬ Fibroids
resumed
¬ Ovarian tumors
LACERATIONS
FETAL
1ST Perineal skin and vaginal
¬ Fetal distress
DEGREE mucosa, may need repair or not
¬ Cord prolapse
2ND
Skin, mucous membrane and
¬ Fetal malpresentations
DEGREE fascia,usually repaired
3RD
Skin, mucous membrane, and
PLACENTAL
DEGREE extends torectal sphincter
¬ Placenta previa (unless marginal)
4TH
As above but into rectal lumen
¬ Abruptio placentae
DEGREE
MATERNAL RISKS
VACUUM EXTRACTION
¬ Infection
- delivery with use of a suction device that is
¬ Hemorrhage
applied to the fetal scalp for traction
¬ Injury to urinary tract
- Used in prolonged second stage
¬ Adverse reactions to anesthesia
- Contraindicated in CPD and face/breech
¬ Prolonged recovery
presentation
ANTIBIOTIC PROPHYLAXIS
FORCEPS ASSISTED
¬ Reduced incidence of endometritis
a) Forceps
¬ Wound infection
- Two double-curved, spoon-like,
¬ Urinary tract infection and fever
articulated blades used to extract the
fetal head
b) Indicated if mother cannot push fetus out
or compromised maternal/fetal status in
late second stage
c) Contraindicated in cephalopelvic

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