JOYCE KATHREEN EBIO LOPEZ | 2C

Bicol University
College of Nursing
Legazpi City, Albay

NCM 107
Maternal and Child Health Nursing
Normal spontaneous delivery activity

1. CARE OF THE MOTHER DURING LABOR AS TO POSITIONING, MOBILITY,

REDUCTION OF PAIN AND OTHER COMFORT MEASURES.

POSITIONING

Upright
positions
promote
effective
pushing and
take advantage
of gravity.
Squatting is a
good position
for
uncomplicated
birth but limits
accessibility to
the woman’s
perineum and
may not be an option for women having epidural analgesia. Maternal positions with the
upper body leaning forward promotes expulsive efforts, directs the fetus efficiently toward
the pelvic outlet, and increases the diameters of the pelvic outlet. Other upright positions for
the birth include standing and kneeling upright positions. The semirecumbent position limits
movement of the coccyx as the fetus descends during birth but maintains some advantages of
gravity. Sitting on a birthing bed with a cutout for the perineal area maintains many
advantages of squatting and may be less tiring. The hands-and-knees position may be helpful
if the fetus is in the occiput posterior position and to rotate wide fetal shoulders. Many
women and birth attendants are more comfortable using stirrups and foot rests to support the
woman’s legs and feet and make her perineum more accessible. If she cannot move her legs
because of motor block from anesthesia, raise and lower her legs together, and do not
separate them too widely. Surfaces that contact the popliteal space behind the knee should be
padded because pressure on veins near the surface could lead to thrombus formation. The
woman’s upper body should be in the semireclining or sitting position rather than the flat
position.

MOBILITY
Mobility is a major advantage of auscultation and palpation for intrapartum fetal assessment.
The woman is free to change position and walk around. Nothing restricts her freedom to
move and she is likely to change positions more often, which promotes normal labor. The
nurse must have regular, close, and frequent personal contact with the woman when

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JOYCE KATHREEN EBIO LOPEZ | 2C

performing IA and palpation. Water-based methods of pain management such as whirlpool

baths or showers can be used more freely. The atmosphere is more natural than technologic
and less invasive, which is important to some women during their birth experience.

REDUCTION OF PAIN AND OTHER COMFORT MEASURES.

Labor pains and the woman’s ability to cope vary. The nurse constantly assesses whether
additional pain control measures are needed. Behaviors that suggest the woman may want
help with pain management include the following:

• Specific requests for medication and other pain control measures such as epidural analgesia
• Statements that current measures are ineffective
• Tension of her muscles and arching of her back during contractions
• Persistence of muscle tension between contractions
• A tense facial expression, rolling in the bed
• Expressions such as “I can’t take it anymore”

Women vary in their responses to labor’s pain and the choices of pain management methods. The
woman with choices for pain management and support for her choices has an increased sense of
control over her birth experience. The woman who successfully masters the pain and other
physical demands of labor is more likely to view her experience as positive. Her support person
also is likely to feel more satisfaction with the experience. The nurse’s role is to teach the patient
and her significant other about various methods of pain management and then support her
decisions and evaluate her responses. Pain and anxiety are related nursing diagnoses. Excess
anxiety reduces pain tolerance, and pain worsens anxiety. The nurse clusters assessment data to
determine what the primary problem is. For example, several cues such as a previous poor
experience during birth and expressions of worry and concern suggest that anxiety is primary.

2. PREPARATION OF THE DELIVERY ROOM LIKE EQUIPMENT, MATERIALS,

SUPPLIES, INSTRUMENTS, ETC.

Preparing to conduct a delivery

When the woman is approaching the second stage of labour you should prepare for the delivery
of the baby.
Preparing the birthing place
Once the onset of the second stage has been confirmed you should make preliminary
preparations for the delivery. The room should be warm and well lit so that the perineum and
vulva can be easily observed. A clean surface should be prepared to receive the baby (Figure 3.7)
using the infection control procedures described in Section 3.5. Spread waterproof covers to
protect the bed and the floor. Make sure there is a warm coat and clothes for the baby.

Equipment and supplies needed to conduct delivery

 Clean water, soap and hand towel.
 Apron, goggle, face mask and gown.
 Sterile gloves.
 Sterile or very clean new string to tie the cord.
 New razor blade or sterilised scissors.
 Two sterile clamp forceps, for clamping the umbilical cord before you cut it.
 Mucus trap or suction bulb to suck mucus from the baby’s airways (if needed).
 Sterile gauze, cotton swab and sanitary pad for the mother.
 Two dry, clean baby towels and two drapes.

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JOYCE KATHREEN EBIO LOPEZ | 2C

 Blood pressure cuff and stethoscope.

 Antiseptic solution for cleaning the mother’s perineum and genital area.
 10 IU (international units) of the injectable drug called oxytocin, or 600 µg (microgram)
tablets of misoprostol. These drugs are used for the prevention of post-partum haemorrhage.
Oxytocin is the preferred drug for this purpose, but if you don’t have it then misoprostol
can be used. (You will learn all about this in Study Session 6.)
 Tetracycline eye ointment (antibiotic eye ointment used for the prevention of eye
infection in the newborn; you will learn about this in the next Module, on Postnatal Care).
 Three buckets or small bowls each with 0.5% chlorine solution, or soap solution and
clean water. (To prepare 0.5% chlorine solution you can use the locally available Berekina.
Read the concentration from the bottle — if it is 5% you can make a solution of 0.5%
strength by mixing one cup of Berekina with nine cups of clean water.)
 Plastic bowl to receive the placenta.

3. PERSONAL PREPARATION OF THE NURSE LIKE ATTIRE AND ROUTINE

PREPARATIONS.

 Change into a hospital gown and provide a urine sample.

 Have an intravenous line (IV) started in your arm or hand. Through this you will receive
necessary fluids and medications as needed.
 Have blood drawn.
 You may be required to take a clear liquid antacid medicine.
 Have your surgical site prepared (shaved). Do not do this in advance.
 Be examined by your obstetrician and anesthesiology specialist, and asked to sign a
consent form.

4. CARE OF THE MOTHER DURING DELIVERY LIKE SAFETY AND SIMPLE

INSTRUCTIONS TO SUPPORT THE MOTHER.

Every woman needs a different kind of support. But all women need kindness, respect and
attention. Watch and listen to her to see how she is feeling. Encourage her, so she can feel strong
and confident in labour. Help her relax and welcome her labour.

Support the labour

When you support the mother’s labour, you help her relax instead of fighting against it (Figure
3.1). Although labour support will not make labour painless, it can make labour easier, shorter

JOYCE KATHREEN EBIO LOPEZ | 2C

JOYCE KATHREEN EBIO LOPEZ | 2C

and safer. You will learn many ways to support the labour in this study session, including by
physical actions (touch, sounds, etc.) and giving psychological and emotional support.

Guard the labour

When you guard the labour, you protect it from interference.
Keep rude and unkind people away. The mother should not have to worry about family
problems. Sometimes even supportive and loving friends can interfere with the labour. At some
births, the best way to help is to ask everyone to leave the room so that the mother can labour
without being distracted.

 Do not use unnecessary drugs or procedures! Do not give the mother drugs to hurry the
labour — they add useless risks.
Some people believe that more drugs, tools and examination of the mother will make the birth
safer. But that is usually not true — they can make the birth harder or cause problems. Injections
or pills that are supposed to hurry the birth can make labour more painful, and can kill both the
mother and the baby.

5. HOW DO WE PROTECT THE

PELVIC FLOOR DURING
DELIVERY OF THE HEAD OF
THE BABY.

PELVIC EXERCISES.

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 JOYCE KATHREEN EBIO LOPEZ | 2C

Pelvic floor muscle training is directed toward strengthening the levator ani and pubococcygeal
muscles which affect urethral closure and pelvic floor support. Kegel exercises are isometric, and
one possible application is for the woman to consciously contract and relax these muscles slowly
eight to 12 times for a count of 6 to 8 seconds each and repeat this series for three sets. Before
teaching pelvic floor muscle training, determine if the woman can contract the muscles by asking
her to sit with her legs apart while she urinates and to squeeze the muscles to stop the stream of
urine. If she can accomplish this, the muscles are contracted and it is possible for her to perform
the exercise. Muscles of abdomen, thighs, and buttocks should not tighten during pelvic floor
muscle training. Women should be taught to exhale and keep the mouth open to avoid bearing
down when contracting their pelvic muscles, and then gradually relax the muscle contraction.
Variations exist about how frequently to repeat pelvic muscle contractions each day. To maintain
pelvic muscle tone, the woman should continue pelvic floor or Kegel exercises for the rest of her
life

6. CARE DURING THE DELIVERY OF THE BABY ESPECIALLY WHEN THE

BABY IS OUT.

The birth of a baby is one of life's most wondrous moments. Few experiences compare to this
event. Newborn babies have amazing abilities. Yet they are dependent on others for feeding,
warmth, and comfort.
Amazing physical changes occur with birth. When the baby is delivered, the umbilical cord is
clamped and cut near the navel. This ends the baby's dependence on the placenta for oxygen and
nutrition. As the baby takes its first breath, air moves into the lungs. Before birth, the lungs are
not used to exchange oxygen and carbon dioxide, and need less blood supply. The fetal
circulation sends most of the blood supply away from the lungs through special connections in
the heart and the large blood vessels. When a baby starts to breathe air at birth, the change in
pressure in the lungs helps close the fetal connections and redirect the blood flow. Now blood is
pumped to the lungs to help with the exchange of oxygen and carbon dioxide. Some babies have
too much fluid in their lungs. Stimulating the baby to cry by massage and stroking the skin can
help bring the fluid up where it can be suctioned from the nose and mouth.

PROVIDING WARMTH FOR THE NEWBORN

 A newborn baby is wet from the amniotic fluid and can easily become cold. Drying the
baby and using warm blankets and heat lamps can help prevent heat loss. Often a knitted
hat is placed on the baby's head. Placing a baby skin-to-skin on your chest or abdomen
also helps to keep the baby warm. This early skin-to-skin contact also reduces crying,
improves your interaction with your baby, and helps you to breastfeed successfully. 

IMMEDIATE CARE FOR THE NEWBORN

Health assessments of the new baby start right away. One of the first checks is the Apgar test.
The Apgar test is a scoring system to evaluate the condition of the newborn at 1 minute and 5
minutes after birth. The healthcare provider or midwife and nurses will evaluate these signs and
give a point value:
 Activity; muscle tone
 Pulse rate
 Grimace; reflex irritability
 Appearance; skin color
 Respiration

JOYCE KATHREEN EBIO LOPEZ | 2C

 JOYCE KATHREEN EBIO LOPEZ | 2C

PHYSICAL EXAM OF THE NEWBORN IN THE DELIVERY ROOM

A brief, physical exam is done to check for obvious signs that the baby is healthy. Other
procedures will be done over the next few minutes and hours. These may be done in the delivery
room, in the nursery, or in your room, depending on the hospital policy and the condition of the
baby. Some of these procedures include:
 Measurement of the temperature, heart rate, and respiratory rate
 Measurement of weight, length, and head circumference. These measurements help
find out if a baby's weight and measurements are normal for the number of weeks of pregnancy.
Small or underweight babies and very large babies may need special attention and care.
 Cord care. The baby's umbilical cord stump will have a clamp. It needs to be kept clean
and dry. 
 Bath. Once a baby's temperature has stabilized, the first bath can be given.
 Eye care. Bacteria in the birth canal can infect a baby's eyes. Your baby will be given
antibiotic or antiseptic eye drops or ointment either right after delivery or later in the nursery to
prevent eye infection.
 Footprints. These are often taken and recorded in the medical record.
Before a baby leaves the delivery area, ID bracelets with matching numbers are placed on the
baby and on you. Babies often have 2, on the wrist and ankle. These should be checked each
time the baby comes or goes from your room.
CARE FOR THE NEWBORN AFTER A VAGINAL DELIVERY
 Healthy babies born in a vaginal delivery are usually able to stay with the mother. In
many hospitals, immediate newborn assessments include weight, length, and medicines.
Even the first bath is done right in your room. As quickly as possible, a new baby is
placed in your arms. Often, the baby is placed skin-to-skin on your chest right after birth.
Some babies will breastfeed right away.
 In the first hour or 2 after birth, most babies are in an alert, wide awake phase. This offers
a chance for you and your partner to get to know your new baby. A baby will often turn
to the familiar sound of the mother's voice. A baby's focus of vision is best at about 8 to
12 inches--just the distance from the baby cradled in your arms to your face.
 This first hour or 2 after birth is also the best time to start breastfeeding. Babies have an
innate ability to start nursing right away after they are born. Some medicines and
anesthesia given to you during labor and delivery may affect the baby's sucking ability.
But most healthy babies are able to breastfeed in these first few hours. This first feeding
helps stimulate breastmilk production. It also causes your uterus to contract. This can
help prevent too much bleeding.

CARE FOR THE NEWBORN AFTER A C-SECTION

 If your baby is born by a cesarean, chances are good that you can be awake for the
surgery. Only in rare cases will you need general anesthesia for delivery. This means you
are not awake for the birth. Most C-sections today are done with a regional anesthesia
such as an epidural or spinal. With this type of anesthesia, only part of the body is
numbed for surgery. You are awake and able to hear and see your baby as soon as he or
she is born.
 Babies born by C-section are usually checked by a nursery nurse or healthcare provider
right after delivery. This is often done right near you in the operating room. Because
babies born by C-section may have trouble clearing some of the lung fluid and mucus,
they often need extra suctioning of the nose, mouth, and throat. In some cases, they may
need deeper suctioning in the windpipe.
 Once a baby is checked over, a nurse will wrap the baby warmly and bring the baby to
you to see and touch. Many hospitals require babies born by C-section to be watched in

JOYCE KATHREEN EBIO LOPEZ | 2C

JOYCE KATHREEN EBIO LOPEZ | 2C

the nursery for a short time. All the usual procedures such as weighing and medicines are
done there. Usually, your baby can be brought to you while you are in the recovery area
after surgery.
 Many mothers think that they will not be able to breastfeed after a C-section. This is not
true. Breastfeeding can start in the first hours right in the recovery room, just as with a
vaginal delivery.
 Plan to have someone stay with you during your hospital stay after a C-section. You will
have quite a bit of pain in the first few days and will need help with the baby.

WHEN A BABY HAS TROUBLE AFTER BIRTH

 All the baby's body systems must work together in a new way after birth. Sometimes a
baby has trouble making the transition. Health assessments such as the Apgar test done
right after birth can help find out if a baby is doing well or having problems.
 If there are signs the baby is not doing well, treatment can be given right in the delivery
room. The healthcare provider or midwife and other members of the healthcare team
work together to help the baby clear excess fluid and start breathing.
 Babies who may have trouble at birth include those born prematurely, those born with a
difficult delivery, or those born with a birth defect. Fortunately, special care is available
for these babies. Newborn babies who need intensive medical care are often admitted into
a special area of the hospital called the neonatal intensive care unit (NICU). The NICU
combines advanced technology and trained health staff to give special care to the tiniest
patients. NICUs may also have intermediate or continuing care areas for babies who are
not as sick, but need special nursing care. Some hospitals don't have a NICU. Babies may
need to be transferred to another hospital.
 Having a sick baby can be stressful. Few parents expect complications of pregnancy or
their baby to be sick or premature. It is quite natural for parents to have many different
emotions as they try to cope with the difficulties of a sick baby. But it is reassuring that
today's advanced technology is helping sick babies get better and go home sooner than
ever before. It also helps to know that although separation from a baby is painful, it does
not harm the relationship between mother and baby.

7. ADMINISTRATION OF OXYTOCIN LIKE WHEN TO GIVE THE MEDICINE.

A nipple is composed of smooth muscle that is capable of erection on manual or sucking

stimulation. On stimulation, it transmits sensations to the posterior pituitary gland to release
oxytocin. Oxytocin acts to constrict milk gland cells and push milk forward into the ducts that
lead to the nipple. The skin surrounding the nipples is darkly pigmented out to approximately 4
cm and is termed the areola. The area appears rough on the surface because it contains many
sebaceous glands, called Montgomery’s tubercles. The blood supply to the breasts is profuse
because it is supplied by thoracic branches of the axillary, internal mammary, and intercostal
arteries. This effective blood supply is important in bringing nutrients to the milk glands and
makes possible a plentiful supply of milk for breastfeeding. However, it also aids in the
metastasis of breast cancer if this is not discovered early with breast examination or
mammography (McCance & Huether, 2007).

8. CLAMPING AND CUTTING OF THE UMBILICAL CORD.

The newborn is held with his or her head in a slightly dependent position, to allow secretions to
drain from the nose and mouth. The mouth may be gently aspirated by a bulb syringe to remove
additional secretions. The infant is then laid on the abdominal drape of the mother while the cord
is cut. The cord continues to pulsate for a few minutes after birth, and then the pulsation ceases.

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There are several theories about the best time for cutting the cord. Delaying the cutting until
pulsation ceases and maintaining the infant at a uterine level allows as much as 100 mL of blood
to pass from the placenta into the fetus; this helps ensure an adequate red blood cell count in the
newborn. On the other hand, late clamping of the cord could cause overinfusion with placental
blood and the possibility of polycythemia and hyperbilirubinemia, a particular concern in
preterm infants. The timing of cord clamping, therefore, varies depending on the physician’s or
nurse-midwife’s preference and the maturity of the infant. Placing the infant on the mother’s
abdomen may modify the amount of blood infused as well as allowing the parents a free,
unobstructed view of their new child. The cord is clamped with two Kelly hemostats placed 8 to
10 inches from the infant’s umbilicus and then is cut between them. A cord blood sample is
obtained to provide a ready source of infant blood if blood typing or other emergency measures
such as establishing whether fetal acidosis was present need to be done. Blood may also be taken
for cord blood banking so the family has stem cells available if needed in the future. An
umbilical clamp is then applied (Fig. 15.33). Some umbilical clamps have an alarm attached that
will ring if the infant is taken farther than set hospital boundaries, a precaution against newborn
kidnapping. The vessels in the cord are then counted to be certain that three are Cutting the cord
is part of the stimulus that initiates a first breath. With this, the infant’s most important transition
to the outside world, the establishment of independent respirations, has begun. present. In most
births, the woman’s partner may have the privilege of cutting the cord.

9. RESPONSIBILITIES DURING THE DELIVERY OF THE PLACENTA.

What does the placenta do?

The placenta is an organ that develops in your uterus during pregnancy. This structure provides
oxygen and nutrients to your growing baby and removes waste products from your baby's blood.
The placenta attaches to the wall of your uterus, and your baby's umbilical cord arises from it.
The organ is usually attached to the top, side, front or back of the uterus. In rare cases, the
placenta might attach in the lower area of the uterus. When this happens, it's called a low-lying
placenta (placenta previa).

What are the most common placental problems?

During pregnancy, possible placental problems include placental abruption, placenta previa and
placenta accreta. These conditions can cause potentially heavy vaginal bleeding. After delivery,
retained placenta is sometimes a concern. Here's what you need to know about these conditions:

 Placental abruption. If the placenta peels away from the inner wall of the uterus before
delivery — either partially or completely — a condition known as placental abruption
develops. This can deprive the baby of oxygen and nutrients and cause you to bleed heavily.

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JOYCE KATHREEN EBIO LOPEZ | 2C

Placenta abruption could result in an emergency situation requiring early delivery.

 Placenta previa. This condition occurs when the placenta partially or totally covers the
cervix — the outlet for the uterus. Placenta previa is more common early in pregnancy and
might resolve as the uterus grows.
Placenta previa can cause severe vaginal bleeding during pregnancy or delivery. The
management of this condition depends on the amount of bleeding, whether the bleeding
stops, how far along your pregnancy is, the position of the placenta, and your and your baby's
health. If placenta previa persists late in the third trimester, your health care provider will
recommend a C-section.

 Placenta accreta. Typically, the placenta detaches from the uterine wall after childbirth.
With placenta accreta, part or all of the placenta remains firmly attached to the uterus. This
condition occurs when the blood vessels and other parts of the placenta grow too deeply into
the uterine wall. This can cause severe blood loss during delivery.
In aggressive cases, the placenta invades the muscles of the uterus or grows through the
uterine wall. Your health care provider will likely recommend a C-section followed by
removal of your uterus.

 Retained placenta. If the placenta isn't delivered within 30 minutes after childbirth, it's
known as a retained placenta. A retained placenta might occur because the placenta becomes

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trapped behind a partially closed cervix or because the placenta is still attached to the uterine
wall. Left untreated, a retained placenta can cause severe infection or life-threatening blood
loss.

What are signs or symptoms of placental problems?

Consult your health care provider during pregnancy if you have:

 Vaginal bleeding
 Abdominal pain
 Back pain
 Uterine contractions

What can I do to reduce my risk of placental problems?

Most placental problems can't be directly prevented. However, you can take steps to promote a
healthy pregnancy:

 Visit your health care provider regularly throughout your pregnancy.

 Work with your health care provider to manage any health conditions, such as high blood
pressure.
 Don't smoke or use drugs.
 Talk with your doctor about the potential risks before deciding to pursue an elective C-
section.
If you've had a placental problem during a previous pregnancy and are planning another
pregnancy, talk to your health care provider about ways to reduce the risk of experiencing the
condition again. Also tell your health care provider if you've had surgery on your uterus in the
past. Expect your health care provider to monitor your condition closely throughout the
pregnancy.

How is the placenta delivered?

If you deliver your baby vaginally, you'll also deliver the placenta vaginally — during what's
known as the third stage of labor.
After you give birth, you'll continue to have mild contractions. Your health care provider might
give you a medication called oxytocin (Pitocin) to continue uterine contractions and reduce
postpartum bleeding. Your health care provider might also massage your lower abdomen to
encourage your uterus to contract and expel the placenta. You might be asked to push one more
time to deliver the placenta.
If you have a C-section, your health care provider will remove the placenta from your uterus
during the procedure.
Your health care provider will examine the placenta to make sure it's intact. Any remaining
fragments must be removed from the uterus to prevent bleeding and infection. If you're
interested, ask to see the placenta. In some cultures, families bury the placenta in a special place,
such as their backyards.
If you have questions about the placenta or placental problems during pregnancy, talk to your
health care provider. He or she can help you better understand the placenta's role during your
pregnancy.

10. CARE DURING THE 4TH STAGE OF LABOR.

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 The fourth stage of labor is the stage of physical recovery for the mother and infant. It
lasts from the delivery of the placenta through the first 1 to 4 hours after birth.
Immediately after birth, the firmly contracted uterus can be palpated through the
abdominal wall as a firm, rounded mass about 10 to 15 cm (4 to 6 inches) in diameter at
or below the level of the umbilicus. Uterine size varies with the size of the infant and
parity of the mother and is larger when the infant is large or the mother is a multipara.
 A full bladder or blood clot in the uterus interferes with uterine contraction, increasing
blood loss. A soft (boggy) uterus and increasing uterine size are associated with
postpartum hemorrhage because large blood vessels at the placenta site are not
compressed The vaginal drainage after childbirth is called lochia. The three stages are
lochia rubra, lochia serosa, and lochia alba (see pp. 329-330). Lochia rubra, consisting
mostly of blood, is present in the fourth stage of labor. Many women are chilled after
birth. The cause of this reaction is unknown but probably relates to the sudden decrease
in effort, loss of the heat produced by the fetus, decrease in intra-abdominal pressure, and
fetal blood cells entering the maternal circulation. The chill lasts for about 20 minutes
and subsides spontaneously.
 A warm blanket, a hot drink, or soup may help shorten the chill and make the woman
more comfortable. Discomfort during the fourth stage usually results from birth trauma
and after pains. Localized discomfort from birth trauma such as lacerations, an
episiotomy, edema, or a hematoma is evident as the effects of local and regional
anesthetics diminish. Ice packs on the perineum limit this edema and hematoma
formation.
 After pains are intermittent uterine contractions occurring after birth as the uterus begins
to return to the pre pregnancy state. The discomfort is similar to menstrual cramps. After
pains are more common in multiparas, women who breastfeed, women who have large
babies or other uterine over distention during pregnancy, and cases involving interference
with uterine contraction because of a full bladder or blood clot that remains in the uterus.
The mother is simultaneously excited and tired after birth. She may be exhausted but too
excited to rest.
 The fourth stage of labor is an ideal time for bonding of the new family because the
interest of both the parents and the newborn is high. It is the best time to initiate
breastfeeding if maternal and infant problems are absent. The baby is alert and seeks eye
contact with the new parents, giving powerful reinforcement for the parents’ attachment
to their newborn.

JOYCE KATHREEN EBIO LOPEZ | 2C