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Handout #10 2. Ambulation has also been found to decrease the

need for analgesia, decrease incidence of FHT
(Part 4) abnormalities and to promote comfort

LABOR AND DELIVERY Enema

• 1. Enema is a procedure of emptying the colon
of fecal matter to:
• Stimulate uterine contractions
Uterine Phases of Parturition (childbirth)
• Prevent infection- expulsion of feces during the
second stage predispose mother and infant
Phase 0
infection
• This extends from the time before implantation
• Facilitate descent of fetus
until late in pregnancy when the uterus is
2. Enema is not a routine procedure in the preparation
relaxed & the cervix is firm & rigid.
of woman in labor. Commonly used enemas are tap
Phase 1
water enema, fleet enema and prepacked disposable
• This is the time when the uterus & cervix
type enema. Soap suds enema is not recommended
undergo several changes in preparation for
because they have been associated with several
labor.
complications. Suppositories are also used.
Phase 2
3. Contraindications to enema:
• This is the time of active labor when the
• Not given during active phase and ruptured
contents of the uterus are expelled.
BOW
• It is divided into 3 stages:
• Vaginal bleeding
• a.) cervical stage
• Abnormal fetal presentation and position
• b.) expulsive stage
• Fetus not yet engaged
• c.) placental stage
• Premature labor because of the danger of cord
Phase 3
prolapsed
• This is the time when the newly delivered
• Abnormal fetal heart rate pattern
mother recovers from the effects of pregnancy
& childbirth.
Transfer to Delivery Room
• 1. Primiparas are transferred to the delivery
room when the cervix is fully dilated and
CARE OF PARTURIENT IN THE FIRST STAGE
perineum is bulging.
• 2. Multiparas are moved to DR when cervix is
Care of the Bladder
8cm dilated
1. A woman in labor should be encouraged to void
frequently, at least every 2 hours to prevent bladder
distention because a full bladder:
CARE OF PARTURIENT IN THE SECOND STAGE
Delay fetal descent
Increases discomfort of labor
• The second stage of labor begins as soon as the
Predispose to urinary tract infection
cervix is fully dilated and is completed with the
Can be traumatized during labor
birth of the baby.
2. A distended bladder can be palpated above the
• Never leave the patient alone once she is
symphysis pubis as it bulges or protrudes.
transferred to the delivery room.
• Never turn your back on the perineum because
Foods & Fluids
the baby could push through the vaginal
1. Early in labor, clear fluids may be allowed. If not, the
opening while your back is turned.
woman may be given ice chips to prevent drying of the
mouth and for comfort.
• During active labor, foods and oral fluid should
PREPARE DELIVERY EQUIPMENTS
be withheld because gastric emptying is
• Place the instrument table near the delivery
prolonged. Foods taken stays in the stomach
table and uncover it.
longer which the woman may vomit and
• Prepare instruments to be needed by the
aspirate especially if she has been given
newborn. Turn on radiant warmer and place
anesthetics and analgesics.
receiving blanket under it to warm.
Ambulation
• Ready resuscitation equipment.
1. Encourage woman to ambulate during the latent
• Prepare also forms and charts that must be
phase of labor to shorten first stage if membranes are
filled up in delivery room.
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.

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
to be performed.
• 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
– 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.
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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
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
in the middle area.
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 intrathoracic
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.
• Open-glottis pushing when the
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.
– 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.
6. Perform Ritgen’s maneuver while delivering the head.
Place a sterile towel over the rectum and apply forward
pressure on the chin while the other hand presses
downward the occiput. Ritgen’s maneuver will:
– Facilitates extension of the head
– Slows down deliver of the head
– Let the smallest diameter of the head to
be born.
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.
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11. 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
blood from placenta to infant. This
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.
– 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.
– 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.
12. Information to include in the 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.
METHODS OF PLACENTAL SEPARATION
• Schultz Mechanism – Separation of the
placenta starts from the center. The shiny
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.

MATERNAL ASSESMENT
1. Monitor vital signs every 15 minutes.
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.
– Do not hurry placental delivery. No
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.
• Inspect for completeness of cotyledons right
after placental delivery. Retained placental
fragments can cause severe hemorrhage by
preventing the uterus to contract.
4. Massage the uterus to keep it contracted.
5. 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.
• Oxytocin (Pitocin, Syntocinon) 10 units: It is
ideally given IM in a dose of 10 USP units or as a
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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 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.
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 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
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
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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, report 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.
3. Locate fundal height. Immediately after
placental delivery, it is located between the umbilicus
and the symphysis. It gradually rises to the level of the
umbilicus afterwards. It should be located at midline
and firm. If the fundus deviates from the middle, check
for fullness of the bladder which is usually the cause.
4. Assess the bladder when assessing the fundus.
Bladder distention displaces the uterus and prevents
proper uterine contraction. 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 lochia flow when the fundus is
massaged.
PROVIDING COMFORT AND PAIN RELIEF 
• During the immediate postpartum period, the
woman may experience pain and discomfort for
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.
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